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View ICR - OIRA Conclusion

OMB Control No: 0938-0997	ICR Reference No: 202401-0720-001CF
Status: Active	Previous ICR Reference No: 202008-0720-002CF
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Health Insurance Claims Form, UB-04 CMS 1450
Type of Information Collection: RCF Recertification	Common Form ICR:
Type of Review Request:
OIRA Conclusion Action: Approved	Conclusion Date: 01/02/2024
	Date Received in OIRA: 01/02/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved	01/31/2024
Responses	858,881	0	858,881
Time Burden (Hours)	8,589	0	7,194
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	858,881	858,881	0
Annual Time Burden (Hours)	8,589	7,194	1,395
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $796,050

Does this IC contain surveys, censuses, or employ statistical methods?

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.

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.

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? No

Agency Contact: Kira Starks 571 372-4529 danikquia.k.starks.ctr@mail.mil

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