[Federal Register Volume 84, Number 168 (Thursday, August 29, 2019)]
[Notices]
[Page 45477]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-18627]


-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary

[Docket ID DoD-2019-HA-0074]


Submission for OMB Review; Comment Request

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

ACTION: 30-Day information collection notice.

-----------------------------------------------------------------------

SUMMARY: 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.

DATES: Consideration will be given to all comments received by 
September 30, 2019.

ADDRESSES: Comments and recommendations on the proposed information 
collection should be emailed to Mr. Josh Brammer, DoD Desk Officer, at 
[email protected]. Please identify the proposed information 
collection by DoD Desk Officer, Docket ID number, and title of the 
information collection.

FOR FURTHER INFORMATION CONTACT: Angela James, 571-372-7574, or [email protected].

SUPPLEMENTARY INFORMATION: 
    Title; Associated Form; and OMB Number: Third Party Collection 
Program (Insurance Information); DD Form 2569; OMB Control Number 0720-
0055.
    Type of Request: Extension.
    Number of Respondents: 3,940,000.
    Responses per Respondent: 1.5.
    Annual Responses: 5,910,000.
    Average Burden per Response: 4 minutes.
    Annual Burden Hours: 394,000.
    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.
    Frequency: On occasion.
    Respondent's Obligation: Voluntary.
    OMB Desk Officer: Mr. Josh Brammer.
    You may also submit comments and recommendations, identified by 
Docket ID number and title, by the following method:
     Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
    Instructions: All submissions received must include the agency 
name, Docket ID 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.
    DOD Clearance Officer: Ms. Angela James.
    Requests for copies of the information collection proposal should 
be sent to Ms. James at [email protected].

    Dated: August 23, 2019.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2019-18627 Filed 8-28-19; 8:45 am]
 BILLING CODE 5001-06-P