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: 202412-0720-001
Status: Active	Previous ICR Reference No: 202110-0720-001
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: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/21/2025
	Date Received in OIRA: 12/27/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2028	36 Months From Approved	02/28/2025
Responses	144,876	0	144,876
Time Burden (Hours)	36,219	0	36,219
Cost Burden (Dollars)	262,588	0	262,588

Annual Cost to Federal Government: $262,589

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: Amanda Grifka 555 555-5555 amanda.b.grifka.civ@health.mil

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