Information Collection

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

IC 43597 under ICR 202412-0720-001 · OMB 0720-0006.

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
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
0720-0006_Agency Disclosure Notice_ Online Submission.docx Agency Disclosure Notice for Online Submission	IC Document

IC Title:

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

FR Citation: 89 FR 63422

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	Previously Approved
Annual Number of Responses for this IC	144,876	144,876
Annual IC Time Burden (Hours)	36,219	36,219
Annual IC Cost Burden (Dollars)	262,588	262,588

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.