### 71175 Federal Register / Vol. 77, No. 230 / Thursday, November 29, 2012 / Notices

**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 TRICARE Management Activity Program, Policy and Benefits Branch, ATTN: Mr. Mark Ellis, 5111 Leesburg Pike, Suite 810, Falls Church, VA 22041–3206, or call 703–681–0039.

Title; Associated Form; and OMB Number: Continued Health Care Benefit Program, DD Form 2837; OMB Number 0720–TBD (previously cleared under OMB Control Number 0704–0364).

Needs and Uses: The continuing information collection requirement is necessary for individuals to apply for enrollment in the Continued Health Care Benefit Program (CHCBP). The CHCBP is a program of temporary health care benefit coverage that is made available to eligible individuals who lose health care coverage under the Military Health System (MHS).

Affected Public: Individuals or households.

Annual Burden Hours: 625. Number of Respondents: 2,500. Responses per Respondent: 1. Average Burden per Response: .25 hours.

Frequency: On occasion.

**SUPPLEMENTARY INFORMATION :**  Summary of Information Collection

Respondents are individuals who are or were beneficiaries of the Military Health System (MHS) and who desire to enroll in the CHCBP following their loss of eligibility or entitlement to health care coverage in the MHS. These beneficiaries include any person formerly eligible for care from the MHS according to Chapter 55 or Section 1145a of Title 10, United States Code.

In order to be eligible for health care coverage under CHCBP, an individual must first enroll in CHCBP. DD Form 2837 is used as the information collection vehicle for that enrollment. The CHCBP is a legislatively mandated program and it is anticipated that the program will continue indefinitely. As such, the DoD is publishing this formal notice.

Dated: November 26, 2012. Aaron Siegel, Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2012–28864 Filed 11–28–12; 8:45 am]

**BILLING CODE 5001–06–P DEPARTMENT OF DEFENSE** 

**Office of the Secretary**

**[Docket ID DoD–2012–HA–0141]**
**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 January 28, 2013.

**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, 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 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, 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.

**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 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]

**BILLING CODE 5001–06–P**