Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

ICR 201604-0720-001

OMB: 0720-0020

Federal Form Document

IC Document Collections
ICR Details
0720-0020 201604-0720-001
Historical Active 200609-0720-001
DOD/DODOASHA
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/02/2016
Retrieve Notice of Action (NOA) 04/07/2016
  Inventory as of this Action Requested Previously Approved
08/31/2019 36 Months From Approved
300 0 0
100 0 0
1,710 0 0

The information collection requirement is necessary to ensure that applicants for TRICARE-Provider Status meet the conditions for authorization as a TRICARE Corporate Services Provider. The collected nformation will be used by TRICARE contractors to process claims and verify authorization status.

None
None

Not associated with rulemaking

  80 FR 61396 10/13/2015
81 FR 18842 04/01/2016
No

1
IC Title Form No. Form Name
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER DD Form X644 Corporate Services Provider Application for TRICARE Provider Status

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 300 0 0 -700 0 1,000
Annual Time Burden (Hours) 100 0 0 -233 0 333
Annual Cost Burden (Dollars) 1,710 0 0 1,710 0 0
No
Yes
Changing Forms
This is a reinstatement with changes in the time interval required for a respondent to fill out the provider authorization form (i.e., from one hour to 20 minutes). It was felt that this change was justified due to the simplicity of form design which minimizes the administrative burden upon the corporate entity. The number of respondents was also changed from 1,000 to 300 respondents based on the increasing popularity of less restrictive treatment settings. Governmental and facility costs were increased for inflation.

$18,235
No
No
No
No
No
Uncollected
Caitlyn Borghi 571 372-0492 caitlyn.a.borghi.ctr@mail.mil

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/07/2016


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