Information Collection

CHAMPUS Claim Form, Patient's Request for Medical Payment

IC 5570 under ICR 199608-0720-001 · OMB 0720-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0006 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CHAMPUS Claim Form, Patient's Request for Medical Payment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	DD-FORM-2642				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500,000	1,500,000
Annual IC Time Burden (Hours)	375,000	375,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.