SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION
Statement of Personal Injury – Possible Third Party Liability (DD Form 2527).
1. Need and Use
The Federal Medical
Care Recovery Act, 42 U.S.C. 2651-2653 as implemented by Executive
Order No. 1060 and 28 CFR 43 provides for recovery of the reasonable
value of medical care provided by the United States to a person who
is injured or suffers a disease under circumstances creating tort
liability in some third person.
DD Form 2527 is required for
investigating and asserting claims in favor of the United States
arising out of such incidents.
When a claim for
CHAMPUS benefits is identified as involving possible third party
liability and the information is not submitted with the claim the
TRICARE/ CHAMPUS contractors request that the injured party (or a
designee) complete
DD Form 2527. To protect the interests of
the Government the contractor suspends claims processing until the
requested third party liability information is received. The
contractor conducts a preliminary evaluation based upon the
collection of information and refers the case to a designated
appropriate legal officer of the Uniformed Services. The responsible
Uniformed Services legal officer uses the information as a basis for
asserting and settling the Government’s claim. When
appropriate the information is forwarded to the Department of Justice
as the basis for litigation.
2. Purpose and users of the information.
Section 1 of the Form is used to collect general information, such as name, address and telephone numbers about the military sponsor and the injured beneficiary and the date, time and location where the injury occurred.
Section 2 of the Form is used to collect information about motor vehicle accidents. Most of the investigations for possible third party liability involve motor vehicle accidents. Information about insurance coverage of the parties and whether the accident was work related is collected. Section 2 of the Form is also used to collect information about accidents that do not involve motor vehicles. Information such as the type of accident, the place where the injury occurred, the name of the property owner where the injury occurred and the cause of the injury is collected. The name and address of the employer is collected when the injury was work related.
Section 3 of the Form is used to collect miscellaneous information such as possible medical treatment at a Government hospital, the name and address of the beneficiary’s attorney, and information regarding any possible releases or settlements with another party to the accident. It also contains the certification, date and signature of the beneficiary (or a designee).
3. Information Collection Techniques
There are currently no information technology techniques available as alternatives to reduce the burden. This form is used to collect specific factual information unique to individual beneficiaries.
There is a fillable
pdf form on the DoD forms Web site at
:
http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm
4. Duplication and Similar Information
Duplicate information may be available in the form of police reports, and the form allows substitution of the police report for information duplicated on the form.
5. Small Business
No small business or other small entities are involved in this collection of information.
6. Less Frequent Collections
The collection can be conducted no less frequently than once, upon occurrence of the accidental injury.
7. Special Circumstances
There are no special circumstances that require the collection to be conducted in a manner consistent with the guidelines in 5 CFR 1320.5(d)(2).
8. Federal Register Notice
The Federal Register Notice for this collection of information was published on April 10, 2007 (Vol. 72, No.68, p. 17877 & 17878). Copy attached. No public comments were received on this collection.
9. Payment/Gifts to Respondents
No payments or gifts will be provided respondents other than the initial remuneration of claims by contractors.
10. Confidentiality
There is no specific statement of assurance of confidentiality. However, the form contains the necessary Privacy Act disclosures and statements.
SSN is needed for identification/tracking purposes. To date the Department has made no decisions on the use of another unique identifier.
11. Sensitive Questions
There are no questions of a sensitive nature.
12. Burden estimate (hour)
The total hour burden for the respondents of 33,250 hours is based on an annual projected use of 133,000. The burden is based on an estimate of 20 minutes to complete the form. The annual burden hours calculated as follows:
Respondents: 133,000
Response time: 0.20
Response Frequency: (on occasion)
Burden Hours: 33,250
Annualized cost to respondents is estimated at $54,530.00 based upon postage costs for 133,000 respondents.
Cost to Respondents
There is no additional cost to the respondents.
Cost to Federal Government
Costs to the Federal Government are indirect as the form is processed by government contractors. This indirect cost is estimated to be $6,650,000.00 at $50.00 per form processed. This cost is offset by the millions of dollars collected by the uniformed services under the Federal Medical Case Recovery Act.
15. Change in Burden
This is an extension of a previously approved collection.
16. Publication/Tabulation
There are no plans to publish or tabulate the information collected.
17. Expiration Date
Approval is not sought for avoiding display of the expiration date.
18. Certification Statement
There are no exceptions to the certification statement in Item 19, “Certification for
Paperwork reduction Act Submission,” of OMB Form 83-1.
Utilize any statistical methods.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION |
| Author | OCHAMPUS |
| Last Modified By | pltoppings |
| File Modified | 2007-08-31 |
| File Created | 2007-06-06 |