Third Party Collection Program (Insurance Information)

Forms and Documents

Document Name	Status
Form DD Form 2569 Third Party Collection Program (Insurance Information) Form	Modified
0720-0055_SS-A_8.29.19.docx Supporting Statement A	2019-08-29
ABACUS Draft SSN Justification Memorandum 09202018-DHAPCLO Clean_signed (JM).pdf Supplementary Document	2019-08-29

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: 201908-0720-002
Status: Active	Previous ICR Reference No: 201606-0720-003
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: 10/23/2019
	Date Received in OIRA: 08/29/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved	10/31/2019
Responses	5,910,000	0	5,850,000
Time Burden (Hours)	394,000	0	390,000
Cost Burden (Dollars)	10,933,500	0	9,956,700

---

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.

---

Authorizing Statute(s): US Code: 10 USC 1095 Name of Law: Health Care Services Incurred on Behalf of Covered Beneficiaries: Collection from Third-Party Payers
   US Code: 10 USC 1079b Name of Law: Procedures for Charging Fees for Care Provided to Civilians; Retention and Use of Fees Collected
   US Code: 10 USC 1085 Name of Law: Medical and Dental Care from Another Executive Department: Reimbursement
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 29853	06/25/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 45477	08/29/2019
Did the Agency receive public comments on this ICR? No

---

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

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

---

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	5,910,000	5,850,000	0	60,000	0	0
Annual Time Burden (Hours)	394,000	390,000	0	4,000	0	0
Annual Cost Burden (Dollars)	10,933,500	9,956,700	0	976,800	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: The burden has increased since the previous approval due to an increase in the estimated number of respondents and cost burden since the last approval in 2016.

---

Annual Cost to Federal Government: $7,883,940

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

---

Common Form ICR:  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:

(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: 08/29/2019

---