Federal Register / Vol. 77, No. 31 / Wednesday, February 15, 2012 / Notices 8821 

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 TRICARE Management 

Activity, Purchased Care Procurement 

Branch, 16401 E. Centretech Parkway, 

Aurora, CO 80011–9066, or telephone 

(303) 676–3613. 

Title; Associated Form; and OMB 

Number: Health Insurance Claim Form, 

UB–04 CMS–1450, OMB Number 0720– 

0013. 

Needs and Uses: The information 

collection requirement is necessary for a 

medical institution to claim benefits 

under the Defense Health Program, 

TRICARE, which includes the Civilian 

Health and Medical Program for the 

Uniform Services (CHAMPUS). The 

information collected will be used by 

TRICARE/CHAMPUS to determine 

beneficiary eligibility, other health 

insurance liability, certification that the 

beneficiary received the care, and that 

the provider is authorized to receive 

TRICARE/CHAMPUS payments. The 

form will be used by TRICARE/ 

CHAMPUS and its contractors to 

determine the amount of benefits to be 

paid to TRICARE/CHAMPUS 

institutional providers. 

Affected Public: Business or other for 

profit; not-for-profit institutions. 

Annual Burden Hours: 2,125,000. 

Number of Respondents: 8,500,000. 

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 medical institutions filing for 

reimbursement with the Defense Health 

Program, TRICARE, which includes the 

Civilian Health and Medical Program of 

the Uniformed Services (TRICARE/ 

CHAMPUS). TRICARE/CHAMPUS is a 

health benefits entitlement program for 

the dependents of active duty members 

of the Uniformed Service, and deceased 

sponsors, retirees and their dependents, 

dependents of department of 

transportation (Coast Guard) sponsors, 

and certain North Atlantic treaty 

Organization, National Oceanic and 

Atmospheric Administration, and 

Public Health Service eligible 

beneficiaries. Use of the UB–04 

CMS1450 continues TRICARE/ 

CHAMPUS commitments to use the 

national standard claim form for 

reimbursement of medical services/ 

supplies provided by institutional 

providers. 

Dated: January 31, 2012. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. 2012–3517 Filed 2–14–12; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

[Docket No. DoD–2008–OS–0016] 

Proposed Collection; Comment 

Request 

AGENCY: Defense Finance and 

Accounting Service, DoD. 

ACTION: Notice. 

SUMMARY: In compliance with Section 

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

Reduction Act of 1995, the Defense 

Finance and Accounting Service 

announces a 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 estimation 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 March 26, 2012. 

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, 

2nd Floor, 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 Disbursing 

Management Policy Division, Defense 

Finance and Accounting Service Kansas 

City, DFAS–NPD/KC, 1500 E. 95th 

Street, Kansas City, MO 64197–0030, or 

call at (816) 926–3600. 

Title, Associated Form, and OMB 

Number: Application Form for 

Department of Defense (DoD) Stored 

Value Card (SVC) Programs; DD Form 

2887; OMB Control Number 0730–0016. 

Needs and Uses: Department of 

Defense (DoD) Financial Management 

Regulation 7000.14–R, Volume 5, 

requires that eligible individuals 

desiring to enroll in the Navy/Marine 

Corps Cash and the EagleCash program 

complete the DD Form 2887. Also used 

to authorize the transfer of funds from 

their personal bank accounts to the SVC 

for the Navy/Marine Cash Program and 

to provide a means to effect immediate 

checkage of the individual’s pay if a 

debt occurs. 

Affected Public: Individuals or 

Households; Business or Other ForProfit; Not-for-Profit Institutions; State, 

Local or Tribal Government. 

Annual Burden Hours: 7,416 hours. 

Number of Respondents: 44,500. 

Responses Per Respondent: 1. 

Average Burden Per Response: 10 

minutes. 

Frequency: On occasion. 

SUPPLEMENTARY INFORMATION: 

Summary of Information Collection 

The Application Form for DoD SVC 

Programs is used to ascertain pertinent 

information needed by DoD in order to 

have the authorization for the transfer of 

funds from a financial institution to the 

SVC and to obtain an agreement from 

the individual for the immediate 

checkage of their pay in the event a debt 

to the United States Government occurs. 

Dated: January 31, 2012. 

Patricia L. Toppings, 

OSD Federal Register Liaison Officer, 

Department of Defense. 

[FR Doc. 2012–3519 Filed 2–14–12; 8:45 am] 

BILLING CODE 5001–06–P 


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