[Federal Register Volume 61, Number 47 (Friday, March 8, 1996)] [Notices] [Pages 9439-9440] From the Federal Register Online via the Government Publishing Office [www.gpo.gov] [FR Doc No: 96-5553] ======================================================================= ----------------------------------------------------------------------- DEPARTMENT OF DEFENSE Office of the Secretary Proposed Collection; Comment Request AGENCY: Office of the Assistant Secretary of Defense for Health Affairs. ACTION: Notice. ----------------------------------------------------------------------- In accordance 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 reinstatement of a public information collection and seeks public comment on the provisions thereof. Comments are invited on: (a) whether the proposed extension of 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 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: Considerations will be given to all comments received May 7, 1996. ADDRESSES: Written comments and recommendations on the proposed information collection should be sent to the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS), Fitzsimons Army Medical Center, Program Development Branch, ATTN: Mr. Graham Kolb, Aurora, CO 80045-6900. FOR FURTHER INFORMATION CONTACT: To request more information on this proposed information collection, please write to the above address or call, OCHAMPUS, Program Requirements Branch at (303) 361-1180. TITLE, ASSOCIATED FORM, AND OMB NUMBER: CHAMPUS Claim--Patient's Request for Medical Payment; DD Form 2642; OMB Number: 0720-0006. needs and uses: This form is used by beneficiaries claiming reimbursement for medical expenses under the Civilian Health and Medical Program of the Uniformed Services (TRICARE/CHAMPUS). The information collected will be used by TRICARE/CHAMPUS to determine beneficiary eligibility, other health insurance liability and certification that the beneficiary received the care. Affected Public: Individuals or households [[Page 9440]] Annual Burden Hours: 812,500 Number of Respondents: 3,250,000 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 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 Uniformed Services members 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. DD Form 2642 is used by TRICARE/CHAMPUS beneficiaries to file for reimbursement of costs paid to providers and suppliers for authorized health care service supplies. Dated: March 5, 1996. Patricia L. Toppings, Alternate OSD Federal Register Liaison Officer, Department of Defense. [FR Doc. 96-5553 Filed 3-7-96; 8:45 am] BILLING CODE 5000-04-M