Third-Party Collection Program, Insurance Information

ICR 199705-0704-001

OMB: 0704-0323

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
5376 Migrated
ICR Details
0704-0323 199705-0704-001
Historical Active 199409-0704-002
DOD/DODDEP
Third-Party Collection Program, Insurance Information
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 06/25/1997
Retrieve Notice of Action (NOA) 05/16/1997
  Inventory as of this Action Requested Previously Approved
09/30/2000 09/30/2000
74,224 0 0
3,043 0 0
0 0 0

DoD is required to collect from third-party payers the cost of inpatient hospitalization provided to retirees, dependents, and others utilizing the services of Military Treatment Facilities (MTFs) who have private health insurance. The funds collected will be used to enhance the services provided in the MTF that provided the original care. This form is designed to solicit information from beneficiaries concerning their health insurance coverage.

None
None


No

1
IC Title Form No. Form Name
Third-Party Collection Program, Insurance Information DD-2569

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 74,224 0 0 74,224 0 0
Annual Time Burden (Hours) 3,043 0 0 3,043 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
05/16/1997


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