[Federal Register Volume 69, Number 31 (Tuesday, February 17, 2004)]
[Notices]
[Page 7456]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-3290]



[[Page 7456]]

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DEPARTMENT OF DEFENSE

Office of the Secretary


Submission for OMB Review; Comment Request

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).

DATES: Consideration will be given to all comments received by March 
18, 2004.
    Title, Form, and OMB Number: Health Insurance Claim Form (HCFA 
1500); OMB Number 0720-0001.
    Type of Request: Reinstatement.
    Number of Respondents: 22,400,000.
    Responses Per Respondent: 1.
    Annual Responses: 5,600,000.
    Average Burden Per Response: 15 minutes.
    Annual Burden Hours: 5,600,000.
    Needs and Uses: This information collection is used by TRICARE to 
determine reimbursement for health care services or supplies rendered 
by individual professional providers to TRICARE beneficiaries. The 
requested information is used to determine beneficiary eligibility, 
appropriations and costs of care, other health insurance liability, and 
whether services received are benefits. Use of this form continues 
TRICARE's commitment to use the national standard claim form for 
reimbursement of services/supplies provided by individual professional 
providers.
    Affected Public: Business or other for-profit.
    Frequency: On occasion.
    Respondent's Obligation: Required to obtain or retain benefits.
    OMB Desk Officer: Ms. Jacqueline Zeiher.
    Written comments and recommendations on the proposed information 
collection should be sent to Ms. Zeiher at the Office of Management and 
Budget, Desk Officer for DoD, Room 10236, New Executive Office 
Building, Washington, DC 20503.
    DoD Clearance Officer: Ms. Jacqueline Davis.
    Written requests for copies of the information collection proposal 
should be sent to Ms. Davis, WHS/DIOR, 1215 Jefferson Davis Highway, 
Suite 1204, Arlington, VA 22202-4302.

    February 9, 2004.
L.M. Bynum,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 04-3290 Filed 2-13-04; 8:45 am]
BILLING CODE 5001-06-M