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Federal forms, ICRs, and supporting documents

Information Collection Request

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

ICR 201808-0720-001 · OMB 0720-0006 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction Modified Repair queued
SS-A_0720-0006_08.29.18.docx Supporting Statement A Uploaded 2018-08-29 Repair queued
DD 2642 SSN Justification Memo_For Signature_08.28.2018signed.pdf Supplementary Document Uploaded 2018-08-28 Available
0720-0006_DRAFT_PIA_04.06.18.pdf Supplementary Document Uploaded 2018-08-27 Available
IC Document Collections
IC IDCollectionTypeStatusForm
43597 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction Modified
ICR Details
0720-0006 201808-0720-001
Active 201501-0720-001
DOD/DODOASHA 0720-0006
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Extension without change of a currently approved collection   No
Regular
Approved without change 10/16/2018
Retrieve Notice of Action (NOA) 08/30/2018
  Inventory as of this Action Requested Previously Approved
10/31/2021 36 Months From Approved 10/31/2018
830,000 0 774,000
207,500 0 193,500
1,504,375 0 4,992,300
The DD-2642, “TRICARE DoD/ CHAMPUS Medical Claim Patient’s Request for Medical Payment” form is used by TRICARE beneficiaries to claim reimbursement for medical expenses under the TRICARE Program (formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).
US Code: 10 USC 55 Name of Law: Medical and Dental Care
  
None
Not associated with rulemaking
  83 FR 29765 06/26/2018
83 FR 44034 08/29/2018
No
  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 830,000 774,000 0 0 56,000 0
Annual Time Burden (Hours) 207,500 193,500 0 0 14,000 0
Annual Cost Burden (Dollars) 1,504,375 4,992,300 0 0 -3,487,925 0
No
No
Based on previous respondent data captured, the estimated number of responses and time burden has increased. The cost burden has decreased due to a recalculation of respondent wages.
$1,502,300
No
    Yes
    Yes
No
No
No
Uncollected
Kira Starks 571 372-4529 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/30/2018