Submission for OMB Review; Comment Request

AGENCY:

Office of the Assistant Secretary of Defense for Health Affairs, Department of Defense (DoD).

ACTION:

30-Day information collection 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 November 22, 2021.

ADDRESSES:

Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to www.reginfo.gov/public/do/PRAMain. Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function.

FOR FURTHER INFORMATION CONTACT:

Angela Duncan, 571-372-7574, or whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil .

SUPPLEMENTARY INFORMATION:

Title; Associated Form; and OMB Number: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment; DD Form 2642; OMB Control Number 0720-0006.

Type of Request: Extension.

Number of Respondents: 830,000.

Responses per Respondent: 1.

Annual Responses: 830,000.

Average Burden per Response: 15 Minutes.

Annual Burden Hours: 207,500.

Needs and Uses: The DD-2642, “TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment” form is used by TRICARE beneficiaries to claim reimbursement for medical expenses under the TRICARE Program (formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)). The information collected will be used by TRICARE to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary has the received care, and reimbursement for medical services received.

Affected Public: Individuals or households.

Frequency: As required.

Respondent's Obligation: Voluntary.

OMB Desk Officer: Ms. Julie Wise.

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: Ms. Angela Duncan.

Requests for copies of the information collection proposal should be sent to Ms. Duncan at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil.