Information Collection Request

Implementation of the Military Health System Modified Payment and Waiver Program

ICR 202308-0720-001 · OMB 0720-0083 · Historical Inactive

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0720-0083 can be found here:

2026-02-06 - New collection (Request for a new OMB Control Number)

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form DD3201-1 Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	Form and Instruction	New	Repair queued
Form DD3201 Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	New	Repair queued
0720-HFSA_SSA_9.27.2024.docx	Supporting Statement A	Uploaded 2024-09-27	Available
Disapproval Memo script.docx	Supplementary Document	Uploaded 2024-05-09	Available
SSNJ_DDFormx3201_07.13.2023.pdf	Supplementary Document	Uploaded 2023-09-13	Available

IC Document Collections

Information collection document groups
IC ID	Collection	Type	Status	Form
264328	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	Form and Instruction	New	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program
264328	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	Form and Instruction	New
262159	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	New	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program
262159	Application for Military Health System Modified Payment and Waiver Program	Form	New

ICR Details

OMB Control No: 0720-0083

ICR Reference No: 202308-0720-001

Status: Historical Inactive

Previous ICR Reference No:

Agency/Subagency: DOW/DODOASHA

Agency Tracking No: 0720-HFSA

Title: Implementation of the Military Health System Modified Payment and Waiver Program

Type of Information Collection: New collection (Request for a new OMB Control Number)

Common Form ICR: No

Type of Review Request: Regular

OIRA Conclusion Action: Comment filed on proposed rule

Conclusion Date: 10/03/2024

Date Received in OIRA: 05/10/2024

Terms of Clearance: OMB files this comment in accordance with 5 CFR 1320.11(c). This OMB action is not an approval to conduct or sponsor an information collection under the Paperwork Reduction Act of 1995. This action has no effect on any current approvals. If OMB has assigned this ICR a new OMB Control Number, the OMB Control Number will not appear in the active inventory. For future submissions of this information collection, reference the OMB Control Number provided. In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision
	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

Abstract: This information collection will assist the Department of Defense (DoD) in determining the eligibility of an individual for the Military Health System Financial Assistance Program/ Waiver Program (MHS FAP). DoD will apply a sliding scale or catastrophic waiver discount to medical bills for eligible civilian patients who are not entitled beneficiaries of DoDâs Military Health System, but who receive healthcare at DoD military medical treatment facilities (MTFs), in order to prevent serious financial harm to the patient.

Authorizing Statute(s): US Code: 10 USC 1079b Name of Law: Procedures for charging fees for care provided to civilians; retention and use of fees collected
PL: Pub.L. 117 - 263 716 Name of Law: James M. Inhofe National Defense Authorization Act for Fiscal Year 2023

Citations for New Statutory Requirements: None

Associated Rulemaking Information

RIN:

Stage of Rulemaking:

Federal Register Citation:

Date:

0720-AB87

Proposed rulemaking

89 FR 79804

10/01/2024

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden
IC Title	Form No.	Form Name
Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	DD3201
Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	DD3201-1

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection with a new associated burden.

Annual Cost to Federal Government: $10,867

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Amanda Grifka 555 555-5555 [email protected]

Reginfo record details
Common Form ICR: No