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.
Consideration will be given to all comments received by March 2, 2015.
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FOR FURTHER INFORMATION CONTACT:
Fred Licari, 571-372-0493.
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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.
Type of Request: Reinstatement.
Number of Respondents: 774,000.
Responses per Respondent: 1.
Annual Responses: 774,000.
Average Burden per Response: 15 minutes.
Annual Burden Hours: 193,500.
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.
Frequency: On occasion.
Respondent's Obligation: Voluntary.
OMB Desk Officer: Mr. Joshua Brammer.
Written comments and recommendations on the proposed information collection should be sent to Mr. Joshua Brammer at the Office of Management and Budget, Desk Officer for DoD, Room 10236, 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 http://www.regulations.gov as they are received without change, including any personal identifiers or contact information.
DOD Clearance Officer: Mr. Frederick Licari.
Written requests for copies of the information collection proposal should be sent to Mr. Licari at WHS/ESD Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.
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Dated: January 26, 2015.
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-01655 Filed 1-28-15; 8:45 am]
BILLING CODE 5001-06-P