Active Duty Dental Program Claim Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Active Duty Dental Program Claim Form	Form	Modified	Available
Active Duty Dental Program Claim Form	Form	Modified	Available
150917_SSN Justification 0720-0053.pdf	Supplementary Document	Uploaded 2023-03-07	Available
150917_SSN Justification 0720-0053.pdf	Supplementary Document	Uploaded 2023-03-07	Available
0720-0053_SSA_3.31.2026 (1).docx	Supporting Statement A	Uploaded 2026-03-31	Available
0720-0053_SSA_3.31.2026 (1).docx	Supporting Statement A	Uploaded 2026-03-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203005	Active Duty Dental Program Claim Form	Form	Modified	Active Duty Dental Program Claim Form
203005	Active Duty Dental Program Claim Form	Form	Modified	Active Duty Dental Program Claim Form
203005	Active Duty Dental Program Claim Form	Form	Modified

ICR Details

OMB Control No: 0720-0053	ICR Reference No: 202603-0720-003
Status: Active	Previous ICR Reference No: 202301-0720-002
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0053
Title: Active Duty Dental Program Claim Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/04/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/31/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2029	36 Months From Approved	05/31/2026
Responses	420,000	0	420,000
Time Burden (Hours)	105,000	0	105,000
Cost Burden (Dollars)	2,466,450	0	2,007,600

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Abstract: The information collection is necessary to obtain and record the dental readiness of Service Members using the Active Duty Dental Program (ADDP) and at the same time submit the claim form for the dental procedures provided. Many of these Service Members are not located near a military dental clinic and receive their dental care in the private sector under ADDP. The form is needed to update the dental readiness of all Service Members so that they can maintain worldwide deployment status and reduces paperwork by combining the dental claim and dental readiness into one form.

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Authorizing Statute(s): US Code: 10 USC 1074 Name of Law: Medical and Dental Care for Members and Certain Former Members
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 2926	01/23/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 15978	03/31/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Active Duty Dental Program Claim Form	N/A	Active Duty Dental Program Claim Form

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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	420,000	420,000	0	0	0	0
Annual Time Burden (Hours)	105,000	105,000	0	0	0	0
Annual Cost Burden (Dollars)	2,466,450	2,007,600	0	458,850	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,466,450

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.     No

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: 03/31/2026

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