[Federal Register Volume 74, Number 196 (Tuesday, October 13, 2009)]
[Notices]
[Page 52460]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-24503]


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DEPARTMENT OF DEFENSE

Office of the Secretary

[Docket ID: DoD-2009-HA-0144]


Proposed Collection; Comment Request

AGENCY: Office of the Assistant Secretary of Defense for Health 
Affairs, DoD.

ACTION: Notice.

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SUMMARY: In compliance 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 extension of a public 
information collection and seeks public comment on the provisions 
thereof. Comments are invited on: 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; the accuracy of the agency's estimate of the 
burden of the proposed information collection; ways to enhance the 
quality, utility, and clarity of the information to be collected; and 
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: Consideration will be given to all comments received December 
14, 2009.

ADDRESSES: You may submit comments, identified by document number and 
title, by any of the following methods:
     Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
     Mail: Federal Document Management System Office, 1160 
Defense Pentagon, Washington, DC 20301-1160.
    Instructions: All submissions received must include the agency 
name, docket number, and title for this Federal Register document. The 
general policy for comments and other submissions from members of the 
public is to make these submissions available for public viewing on the 
Internet at http://www.regulations.gov as they are received without 
change, including any personal identifiers or contact information.

FOR FURTHER INFORMATION CONTACT: To request more information on this 
proposed information collection or to obtain a copy of the proposal and 
associated collection instruments, please write to the TRICARE 
Management Activity, Performance Evaluation and Transition Management 
Branch, ATTN: [John J.M. Leininger], Aurora, CO 80011-9066 or call 
TRICARE Management Activity, Performance Evaluation and Transition 
Management Branch at (303) 676-3613.
    Title, Associated Form, and OMB Number: TRICARE DoD/CHAMPUS Medical 
Claim Patient's Request for Medical Payment, DD Form 2642, OMB Number 
0720-0006.
    Needs and Uses: This form is used solely by beneficiaries claiming 
reimbursement for medical expenses under the TRICARE Program. The 
information collected will be used by TRICARE/CHAMPUS to determine 
beneficiary eligibility, other health insurance eligibility, 
certification of the beneficiary eligibility and other health insurance 
liability, certification that the beneficiary received the care, and 
reimbursement for the medical services received.
    Affected Public: Individual or households.
    Annual Burden Hours: 750,000.
    Number of Respondents: 3,000,000.
    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 
TRICARE Program. 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 Homeland Security (Coast Guard) sponsors, and certain 
North Atlantic Treaty Organizations, National Oceanic and Atmospheric 
Administration, and Public Health Service eligible beneficiaries. DD 
Form 2642 is used solely by TRICARE/CHAMPUS beneficiaries to file for 
reimbursement of costs paid to providers and suppliers for authorized 
health care services or supplies.

    Dated: October 2, 2009.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. E9-24503 Filed 10-9-09; 8:45 am]
BILLING CODE 5001-06-P