MHS GENESIS Patient Registration Module & Patient Portal

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0720-AHBJ_SS-A_08.21.19.docx	Supporting Statement A	Uploaded 2019-08-21	Available
MHS_GENESIS_DD_2930_PIA_5.24.2018_FNAL_FLATTEND.pdf	Supplementary Document	Uploaded 2019-08-08	Available
Email example - from DHA Global Service Center 8.7.19.doc	Supplementary Document	Uploaded 2019-08-08	Available
TAB A Justification Memo_MHS GENESIS_Final_Signed.pdf	Supplementary Document	Uploaded 2019-08-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
237231	Patient Registration Data Fields	Other-Screenshots	New

ICR Details

OMB Control No: 0720-0064	ICR Reference No: 201908-0720-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-AHBJ
Title: MHS GENESIS Patient Registration Module & Patient Portal
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: Approved without change	Conclusion Date: 10/15/2019
	Date Received in OIRA: 08/26/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved
Responses	2,870,338	0	0
Time Burden (Hours)	334,873	0	0
Cost Burden (Dollars)	8,783,234	0	0

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Abstract: The information collection requirement is necessary to provide and document medical care; determine eligibility for benefits and entitlements; adjudicate claims; determine whether a third party is responsible for the cost of MHS provided healthcare and recover that cost; and evaluate fitness for duty and medical concerns which may have resulted from an occupational or environmental hazard. Obtaining this information is essential for DoD providing medical care and recovering costs.

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Authorizing Statute(s): US Code: 10 USC 1104 Name of Law: Sharing of Healthcare Resources with the Department of Veterans Affairs
   US Code: 10 USC 55 Name of Law: Medical and Dental Care
   US Code: 42 USC 32 Name of Law: Third Party Liability for Hospital and Medical Care
   US Code: 10 USC 8111 Name of Law: Sharing of Department of VA and DoD Healthcare Resources
  

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:
	84 FR 23538	05/22/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 43114	08/20/2019
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
Patient Registration Data Fields

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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	2,870,338	0	0	2,870,338	0	0
Annual Time Burden (Hours)	334,873	0	0	334,873	0	0
Annual Cost Burden (Dollars)	8,783,234	0	0	8,783,234	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: This is a new collection with a new associated burden.

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Annual Cost to Federal Government: $51,364,139

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 08/26/2019

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