Agency Disclosure Notice for Online Submission

0720-0006_Agency Disclosure Notice_ Online Submission.docx

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

Agency Disclosure Notice for Online Submission

OMB: 0720-0006

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OMB CONTROL NUMBER: 0720-0006

OMB EXPIRATION DATE: XX/XX/XXXX


AGENCY DISCLOSURE NOTICE


The public reporting burden for this collection of information, 0720-0006, is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

Version 1.1 – Effective 7/18/2017


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleThe following is a sample Agency Disclosure Notice:
AuthorPatricia Toppings
File Modified0000-00-00
File Created2021-12-13

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