OMB control number
Implementation of the Military Health System Modified Payment and Waiver Program
OMB 0720-0083 · DOD/DODOASHA.
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.
The latest form for Implementation of the Military Health System Modified Payment and Waiver Program expires 2029-02-28 and can be found here.
Document Name |
|---|
Form and Instruction |
Form |
Form |
Supporting Statement A |
Supplementary Document |
Supplementary Document |
Form DD3201-1 Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program
0720-0083_SSA_1.30.2026.docx
Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program | New collection (Request for a new OMB Control Number) | 2026-02-06 | ||
|
Comment filed on proposed rule |
New collection (Request for a new OMB Control Number) | 2024-05-10 |
Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program
Federal Enterprise Architecture: Health - Health Care Services
| Form DD3201 | Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program | Fillable Fileable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.