Federal Register / Vol. 75, No. 247 / Monday, December 27, 2010 / Notices 81241 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

[Docket ID DOD–2010–HA–0176] 

Proposed Collection; Comment 

Request 

AGENCY: Office of the Assistant 

Secretary of Defense for Health Affairs, 

DoD. 

ACTION: Notice. 

SUMMARY: 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. 

DATES: Consideration will be given to all 

comments received by February 25, 

2011. 

ADDRESSES: You may submit comments, 

identified by docket number and title, 

by any of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Federal Docket Management 

System Office, Room 3C843, 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 http:// 

www.regulations.gov as they are 

received without change, including any 

personal identifiers or contact 

information. 

FOR FURTHER INFORMATION CONTACT: To 

request more information on this 

proposed information collection or to 

obtain a copy of the proposal and 

associated collection instruments, 

please write to Appeals, Hearings and 

Claims Collection Division, Office of 

General Counsel, TRICARE®

Management Activity, Attn: Mark P. 

Donahue, 16401 East Centretech 

Parkway, Aurora, CO 80011–9066, or 

via telephone at (303) 676–3411. 

Title; Associated Form; and OMB 

Number: Professional Qualifications 

Medical/Peer Reviewers, CHAMPUS 

Form 780, OMB Number 0720–0005. 

Needs and Uses: The information 

collection requirement is necessary to 

obtain and record the professional 

qualifications of medical and peer 

reviewers utilized within TRICARE®. 

The form is included as an exhibit in an 

appeal or hearing case file as evidence 

of the reviewer’s professional 

qualifications to review the medical 

documentation contained in the case 

file. 

Affected Public: Business or other for 

profit. 

Annual Burden Hours: 20. 

Number of Respondents: 60. 

Responses per Respondent: 1. 

Average Burden per Response: 20 

minutes. 

Frequency: On occasion. 

SUPPLEMENTARY INFORMATION: 

Summary of Information Collection 

Respondents are medical 

professionals who provide medical and 

peer review of cases appealed to the 

Appeals, Hearings and Claims 

Collection Division, Office of General 

Counsel, TRICARE® Management 

Activity. CHAMPUS Form 780 records 

the professional qualifications of the 

medical or peer reviewer. The 

completed form is included as an 

exhibit in the appeal or hearing case file 

to document the professional 

qualifications of the medical 

professional who reviewed the case. If 

the form is not included in the case file, 

individuals reviewing the file cannot 

confirm the qualifications of the 

reviewing medical professional. Having 

qualified professionals provide medical 

and peer review is essential in 

maintaining the integrity of the appeal 

and hearing process. 

Dated: December 20, 2010. 

Morgan F. Park, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2010–32394 Filed 12–23–10; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

[Docket ID DOD–2010–OS–0175] 

Proposed Collection; Comment 

Request 

AGENCY: Office of the Assistant 

Secretary of Defense for Health Affairs, 

DoD. 

ACTION: Notice. 

SUMMARY: In accordance 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 currently approved 

collection and seeks public comment on 

the provisions thereof. Comments are 

invited on: (a) Whether the proposed 

extension of 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 

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. 

DATES: Consideration will be given to all 

comments received by February 25, 

2011. 

ADDRESSES: You may submit comments, 

identified by document number and 

title by any of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Federal Docket Management 

System Office, Room 3C843, 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 http:// 

www.regulations.gov as they are 

received without change, including any 

personal identifiers or contact 

information. 

FOR FURTHER INFORMATION CONTACT: To 

request more information on this 

proposed information collection, please 

write to the TRICARE Management 

Activity—Aurora, Performance 

Evaluation and Transition Management 

Branch, 16401 E. Centretech Parkway, 


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81242 Federal Register / Vol. 75, No. 247 / Monday, December 27, 2010 / Notices 

Attn; John J.M. Leininger, Aurora, CO 

80011–9066 or call TRICARE 

Management Activity—Aurora, 

Performance Evaluation and Transition 

Management Branch, at (303) 676–3613. 

Title, Associated Form and OMB 

Number: Health Insurance Claim Form, 

CMS–1500, OMB Control Number 

0720–0001. 

Needs and Uses: This information 

collection requirement is used by 

TRICARE to determine reimbursement 

for health care services or supplies 

rendered by individual professional 

providers to TRICARE beneficiaries. The 

requested information is used to 

determine beneficiary eligibility, 

appropriateness and costs of care, other 

health insurance liability and whether 

services received are benefits. Use of 

this form continues TRICARE’s 

commitment to use the national 

standard claim form for reimbursement 

of services/supplies provided by 

individual professional providers. 

Affected Public: Business or other for 

profit institutions, not-for-profit 

institutions, Federal government, state, 

local or tribal government. 

Annual Burden Hours: 21,500,000. 

Number of Respondents: 86,000,000. 

Responses per Respondent: 1. 

Average Burden per Response: 15 

minutes. 

Frequency: On occasion. 

SUPPLEMENTARY INFORMATION: 

Summary of Information Collection 

This collection instrument is for use 

by health care providers under the 

TRICARE Program. TRICARE is a health 

benefits entitlement program for active 

duty, the dependents of active duty 

Uniformed Services members and 

deceased sponsors, retirees and their 

dependents, dependents of Department 

of Homeland Security (Coast Guard) 

sponsors, and certain North Atlantic 

Treaty Organizations, National Oceanic 

and Atmospheric Administration, and 

Public Health Service eligible 

beneficiaries. The CMS–1500 Form is 

used by individual professional health 

care or health care related providers to 

file for reimbursement of civilian health 

care services or supplies provided to 

TRICARE beneficiaries. This is the 

national standard claim form accepted 

by all major commercial and 

government payers. 

Dated: December 20, 2010. 

Morgan F. Park, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2010–32393 Filed 12–23–10; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

[Docket ID DOD–2010–HA–0177] 

Proposed Collection; Comment 

Request 

AGENCY: Office of the Assistant 

Secretary of Defense for Health Affairs, 

DoD. 

ACTION: Notice. 

SUMMARY: In compliance with Section 

3506(c)(2)(A) of the Paperwork 

Reduction Act of 1995, the Naval Health 

Research Center (NHRC), Department of 

the Navy, announces a new 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. 

DATES: Consideration will be given to all 

comments received by February 25, 

2011. 

ADDRESSES: You may submit comments, 

identified by docket number and title, 

by any of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Federal Docket Management 

System Office, Room 3C843, 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 http://www.

regulations.gov as they are received 

without change, including any personal 

identifiers or contact information. 

FOR FURTHER INFORMATION CONTACT: To 

request more information on this 

proposed information collection or to 

obtain a copy of the proposal and 

associated collection instruments, 

please write to: Commanding Officer, 

Naval Health Research Center, ATTN: 

Michael Galarneau, MS, NREMT, Code 

161, 140 Sylvester Road, San Diego, CA 

92106, or call at (619) 553–841 (this is 

not a toll-free number). 

Title; Associated Form; and OMB 

Number: Traumatic Brain Injury, PostTraumatic Stress Disorder, and LongTerm Quality of Life Outcomes in 

Injured Tri-Service U.S. Military 

Personnel; OMB Control Number 0720– 

TBD. 

Needs and Uses: The information 

collection requirement is necessary for 

the Naval Health Research Center 

(NHRC) to carry out the research study 

it has been tasked to perform. This 

research study will assess the long-term 

health impact of injury on quality of life 

outcomes in injured tri-service U.S. 

military personnel, with a special focus 

on the effects of traumatic brain injury 

(TBI) and Post-traumatic Stress Disorder 

(PTSD). 

Information collected will be used to 

investigate the long-term effects of 

injury, TBI, and PTSD on the overall 

physical and psychological health of 

military personnel injured in overseas 

contingency operations. Participants 

will respond to a health-related 

questionnaire bi-annually for three to 

six years. Respondents to this study will 

include both active-duty and separated 

members of all branches of the U.S. 

Armed Forces that have been injured 

and that have indicated a desire to 

participate through an Institutional 

Review Board (IRB)-approved informed 

consent process. 

Affected Public: Current and former 

members of the U.S. Armed Forces that 

have been injured in overseas 

contingency operations and that have 

indicated a desire to participate. 

Annual Burden Hours: 3,065 hours. 

Number of Respondents: Approx. 

4,644. 

Responses per Respondent: 2. 

Average Burden per Response: 20 

minutes. 

Frequency: Bi-annual. 

SUPPLEMENTARY INFORMATION: 

Summary of Information Collection 

This information collection is 

necessary for the Naval Health Research 

Center (NHRC) to carry out the research 

study ‘‘TRAUMATIC BRAIN INJURY, 

POST-TRAUMATIC STRESS 

DISORDER, AND LONG-TERM 

QUALITY OF LIFE OUTCOMES IN 

INJURED TRI-SERVICE U.S. MILITARY 

PERSONNEL.’’ NHRC has been tasked 

by the office of Congressionally Directed 

Medical Research Programs (CDMRP) to 

conduct this longitudinal 

epidemiological study. The NHRC team 

will collect information about physical 

and psychological health from members 

of the U.S. Armed Forces that have been 


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