View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0720-0006	ICR Reference No: 202110-0720-001
Status: Historical Active	Previous ICR Reference No: 201808-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0006
Title: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/07/2021
	Date Received in OIRA: 10/25/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2024	36 Months From Approved	12/31/2021
Responses	144,876	0	830,000
Time Burden (Hours)	36,219	0	207,500
Cost Burden (Dollars)	262,588	0	1,504,375

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	144,876	830,000	-685,124
Annual Time Burden (Hours)	36,219	207,500	-171,281
Annual Cost Burden (Dollars)	262,588	1,504,375	-1,241,787

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden has decreased since the previous approval due to the limited necessity for this form as more providers file on behalf of patients.

Annual Cost to Federal Government: $262,588

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Sandra Dennis 703 681-8818 sandra.e.dennis4.ctr@mail.mil

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