[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