Information Collection

Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program

IC 262159 under ICR 202308-0720-001 · OMB 0720-0083.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD3201 Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form
DD3201 Request for Medical Debt Discount, Military Health Syste DD3201 DRAFT 20240918..pdf	Form

IC Title:

Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 220

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	DD3201				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,160

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,160	2,160
Annual IC Time Burden (Hours)	144	144
Annual IC Cost Burden (Dollars)	4,836	4,836

Documents for IC

table that charts IC Documents
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.

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