Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0020 can be found here:

Documents and Forms

Document Name Document Type
Form DD Form 3030 Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER Form
DD Form 3030 Corporate Services Provider Application for TRICARE Prov ddx644_20160112.PDF www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd3030.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD Form 3030	Corporate Services Provider Application for TRICARE Provider Status	ddx644_20160112.PDF	https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd3030.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 335	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	335	35	300
Annual IC Time Burden (Hours)	112	12	100
Annual IC Cost Burden (Dollars)	2,087	377	1,710

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.