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 August 2, 2006.
Title, Form and OMB Number: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment; DD Form 2642; OMB Control Number 0720-0006.Start Printed Page 37911
Type of Request: Extension.
Number of Respondents: 2,400,000.
Responses per Respondent: 1.
Annual Responses: 2,400,000.
Average Burden per Response: 15 minutes.
Annual Burden Hours: 600,000.
Needs and Uses: The 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 liability, certification that the beneficiary received the case, and reimbursement for the medical services received.
Affected Public: Individuals and households.
Frequency: On occasion.
Respondent's Obligation: Required to obtain or retain benefits.
OMB Desk Officer: Mr. John Kraemer.
Written comments and recommendations on the proposed information collection should be sent to Mr. Kraemer at the Office of Management and Budget, DoD Health Desk Officer, Room 10102, New Executive Office Building, Washington, DC 20503.
You may also submit comments, identified by docket 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 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. Patricia Toppings.
Written requests for copies of the information collection proposal should be sent to Ms. Toppings at WHS/ESD/Information Management Division, 1777 North Kent Street, RPN, Suite 11000, Arlington, VA 22209-2133.Start Signature
Dated: June 26, 2006.
Patricia L. Toppings,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 06-5948 Filed 6-30-06; 8:45 am]
BILLING CODE 5001-06-M