Implementation of the Military Health System Modified Payment and Waiver Program

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	Modified	Available
Form DD3201-1 Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	Form and Instruction	Modified	Repair queued
Form DD3201 Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	Modified	Available
Form DD3201 Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	Modified	Repair queued
0720-0083_SSA_1.30.2026.docx	Supporting Statement A	Uploaded 2026-01-30	Available
0720-0083_SSA_1.30.2026.docx	Supporting Statement A	Uploaded 2026-01-30	Repair queued
Disapproval Memo script.docx	Supplementary Document	Uploaded 2024-05-09	Available
Disapproval Memo script.docx	Supplementary Document	Uploaded 2024-05-09	Missing upstream
SSNJ_DDFormx3201_07.13.2023.pdf	Supplementary Document	Uploaded 2023-09-13	Available
SSNJ_DDFormx3201_07.13.2023.pdf	Supplementary Document	Uploaded 2023-09-13	Repair queued

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	Modified	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	Modified
262159	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	Modified	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program
262159	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	Form	Modified

ICR Details

OMB Control No: 0720-0083	ICR Reference No: 202508-0720-002
Status: Active	Previous ICR Reference No: 202308-0720-001
Agency/Subagency: DOD/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: Approved with change	Conclusion Date: 02/09/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/06/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2029	36 Months From Approved
Responses	3,240	0	0
Time Burden (Hours)	216	0	0
Cost Burden (Dollars)	7,254	0	0

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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 DoD’s Military Health System, but who receive healthcare at DoD military medical treatment facilities (MTFs), in order to prevent serious financial harm to the patient.

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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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0720-AB87	Final or interim final rulemaking	91 FR 5303	02/05/2026

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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 Discount, Military Health System Modified Payment and Waiver Program
Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	DD3201-1	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,240	0	0	3,240	0	0
Annual Time Burden (Hours)	216	0	0	216	0	0
Annual Cost Burden (Dollars)	7,254	0	0	7,254	0	0

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.

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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

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/06/2026

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