Third Party Collection Program (Insurance Information)

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	Modified	Available
Supporting Statement A 0720-0055.DOC	Supporting Statement A	Uploaded 2016-06-30	Available
DEERS PIA(2).PDF	Supplementary Document	Uploaded 2016-06-29	Available
CHCS - PIA 2015 TC2DD Form 2930PIASections1and206292015(2).PDF	Supplementary Document	Uploaded 2016-06-29	Available
ABACUSDD Form 2930PIASections1and206292015(2).PDF	Supplementary Document	Uploaded 2016-06-29	Available
EDHA 12 _ Third Pary Collection System(2).PDF	Supplementary Document	Uploaded 2016-06-29	Available
Third Party Collection Prog_0720-0055_ SSN Justification Memo Signed 02-04-16.PDF	Supplementary Document	Uploaded 2016-06-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5378	Third Party Collection Program (Insurance Information)	Form	Modified	Third Party Collection Program/Medical Services Account/Other Health Insurance

ICR Details

OMB Control No: 0720-0055	ICR Reference No: 201606-0720-003
Status: Historical Active	Previous ICR Reference No: 201304-0720-003
Agency/Subagency: DOW/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: 08/05/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/30/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved	08/31/2016
Responses	5,850,000	0	2,936,905
Time Burden (Hours)	390,000	0	146,845
Cost Burden (Dollars)	9,956,700	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
   US Code: 10 USC 1079b
  

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:
	81 FR 5013	01/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 42692	06/30/2016
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 (Insurance Information)	DD Form 2569	Third Party Collection Program/Medical Services Account/Other Health Insurance

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ICR Summary of Burden

table that charts list 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	5,850,000	2,936,905	0	2,913,095	0	0
Annual Time Burden (Hours)	390,000	146,845	0	243,155	0	0
Annual Cost Burden (Dollars)	9,956,700	0	0	9,956,700	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Average burden per response has been increased by 1 minute as adding new question #7 to identify Veterans Affairs (VA) patients will slightly increase the time spent filling out the DD Form 2569.

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Annual Cost to Federal Government: $7,441,200

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: 06/30/2016

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