Third Party Collection Program (Insurance Information)

Forms and Documents

Document Name	Status
Form DD-2569 Third Party Collection Program (Insurance Information) Form	Modified
DHA 12.docx Supplementary Document	2013-04-30
DD Form 2569 SSN Justification dtd 6 25 10.pdf Supplementary Document	2013-04-29
OMB_83I Supporting Document_03272013_WHS revisions.doc Supporting Statement A	2013-04-29

IC Document Collections

IC ID	Document Title	Status
5378	Third Party Collection Program (Insurance Information) Form	Modified

ICR Details

OMB Control No: 0720-0055	ICR Reference No: 201304-0720-003
Status: Historical Active	Previous ICR Reference No: 201304-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Third Party Collection Program (Insurance Information)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2013
	Date Received in OIRA: 04/30/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	06/30/2013
Responses	2,936,905	0	3,507,390
Time Burden (Hours)	146,845	0	175,370
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 10 USC 1095 Name of Law: null
   US Code: 10 USC 1079b 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 74175	12/13/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 18342	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

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

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ICR Summary of Burden

	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	2,936,905	3,507,390	0	0	-570,485	0
Annual Time Burden (Hours)	146,845	175,370	0	0	-28,525	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: The estimated total burden hours for collecting the information requested on this form has been reduced to more accurately reflect the volume of the collection. The information collected on this form is not required for active duty service members (including National Guard members and reservists on active duty) or beneficiaries receiving care at locations other than an MTF. Number of persons receiving care in MTFs has decreased. Therefore, an adjustment to the number of respondents has been made accordingly. The reduced burden hours will support information collection from all eligible beneficiaries.

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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: 04/30/2013

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