Submission for OMB Review; Comment Request

ACTION:

Notice.

The Department of Defense has submitted to OMB for clearance, the following proposal for collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. Chapter 35).

Title, Associated Form, and OMB Number: Third Party Collection program (Record of Other Health Insurance; DD Form 2569; OMB Number 0704-0323.

Type of Request: Revision.

Number of Respondents: 293,401.

Responses Per Respondent: 1.

Annual Responses: 293,401.

Average Burden Per Response: 2.5 minutes.

Annual Burden Hours: 12,030.

Needs and Uses: The information contained in the DD Form 2569 will be used to collect reimbursement from private insurers for medical care provided to family members of retirees and decreased Service members having health insurance. This information is collected either during the inpatient stay admission and/or discharge process or during the visit when a patient presents for an outpatient procedure. Reimbursement will be used to enhance healthcare delivery in the Medical Treatment Facility (MTF). Information will also be used by the Military Health Services System and CHAMPUS Fiscal intermediaries to determine eligibility for care, deductibles, and copayments and by Health Affairs for program planning and management.

Affected Public: Individuals or Households.

Frequency: On occasion; annually.

Respondent's Obligation: Required to obtain or retain benefits.

OMB Desk Officer: Ms. Allison Eydt.

Written comments and recommendations on the proposed information collection should be sent to Ms. Eydt at the Office of Management and Budget, Desk Officer for DoD, Room 10235, New Executive Office Building, Washington, DC 20503.

DoD Clearance Officer: Mr. Robert Cushing.

Written requests for copies of the information collection proposal should be sent to Mr. Cushing, WHS/DIOR, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302.