Information Collection

Active Duty Dental Program Claim Form

IC 203005 under ICR 202603-0720-003 · OMB 0720-0053.

Documents and Forms

Document Name Document Type
Active Duty Dental Program Claim Form Active Duty Dental Program Claim Form Form
Active Duty Dental Program Claim Form Active Duty Dental Program Claim Form Form
Active Duty Dental Program Claim Form ADDP UCCI OCONUS Claim Form.pdf secure.addp-ucci.com/dentist/tools-and-resources/forms Form
Active Duty Dental Program Claim Form ADDP UCCI OCONUS Claim Form.pdf secure.addp-ucci.com/dentist/tools-and-resources/forms Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Active Duty Dental Program Claim Form	Agency IC Tracking Number:	0720-0053

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Active Duty Dental Program Claim Form	ADDP UCCI OCONUS Claim Form.pdf	https://secure.addp-ucci.com/dentist/tools-and-resources/forms	Yes	Yes	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 105,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 68 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420,000	0	420,000
Annual IC Time Burden (Hours)	105,000	0	105,000
Annual IC Cost Burden (Dollars)	2,466,450	458,850	2,007,600

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.

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