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###### Department of Defense

###### Office of the Secretary

          - [Docket ID: DoD-2009-HA-0144]

# 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: 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; 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.

# DATES:

Consideration will be given to all comments received December 14, 2009.

# 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 Document 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                         *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 the TRICARE Management Activity, Performance Evaluation and Transition Management Branch, ATTN: [John J.M. Leininger], Aurora, CO 80011-9066 or call TRICARE Management Activity, Performance Evaluation and Transition Management Branch at (303) 676-3613.

*Title, Associated Form, and OMB Number:*                         TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment, DD Form 2642, OMB Number 0720-0006.                    

*Needs and Uses:*                         This form is used solely by beneficiaries claiming 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:*                         Individual 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.                    

# SUPPLEMENTARY INFORMATION:

## 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 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: October 2, 2009.

Patricia L. Toppings,

OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. E9-24503 Filed 10-9-09; 8:45 am]

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