This information collection requirement is necessary for a medical institution to claim benefit under the Defense Health Agency, TRICARE, which includes the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The information collected will be used by CHAMPUS/TRICARE contractors to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary received the care and that the provider is authorized to receive CHAMPUS/TRICARE payments.
The latest form for Health Insurance Claims Form, UB-04 CMS 1450 expires 2020-08-31 and can be found here.
Document Name |
---|
Form |
Supplementary Document |
Supplementary Document |
Supporting Statement A |
Approved with change |
Reinstatement with change of a previously approved collection | 2017-05-12 | |
Approved without change |
Extension without change of a currently approved collection | 2012-01-31 | |
Approved without change |
Extension without change of a currently approved collection | 2008-11-26 | |
Approved without change |
Extension without change of a currently approved collection | 2005-06-14 | |
Approved without change |
Reinstatement without change of a previously approved collection | 2002-01-24 | |
Approved without change |
New collection (Request for a new OMB Control Number) | 1997-04-18 |