Application for CHAMPUS-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⚠️ Notice: This information collection may be referencing outdated material.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
Application for TRICARE Provider Status.pdf Other-Application
0720-0020 Signed 83-I.pdf 0720-0020 Signed 83-I.pdf IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for CHAMPUS-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: 32 CFR 199.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Application			Application for TRICARE Provider Status.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: 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	200	-800	1,000
Annual IC Time Burden (Hours)	200	-133	333
Annual IC Cost Burden (Dollars)	4,400	4,400	0

Documents for IC

Title	Document	Date Uploaded
0720-0020 Signed 83-I.pdf	0720-0020 Signed 83-I.pdf	09/29/2006

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