Third Party Collection Program (Insurance Information)

ICR 201003-0704-001

OMB: 0704-0323

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2010-03-01
IC Document Collections
ICR Details
0704-0323 201003-0704-001
Historical Active 200612-0704-002
DOD/DODDEP
Third Party Collection Program (Insurance Information)
Extension without change of a currently approved collection   No
Regular
Approved without change 03/31/2010
Retrieve Notice of Action (NOA) 03/01/2010
  Inventory as of this Action Requested Previously Approved
03/31/2013 36 Months From Approved 03/31/2010
3,507,390 0 2,807,212
175,370 0 140,361
0 0 0

DOD is required to collect from third party payers the cost of medical care 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 the beneficiaries concerning their health insurance coverage.

US Code: 10 USC 1095 Name of Law: null
   US Code: 10 USC 1079b Name of Law: null
  
None

Not associated with rulemaking

  74 FR 55825 10/29/2009
74 FR 55825 10/29/2009
No

1
IC Title Form No. Form Name
Third Party Collection Program (Insurance Information) DD-2569 Third Party Collection Program/Medical Services Account/Other Health Insurance

  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 3,507,390 2,807,212 0 0 700,178 0
Annual Time Burden (Hours) 175,370 140,361 0 0 35,009 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Adjustment burden due to increase in number of respondents.

$2,735,765
No
No
Uncollected
Uncollected
No
Uncollected
Patricia Toppings 703 696-5284 [email protected]

  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.
03/01/2010


© 2024 OMB.report | Privacy Policy