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Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program
Implementation of the Military Health System Modified Payment and Waiver Program
OMB:
IC ID: 264328
OMB.report
DODOASHA
ICR 202308-0720-001
IC 264328
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
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IC Title:
Request for Medical Debt Waiver, 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:
Voluntary
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 and Instruction
DD3201-1
Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
1,080
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
95 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,080
0
1,080
0
0
0
Annual IC Time Burden (Hours)
72
0
72
0
0
0
Annual IC Cost Burden (Dollars)
2,418
0
2,418
0
0
0
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.