Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER

Forms and Documents

Document Name	Status
Form DD Form X644 Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER Form	Modified
OMB Sppting_Stmt_0720-0020_ICB COMMENTS 1.28.16_DHA response4.6.2016_CLEAN.DOCX Supporting Statement A	2016-04-07
TRICARE Provider Manual - Chapter 11, Section 12.1.PDF Supplementary Document	2016-04-01
32cfr199.6.pdf Supplementary Document	2006-09-29

IC Document Collections

IC ID	Document Title	Status
5593	Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER Form	Modified

ICR Details

OMB Control No: 0720-0020	ICR Reference No: 201604-0720-001
Status: Historical Active	Previous ICR Reference No: 200609-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/02/2016
	Date Received in OIRA: 04/07/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved
Responses	300	0	0
Time Burden (Hours)	100	0	0
Cost Burden (Dollars)	1,710	0	0

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Abstract: 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.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 61396	10/13/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 18842	04/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 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

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: 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.

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Annual Cost to Federal Government: $18,235

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/07/2016

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