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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 January 16, 2007.

Title, Form and OMB Number: Third Party Collection Program/Medical Services Account/Other Health Insurance; DD Form 2569; OMB Number 0704-0323.

Type of Request: Extension.

Number of Respondents: 2,807,212.

Responses Per Respondent: 1.

Annual Responses: 2,807,212.

Average Burden Per Response: 3 minutes.

Annual Burden Hours: 140,361.

Needs and Uses: The information contained in the DD Form 2569 will be used to collect reimbursement from healthcare insurers for medical care provided to dependents of Active Duty members, military retirees and their dependents, and civilians who present at a Military Treatment Facility (MTF) on an emergency basis, and anyone else who is otherwise eligible for care at the MTF. Such monetary benefits accruing to the MTF will be used to enhance healthcare delivery in the MTF. Information will also be used by MTF staff and CHAMPUS Fiscal Intermediaries to determine eligibility for care, deductibles, and co-payments and by Health Affairs for program planning and management.

Affected Public: Individuals or households.

Frequency: On occasion and annually.

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:

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 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.

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Dated: December 8, 2006.

Patricia L. Toppings,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 06-9720 Filed 12-14-06; 8:45 am]