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Proposed Collection; Comment Request

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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.


Consideration will be given to all comments received by January 28, 2013.


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, 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 as they are received without change, including any personal identifiers or contact information.


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.


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]