[Federal Register Volume 61, Number 169 (Thursday, August 29, 1996)]
[Notices]
[Page 45412]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-21997]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Public Information Collection Requirement Submitted to the Office 
of Management and Budget (OMB) for Review

ACTION: Notice.

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    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, Applicable Form, and OMB Control Number: CHAMPUS Claim 
Form--Patient's Request for Medical Payment; DD Form 2642, OMB Number 
0720-0006.
    Type of Request: Reinstatement, with change.
    Number of Respondents: 1,500,000.
    Responses Per Respondent: 1.
    Annual Responses: 1,500,000.
    Average Burden Per Response: 15 minutes.
    Annual Burden Hours: 375,000 hours.
    Needs and Uses: Respondents to this information collection are 
beneficiaries claiming reimbursement for medical expenses under the 
Civilian Health and Medical Program for the Uniformed Services 
(TRICARE/CHAMPUS). DD Form 2642, CHAMPUS Claim--Patient's Request for 
Medical Payment, is used by TRICARE/CHAMPUS beneficiaries to file for 
reimbursement of costs paid to providers and suppliers for authorized 
health care services or supplies. The information collected will be 
used to determine beneficiary eligibility, other health insurance 
liability, and certification that the beneficiary received the care.
    Affected Public: Individuals or households.
    Frequency: On occasion.
    Respondent's 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, Room 10235, New Executive Office 
Building, Washington, DC 20503.
    DOD Clearance Officer: Mr. William Pearce.
    Written request for copies of the information collection proposal 
should be sent to Mr. Pearce, WHS/DIOR, 1215 Jefferson Davis Highway, 
Suite 1204, Arlington, VA 22202-4302.

    Dated August 23, 1996.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 96-21997 Filed 8-28-96; 8:45 am]
BILLING CODE 5000-04-M