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Submission for OMB Review; Comment Request

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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).


Consideration will be given to all comments received by March 18, 2004.

Title, Form, and OMB Number: Health Insurance Claim Form (HCFA 1500); OMB Number 0720-0001.

Type of Request: Reinstatement.

Number of Respondents: 22,400,000.

Responses Per Respondent: 1.

Annual Responses: 5,600,000.

Average Burden Per Response: 15 minutes.

Annual Burden Hours: 5,600,000.

Needs and Uses: This information collection is used by TRICARE to determine reimbursement for health care services or supplies rendered by individual professional providers to TRICARE beneficiaries. The requested information is used to determine beneficiary eligibility, appropriations and costs of care, other health insurance liability, and whether services received are benefits. Use of this form continues TRICARE's commitment to use the national standard claim form for reimbursement of services/supplies provided by individual professional providers.

Affected Public: Business or other for-profit.

Frequency: On occasion.

Respondent's Obligation: Required to obtain or retain benefits.

OMB Desk Officer: Ms. Jacqueline Zeiher.

Written comments and recommendations on the proposed information collection should be sent to Ms. Zeiher at the Office of Management and Budget, Desk Officer for DoD, Room 10236, New Executive Office Building, Washington, DC 20503.

DoD Clearance Officer: Ms. Jacqueline Davis.

Written requests for copies of the information collection proposal should be sent to Ms. Davis, WHS/DIOR, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302.

Start Signature

February 9, 2004.

L.M. Bynum,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 04-3290 Filed 2-13-04; 8:45 am]