[Federal Register Volume 61, Number 47 (Friday, March 8, 1996)]
[Notices]
[Pages 9439-9440]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-5553]
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DEPARTMENT OF DEFENSE
Office of the Secretary
Proposed Collection; Comment Request
AGENCY: Office of the Assistant Secretary of Defense for Health
Affairs.
ACTION: Notice.
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In accordance with Section 3506(c)(2)(A) of the Paperwork Reduction
Act of 1995, the Office of the Assistant Secretary of Defense for
Health Affairs announces the proposed reinstatement of a public
information collection and seeks public comment on the provisions
thereof. Comments are invited on: (a) whether the proposed extension of
collection of information is necessary for the proper performance of
the functions of the agency, including whether the information shall
have practical utility; (b) the accuracy of the agency's estimate of
the burden of the information collection; (c) ways to enhance the
quality, utility, and clarity of the information to be collected; and
(d) ways to minimize the burden of the information collection on
respondents, including through the use of automated collection
techniques or other forms of information technology.
DATES: Considerations will be given to all comments received May 7,
1996.
ADDRESSES: Written comments and recommendations on the proposed
information collection should be sent to the Office of the Civilian
Health and Medical Program of the Uniformed Services (OCHAMPUS),
Fitzsimons Army Medical Center, Program Development Branch, ATTN: Mr.
Graham Kolb, Aurora, CO 80045-6900.
FOR FURTHER INFORMATION CONTACT:
To request more information on this proposed information collection,
please write to the above address or call, OCHAMPUS, Program
Requirements Branch at (303) 361-1180.
TITLE, ASSOCIATED FORM, AND OMB NUMBER: CHAMPUS Claim--Patient's
Request for Medical Payment; DD Form 2642; OMB Number: 0720-0006.
needs and uses: This form is used by beneficiaries claiming
reimbursement for medical expenses under the Civilian Health and
Medical Program of the Uniformed Services (TRICARE/CHAMPUS). The
information collected will be used by TRICARE/CHAMPUS to determine
beneficiary eligibility, other health insurance liability and
certification that the beneficiary received the care.
Affected Public: Individuals or households
[[Page 9440]]
Annual Burden Hours: 812,500
Number of Respondents: 3,250,000
Responses Per Respondent: 1
Average Burden Per Response: 15 minutes
Frequency: On occasion.
SUPPLEMENTARY INFORMATION:
Summary of Information Collection
This collection instrument is for use by beneficiaries under the
Civilian Health and Medical Program of the Uniformed Services (TRICARE/
CHAMPUS). TRICARE/CHAMPUS is a health benefits entitlement program for
the dependents of active duty Uniformed Services members and deceased
sponsors, retirees and their dependents, dependents of Department of
Transportation (Coast Guard) sponsors, and certain North Atlantic
Treaty Organization, National Oceanic and Atmospheric Administration,
and Public Health Service eligible beneficiaries. DD Form 2642 is used
by TRICARE/CHAMPUS beneficiaries to file for reimbursement of costs
paid to providers and suppliers for authorized health care service
supplies.
Dated: March 5, 1996.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 96-5553 Filed 3-7-96; 8:45 am]
BILLING CODE 5000-04-M
