[Federal Register Volume 80, Number 19 (Thursday, January 29, 2015)]
[Notices]
[Pages 4906-4907]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-01655]


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DEPARTMENT OF DEFENSE

Office of the Secretary

[Docket ID: DoD-2014-HA-0085]


Submission for OMB Review; Comment Request

ACTION: Notice.

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SUMMARY: The Department of Defense has submitted to OMB for clearance, 
the following proposal for collection of information under the 
provisions of the Paperwork Reduction Act.

DATES: Consideration will be given to all comments received by March 2, 
2015.

FOR FURTHER INFORMATION CONTACT: Fred Licari, 571-372-0493.

SUPPLEMENTARY INFORMATION: 
    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.
    Type of Request: Reinstatement.
    Number of Respondents: 774,000.
    Responses per Respondent: 1.
    Annual Responses: 774,000.
    Average Burden per Response: 15 minutes.
    Annual Burden Hours: 193,500.
    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.
    Frequency: On occasion.
    Respondent's Obligation: Voluntary.
    OMB Desk Officer: Mr. Joshua Brammer.
    Written comments and recommendations on the proposed information 
collection should be sent to Mr. Joshua Brammer at the Office of 
Management and Budget, Desk Officer for DoD, Room 10236, New Executive 
Office Building, Washington, DC 20503.
    You may also submit comments, identified by docket number and 
title, by the following method:
    <bullet> Federal eRulemaking Portal: http://www.regulations.gov. 
Follow the instructions for submitting comments.
    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.
    DOD Clearance Officer: Mr. Frederick Licari.
    Written requests for copies of the information collection proposal 
should be sent to Mr. Licari at WHS/ESD Directives Division, 4800 Mark 
Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.


[[Page 4907]]


    Dated: January 26, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-01655 Filed 1-28-15; 8:45 am]
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