TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0006 can be found here:

Documents and Forms

Document Name Document Type
Form DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form
DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for dd2642.pdf Form

Information Collection (IC) Details

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

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 774,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	774,000	-2,226,000	0	3,000,000
Annual IC Time Burden (Hours)	193,500	-556,500	0	750,000
Annual IC Cost Burden (Dollars)	4,992,300	0	4,992,300	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.