[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] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF DEFENSE Office of the Secretary Public Information Collection Requirement Submitted to the Office of Management and Budget (OMB) for Review 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, 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