03-28248. 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).

DATES:

Consideration will be given to all comments received by December 12, 2003.

Title, Form Number, and OMB Number: Third Party Collection Program (Insurance Information); DD Form 2569; OMB Number 0704-0323.

Type of Request: Revision.

Number of Respondents: 511,232.

Responses Per Respondent: 1.

Annual Responses: 511,232

Average Burden Per Response: 2.5 minutes.

Annual Burden Hours: 20,961.

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 deceased Service members having health insurance. Such monetary benefits accruing to the Military Treatment Facility (MTF) will be used to enhance healthcare delivery in the MTF. Information will also be used by MTF staff and CHAMPUS Fiscal Intermediaries to determine eligibility for care, deductibles, and co-payments and by Health Affairs for program planning and management.

Affected Public: Individuals or Households.

Frequency: On Occasion and Annually.

Respondent's Obligation: Voluntary.

OMB Desk Officer: Mr. John Finley. Written comments and recommendations on the proposed information collection should be sent to Mr. Finley at the Office of Management and Budget, Desk Officer for DoD Health Affairs, Room 10235, New Executive Office Building, Washington, DC 20503.

DoD Clearance Officer: Ms. Jacqueline Davis.

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

Dated: October 29, 2003.

Patricia L. Toppings,

Alternate OSD Federal Register Liaison Officer, Department of Defense.