Skip to Content


Proposed Collection; Comment Request

Document Details

Information about this document as published in the Federal Register.

Enhanced Content

Relevant information about this document from provides additional context. This information is not part of the official Federal Register document.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.



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 (OASD(HA)) announces a proposed 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 February 11, 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 Uniform Business Office (UBO), OASD(HA)/TRICARE Management Activity/Management Control & Financial Studies, 7700 Arlington Boulevard, Suite 5101, Falls Church, VA 22042, ATTN: DeLisa E. Prater, Program Manager, 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 0720-TBD (previously OMB Control Number 0704-0323).

Needs and Uses: The information collection requirement is necessary to obtain health insurance policy information used for coordination of health care benefits and billing third-party payers. DoD implemented the Third Party Collection Program (TPCP) in FY87 based on the authority granted in 10 U.S.C. 1095 and implemented by 32 CFR 220 in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) (Pub. L. 99-272, section 2001, April 7, 1986). Under the TPCP, DoD is authorized to collect from third-party payers the cost of inpatient and outpatient services rendered to DoD beneficiaries who have other health insurance. Military treatment facilities are required to make this form 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: 146,845.

Number of Respondents: 2,936,905.

Responses per Respondent: 1.

Average Burden per Response: 3 minutes.

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


Summary of Information Collection

The administration has placed an increased emphasis upon recovery of health care expenses under the TPCP, as authorized by 10 U.S.C. 1095 and 1097b. Completion of this form, while increasing total burden hours, will aid in increasing revenue to improve services, operating efficiency and effectiveness within the Military Health System. Funds collected return directly to the operation and maintenance budget of the MTF where the care was delivered and are used to improve the quality of healthcare. Often the funds allow the continuation of programs or purchasing of equipment at the facilities for which there would otherwise not be funding. This information is collected either during the admission and/or discharge process for an inpatient stay or during the registration process for an outpatient visit.

Dated: December 7, 2012.

Aaron Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 2012-30032 Filed 12-12-12; 8:45 am]