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

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

OMB: 0720-0006

IC ID: 43597

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Screenshots
Other-Screenshots
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

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TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment 0720-0006
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 2642 TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT dd2642 DRAFT 20210913 (003).pdf https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2642.pdf Yes Yes Fillable Fileable Signable
Other-Screenshots 0720-0006_Web Submission Pharmacy Claims.pptx Yes Yes Fillable Fileable

Defense and National Security Operational Defense

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment  89 FR 63422

144,876 0
   
Individuals or Households
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 144,876 0 0 0 0 144,876
Annual IC Time Burden (Hours) 36,219 0 0 0 0 36,219
Annual IC Cost Burden (Dollars) 262,588 0 0 0 0 262,588

Title Document Date Uploaded
Agency Disclosure Notice for Online Submission 0720-0006_Agency Disclosure Notice_ Online Submission.docx 12/01/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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