Information Collection

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

IC 43597 under ICR 202110-0720-001 · OMB 0720-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0006 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Form and Instruction
0720-0006_Web Submission Pharmacy Claims.pptx	Other-Screenshots
2642 TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR dd2642 DRAFT 20210913 (003).pdf www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf	Form and Instruction
2642 TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR dd2642 DRAFT 20210913 (003).pdf www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf	Form and Instruction
0720-0006_Agency Disclosure Notice_ Online Submission.docx Agency Disclosure Notice for Online Submission	IC Document

IC Title:

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

Agency IC Tracking Number:

0720-0006

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2642	TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT	dd2642 DRAFT 20210913 (003).pdf	https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf	Yes	Yes	Fillable Fileable Signable
Other-Screenshots			0720-0006_Web Submission Pharmacy Claims.pptx		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144,876

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	144,876	-685,124	830,000
Annual IC Time Burden (Hours)	36,219	-171,281	207,500
Annual IC Cost Burden (Dollars)	262,588	-1,241,787	1,504,375

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Agency Disclosure Notice for Online Submission	0720-0006_Agency Disclosure Notice_ Online Submission.docx	12/01/2021

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