View Information Collection (IC)

View Information Collection (IC)

IC Title:	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 From 2642	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	dd2642.pdf		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

	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	3,000,000	0	0	600,000	2,400,000	0
Annual IC Time Burden (Hours)	750,000	0	0	150,000	600,000	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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