Information Collection

Application for Military Health System Modified Payment and Waiver Program

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

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Application for Military Health System Modified Payment and Waiver Program	Agency IC Tracking Number:	0720-HSFA

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD3201	APPLICATION FOR MILITARY HEALTH SYSTEM (MHS) MODIFIED PAYMENT AND WAIVER PROGRAM (MPWP)			Yes	Yes	Fillable Fileable Signable

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 %

	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

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