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Proposed Collection; Comment Request

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Information about this document as published in the Federal Register.

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




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: 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; the accuracy of the agency's estimate of the burden of the proposed information collection; ways to enhance the quality, utility, and clarity of the information to be collected; and 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.


Consideration will be given to all comments received by December 28, 2009.


You may submit comments, identified by docket number and title, by any of the following methods:

  • Federal eRulemaking Portal: Follow the instructions for submitting comments.
  • Mail: Federal Docket Management System Office, 1160 Defense Pentagon, Washington, DC 20301-1160.

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.

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To request more information on this proposed information collection or to obtain a copy of the proposal and associated collection instruments, please write to: TMA Uniform Business Office, OASD(HA)/TMA/Management Control & Financial Studies, 5111 Leesburg Pike, Falls Church, Virginia 22041, Skyline 5, Suite 407—ATTN: DeLisa E. Prater, Program Manager, at 703-681-3492 ext.6757 (DSN 761).

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

Needs and Uses: DoD implemented the Coordination of Benefits Program in FY87 based on authority of 10 U.S.C. 1095, enacted as section 2001 of Public Law 99-272, Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), April 7, 1986, and Uniform Business Office (UBO) Manual 6010.15-M, Military Treatment Facility UBO Manual, April 1997. Under this program, DoD is required to collect from third-party payers the cost of inpatient and outpatient services rendered to military retirees, all dependents, and others who have private health insurance. Part 220 of Title 32 of the Code of Federal Regulations, implements 10 U.S.C. 1095. Specifically, 32 CFR 220.2(d) states that the form must be available to third-party payers upon request. A third-party payer may not request any other assignment of benefits form from the subscriber.

Affected Public: Business or other for profit; Not-for-profit institutions.

Annual Burden Hours: 175,370.

Number of Respondents: 3,507,390.

Responses per Respondent: 1.

Average Burden per Response: 3 minutes.

Frequency: Annually or On occasion (when insurance information changes).

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Summary of Information Collection

The administration has placed increased emphasis upon recovery of health care expenses under Third Party Collection Program, as authorized by title 10, section 1095 and 1097b of the United States Code. Completion of this form, while increasing total burden hours, will aid in increasing revenues (O&M dollars), services and operating efficiency and effectiveness within the Military Health Services system. This information is collected either during the inpatient stay admission and/or discharge process or during the visit when a patient presents for an outpatient procedure.

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Dated: October 23, 2009.

Patricia L. Toppings,

OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. E9-26029 Filed 10-28-09; 8:45 am]