Third Party Collection Program/Medical Services Account/Other Health Insurance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance	Form	New	Repair queued
DD Form 2569 SSN Justification dtd 6 25 10.pdf	Supplementary Document	Uploaded 2013-03-28	Repair queued
OMB_83I Supporting Document_03272013_WHS revisions.doc	Supporting Statement A	Uploaded 2013-03-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206286	Third Party Collection Program/Medical Services Account/Other Health Insurance	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201303-0720-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Third Party Collection Program/Medical Services Account/Other Health Insurance
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 04/24/2013
	Date Received in OIRA: 03/28/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The 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 commercial/civilian health insurance. This form will provide the necessary information from these patients to allow MTFs to submit claims for services to insurers.

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Authorizing Statute(s): US Code: 10 USC 1095 Name of Law: null
   PL: Pub.L. 99 - 272 2001 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 74176	12/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 18325	03/26/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Third Party Collection Program/Medical Services Account/Other Health Insurance	DD Form 2569	Third Party Collection Program/Medical Services Account/Other Health Insurance

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is an extension of a collection previously approved under OMB Control Number 0704-0323. The Department is submitting this under the 0720 agency code to properly allign it with the component having responsibility for the collection. The department is decreasing its previous burden of 175,370 by 28,525 to the current burden of 146,845. This is due to a decrease in the number of respondents.

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Annual Cost to Federal Government: $2,320,155

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/28/2013

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