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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 202110-0720-001 · OMB 0720-0006 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction Modified Repair queued
0720-0006_SS-A_10.23.2021.docx Supporting Statement A Uploaded 2021-10-25 Repair queued
DD 2642 SSN Justification Memo_For Signature_08.28.2018signed.pdf Supplementary Document Uploaded 2021-10-22 Missing upstream
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 202110-0720-001
Received in OIRA 201808-0720-001
DOD/DODOASHA 0720-0006
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Revision of a currently approved collection   No
Regular 10/25/2021
  Requested Previously Approved
36 Months From Approved 10/31/2021
144,876 830,000
36,219 207,500
262,588 1,504,375
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
  86 FR 47302 08/24/2021
86 FR 58645 10/22/2021
No
  Total Request 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 144,876 830,000 0 -685,124 0 0
Annual Time Burden (Hours) 36,219 207,500 0 -171,281 0 0
Annual Cost Burden (Dollars) 262,588 1,504,375 0 -1,241,787 0 0
No
Yes
Miscellaneous Actions
The burden has decreased since the previous approval due to the limited necessity for this form as more providers file on behalf of patients.
$262,588
No
    Yes
    Yes
No
No
No
No
Sandra Dennis 703 681-8818 [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.
10/25/2021