Submission for OMB Review; Comment Request

ACTION:

Notice.

SUMMARY:

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.

DATES:

Consideration will be given to all comments received by August 1, 2016.

FOR FURTHER INFORMATION CONTACT:

Fred Licari, 571-372-0493.

SUPPLEMENTARY INFORMATION:

Title, Associated Form and OMB Number: Third Party Collection Program/Medical Services Account/Other Health Insurance; DD Form 2569; OMB Control Number 0720-0055.

Type of Request: Revision.

Number of Respondents: 3,900,000.

Responses per Respondent: 1.5.

Annual Responses: 5,850,000.

Average Burden per Response: 4 minutes.

Annual Burden Hours: 390,000.

Needs and Uses: The information collection requirement is necessary to obtain health insurance policy information used for coordination of health care benefits and billing third party payers and other federal agencies for health care provided to their beneficiaries and also to civilian non-Uniformed Service beneficiaries for health care provided to them. DoD implemented the Third Party Collection Program (TPCP) in FY87 based on the authority granted in 10 U.S.C. 1095 and implemented by 32 CFR 220 in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) (Pub. L. 99-272, section 2001, April 7, 1986). Under the TPCP, DoD is authorized to collect from third-party payers the cost of inpatient and outpatient services rendered to DoD beneficiaries who have other health insurance. Military treatment facilities (MTFs) are required to make this form available to third-party payers upon request. A third-party payer may not request any other assignment of benefits form from the subscriber. Also, for civilian non-Uniformed Services beneficiary and interagency patients, DD Form 2569 is necessary and serves as an assignment of benefits, approval to submit claims to payers on behalf of the patient and authorization to release medical information.

Affected Public: Individuals and households.

Frequency: Annually.

Respondent's Obligation: Required to Obtain Benefits.

OMB Desk Officer: Ms. Stephanie Tatham.

Comments and recommendations on the proposed information collection should be emailed to Ms. Stephanie Tatham, DoD Desk Officer, at Oira_submission@omb.eop.gov. Please identify the proposed information collection by DoD Desk Officer and the Docket ID number and title of the information collection.

You may also submit comments and recommendations, identified by Docket ID number and title, by the following method:

• Federal eRulemaking Portal: http://www.regulations.gov. Follow the instructions for submitting comments.

Instructions: All submissions received must include the agency name, Docket ID number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at http://www.regulations.gov as they are received without change, including any personal identifiers or contact information.

DOD Clearance Officer: Mr. Frederick Licari.

Written requests for copies of the information collection proposal should be sent to Mr. Licari at WHS/ESD Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.