Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program

Implementation of the Military Health System Modified Payment and Waiver Program

Documents and Forms

Document Name Document Type
Form DD3201 Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program Form
DD3201 Request for Medical Debt Discount, Military Health Syste DD3201 DRAFT 20260130.pdf Form

Information Collection (IC) Details

IC Title:	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	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 220

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD3201	Request for Medical Debt Discount, Military Health System Modified Payment and Waiver Program	DD3201 DRAFT 20260130.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,160	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,160	2,160
Annual IC Time Burden (Hours)	144	144
Annual IC Cost Burden (Dollars)	4,836	4,836

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.