Request for Medical Debt Waiver, 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 DD3201-1 Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program Form and Instruction
DD3201-1 Request for Medical Debt Waiver, Military Health System DD3201-1 DRAFT 20260130.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	Agency IC Tracking Number:	0720-HSFA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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 and Instruction	DD3201-1	Request for Medical Debt Waiver, Military Health System Modified Payment and Waiver Program	DD3201-1 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: 1,080	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	1,080	1,080
Annual IC Time Burden (Hours)	72	72
Annual IC Cost Burden (Dollars)	2,418	2,418

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.