Fillable DD Form 2642, TRICARE DoD/CHAMPUS Medical Claim ... - DTIC - dtic
- PATIENT'S COPY TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT
OMB No. 0720-0006 OMB approval expires Aug 31, 2009
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the...
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