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[Federal Register Volume 77, Number 230 (Thursday, November 29, 2012)]
[Notices]
[Page 71175]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-28862]

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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.

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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
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