Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0020 can be found here:

Documents and Forms

Document Name Document Type
Form DD Form X644 Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER Form
DD Form X644 Corporate Services Provider Application for TRICARE Prov ddx644_20160112.PDF Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER	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 Form X644	Corporate Services Provider Application for TRICARE Provider Status	ddx644_20160112.PDF		No		Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	300	-700	1,000
Annual IC Time Burden (Hours)	100	-233	333
Annual IC Cost Burden (Dollars)	1,710	1,710	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.