[Federal Register Volume 70, Number 121 (Friday, June 24, 2005)]
[Notices]
[Page 36566]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-12507]


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DEPARTMENT OF DEFENSE

Office of the Secretary


Submission for OMB review; Comment Request

AGENCY: Department of Defense.

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 July 25, 
2005.
    Title, Form, and OMB Number: Health Insurance Claim form; UB-92 
HCFA-1450; OMB Number 0720-0013.
    Type of Request: Extension.
    Number of Respondents: 7,836.
    Responses per Respondent: 268.
    Annual Responses: 2,100,000.
    Average Burden per Response: 15 minutes
    Annual Burden Hours: 525,000.
    Needs and Uses: This information collection is necessary for a 
medical institution to claim benefits under the defense Health Program, 
TRICARE, which includes the Civilian Health and Medical Program for the 
Uniformed Services (CHAMPUS). The information collected will be used by 
TRICARE/CHAMPUS to determine beneficiary eligibility, other health 
insurance liability, certification that the beneficiary received care, 
and that the provider is authorized to receive TRICARE/CHAMPUS 
payments. The form will be used by TRICARE/CHAMPUS and its contractors 
to determine the amount of benefits to be paid to TRICARE/CHAMPUS 
institutional providers.
    Affected Public: Individuals or households; business or other for-
profit; not-for-profit institutions.
    Frequency: On occasion.
    Respondent's Obligation: Required to obtain or retain benefits
    OMB Desk Officer: Mr. John Kraemer.
    Written comments and recommendations on the proposed information 
collection should be sent to Mr. Kraemer at the Office of Management 
and Budget, Desk Officer for DoD, Room 10236, New Executive Office 
Building, Washington, DC 20503.
    DOD Clearance Officer: Ms.Patricia Toppings.
    Written requests for copies of the information collection proposal 
should be sent to Ms. Toppings, WHS/ESD/Information Management 
Division, 1225 South Clark Street, Suite 504, Arlington, VA 22202-4326.

    Dated: June 15, 2005.
Patricia L.Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 05-12507 Filed 6-23-05; 8:45 am]
BILLING CODE 5001-06-M