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

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 


pmangrum on DSK3VPTVN1PROD with NOTICES