Active Duty Dental Program Claim Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0053 can be found here:

Documents and Forms

Document Name Document Type
Form United Concordia C Active Duty Dental Program Claim Form Form and Instruction
United Concordia C Active Duty Dental Program ADDP Draft Claim Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Active Duty Dental Program Claim Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	United Concordia Claim Form	Active Duty Dental Program	ADDP Draft Claim Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	177,000	177,000
Annual IC Time Burden (Hours)	14,750	14,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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