Third Party Collection Program (Record of Other Health Insurance)

Third Party Collection Program (Record of Other Health Insurance)

OMB: 0704-0323

IC ID: 5377

Documents and Forms
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Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details

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Third Party Collection Program (Record of Other Health Insurance)
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form DD-2569 Yes Yes


    

293,401 0
   
Individuals or Households
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 293,401 0 0 219,177 0 74,224
Annual IC Time Burden (Hours) 12,030 0 0 8,987 0 3,043
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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