00-17411. 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, Form Number, and OMB Number: Health Insurance Claim Form; HCFA Form 1500; OMB Number 0720-0001.

Type of Request: Reinstatement.

Number of Respondents: 14,500,000.

Responses per Respondent: 1.

Annual Responses: 14,500,000.

Average Burden per Response: 15 minutes.

Annual Burden Hours: 3,625,000.

Needs and Uses: This information collection requirement is used by TRICARE/CHAMPUS to determine reimbursement for health care services or supplies rendered by individual professional providers to TRICARE/CHAMPUS beneficiaries. The requested information is used to determine beneficiary eligibility, appropriateness and costs of care, other health insurance liability and whether services received are benefits. Use of this form continues TRICARE/CHAMPUS commitments to use the national standard claim form for reimbursement of services/supplies provided by individual professional providers.

Affected Public: Individuals or Households; Business or Other For-Profit; Not-For-Profit Institutions; Federal Government; State, Local or Tribal Government.

Frequency: On Occasion.

Respondents 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 Health Affairs, Room 10235, New Executive Office Building, Washington, DC 20503.

DOD Clearance Officer: Mr. Robert Cushing. Written request 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.

Dated: June 30, 2000.

Patricia L. Toppings,

Alternate OSD Federal Register Liaison Officer, Department of Defense.