[Federal Register Volume 84, Number 122 (Tuesday, June 25, 2019)]
[Notices]
[Page 29853]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-13468]


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DEPARTMENT OF DEFENSE

Office of the Secretary

[Docket ID DOD-2019-HA-0074]


Proposed Collection; Comment Request

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

ACTION: Information collection notice.

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SUMMARY: In compliance with the Paperwork Reduction Act of 1995, the 
Defense Health Agency announces a proposed public information 
collection and seeks public comment on the provisions thereof. Comments 
are invited on: Whether the proposed 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 by August 
26, 2019.

ADDRESSES: You may submit comments, identified by docket number and 
title, by any of the following methods:
    Federal eRulemaking Portal: http://www.regulations.gov. Follow the 
instructions for submitting comments.
    Mail: Department of Defense, Office of the Chief Management 
Officer, Directorate for Oversight and Compliance, 4800 Mark Center 
Drive, Mailbox #24, Suite 08D09, Alexandria, VA 22350-1700.
    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 Defense Health 
Agency Uniform Business Office, 8111 Gatehouse Road, Suite 200, Falls 
Church, VA 22042 Attn: DeLisa E. Prater, Program Manager, or call 703-
275-6380.

SUPPLEMENTARY INFORMATION: 
    Title; Associated Form; and OMB Number: Third Party Collection 
Program (Insurance Information); DD Form 2569; OMB Control Number 0720-
0055.
    Needs and Uses: The information collection requirement is necessary 
to obtain health insurance policy information used for coordination of 
health care benefits and billing third party payers and other federal 
agencies for health care provided to their beneficiaries and also to 
civilian non-Uniformed Service beneficiaries for health care provided 
to them. DoD is authorized to collect from third-party payers the cost 
of inpatient and outpatient services rendered to DoD beneficiaries who 
have other health insurance. Military treatment facilities (MTFs) are 
required to make this form available to third-party payers upon 
request. A third-party payer may not request any other assignment of 
benefits form from the subscriber. Also, for civilian non-Uniformed 
Services beneficiary and interagency patients, DD Form 2569 is 
necessary and serves as an assignment of benefits approval to submit 
claims to payers on behalf of the patient and authorization to release 
medical information.
    Affected Public: Individuals or households.
    Annual Burden Hours: 394,000.
    Number of Respondents: 3,940,000.
    Responses per Respondent: 1.5.
    Annual Responses: 5,910,000.
    Average Burden per Response: 4 minutes.
    Frequency: On occasion.

    Dated: June 20, 2019.
Morgan E. Park,
Alternate OSD Federal Register, Liaison Officer, Department of Defense.
[FR Doc. 2019-13468 Filed 6-24-19; 8:45 am]
 BILLING CODE 5001-06-P