Proposed Collection; Comment Request, 71175 [2012-28862]
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Federal Register / Vol. 77, No. 230 / Thursday, November 29, 2012 / Notices
To
request more information on this
proposed information collection or to
obtain a copy of the proposal and
associated collection instruments,
please write to TRICARE Management
Activity Program, Policy and Benefits
Branch, ATTN: Mr. Mark Ellis, 5111
Leesburg Pike, Suite 810, Falls Church,
VA 22041–3206, or call 703–681–0039.
Title; Associated Form; and OMB
Number: Continued Health Care Benefit
Program, DD Form 2837; OMB Number
0720–TBD (previously cleared under
OMB Control Number 0704–0364).
Needs and Uses: The continuing
information collection requirement is
necessary for individuals to apply for
enrollment in the Continued Health
Care Benefit Program (CHCBP). The
CHCBP is a program of temporary health
care benefit coverage that is made
available to eligible individuals who
lose health care coverage under the
Military Health System (MHS).
Affected Public: Individuals or
households.
Annual Burden Hours: 625.
Number of Respondents: 2,500.
Responses per Respondent: 1.
Average Burden per Response: .25
hours.
Frequency: On occasion.
FOR FURTHER INFORMATION CONTACT:
SUPPLEMENTARY INFORMATION:
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Summary of Information Collection
Respondents are individuals who are
or were beneficiaries of the Military
Health System (MHS) and who desire to
enroll in the CHCBP following their loss
of eligibility or entitlement to health
care coverage in the MHS. These
beneficiaries include any person
formerly eligible for care from the MHS
according to Chapter 55 or Section
1145a of Title 10, United States Code.
In order to be eligible for health care
coverage under CHCBP, an individual
must first enroll in CHCBP. DD Form
2837 is used as the information
collection vehicle for that enrollment.
The CHCBP is a legislatively mandated
program and it is anticipated that the
program will continue indefinitely. As
such, the DoD is publishing this formal
notice.
Dated: November 26, 2012.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2012–28864 Filed 11–28–12; 8:45 am]
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DEPARTMENT OF DEFENSE
Office of the Secretary
[Docket ID DoD–2012–HA–0141]
Proposed Collection; Comment
Request
Office of the Assistant
Secretary of Defense for Health Affairs,
DoD.
ACTION: Notice.
AGENCY:
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: (a) 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; (b) the accuracy of the
agency’s estimate of the burden of the
proposed information collection; (c)
ways to enhance the quality, utility, and
clarity of the information to be
collected; and (d) 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 January 28, 2013.
ADDRESSES: You may submit comments,
identified by docket number and title,
by any of the following methods:
• Federal eRulemaking Portal: https://
www.regulations.gov. Follow the
instructions for submitting comments.
• Mail: Federal Docket Management
System Office, 4800 Mark Center Drive,
East Tower, Suite 02G09, Alexandria,
VA 22350–3100.
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 https://
www.regulations.gov as they are
received without change, including any
personal identifiers or contact
information.
SUMMARY:
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, Medical Benefits
and Reimbursement Branch (MB&RB),
FOR FURTHER INFORMATION CONTACT:
PO 00000
Frm 00009
Fmt 4703
Sfmt 9990
71175
ATTN: Amber L. Butterfield, 16401 E.
Centretech Parkway, Aurora, CO 80011–
9066, or call TRICARE, MB&RB, at (303)
676–3565.
Title; Associated Form; and OMB
Number: TRICARE DoD/CHAMPUS
Medical Claim—Patient’s Request for
Medical Reimbursement; DD Form
2642; OMB Control Number 0720–0006.
Needs and Uses: This form is used
solely by beneficiaries requesting
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: Individuals 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 the
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: November 26, 2012.
Aaron Siegel,
Alternate OSD Federal Register Liaison
Officer, Department of Defense.
[FR Doc. 2012–28862 Filed 11–28–12; 8:45 am]
BILLING CODE 5001–06–P
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]]>Agencies
[Federal Register Volume 77, Number 230 (Thursday, November 29, 2012)]
[Notices]
[Page 71175]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-28862]
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DEPARTMENT OF DEFENSE
Office of the Secretary
[Docket ID DoD-2012-HA-0141]
Proposed Collection; Comment Request
AGENCY: Office of the Assistant Secretary of Defense for Health
Affairs, DoD.
ACTION: Notice.
-----------------------------------------------------------------------
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: (a) 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; (b) the accuracy of the agency's estimate of the burden of the
proposed information collection; (c) ways to enhance the quality,
utility, and clarity of the information to be collected; and (d) 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 January
28, 2013.
ADDRESSES: You may submit comments, identified by docket number and
title, by any of the following methods:
Federal eRulemaking Portal: https://www.regulations.gov.
Follow the instructions for submitting comments.
Mail: Federal Docket Management System Office, 4800 Mark
Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.
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 https://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, Medical Benefits and Reimbursement Branch (MB&RB),
ATTN: Amber L. Butterfield, 16401 E. Centretech Parkway, Aurora, CO
80011-9066, or call TRICARE, MB&RB, at (303) 676-3565.
Title; Associated Form; and OMB Number: TRICARE DoD/CHAMPUS Medical
Claim--Patient's Request for Medical Reimbursement; DD Form 2642; OMB
Control Number 0720-0006.
Needs and Uses: This form is used solely by beneficiaries
requesting 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: Individuals 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 the
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: November 26, 2012.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2012-28862 Filed 11-28-12; 8:45 am]
BILLING CODE 5001-06-P
