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
Form DD Form 2569 Third Party Collection Program (Insurance Information)	Form	Modified	Repair queued
0720-0055_SSA_9.8.22.docx	Supporting Statement A	Uploaded 2022-09-08	Repair queued
DD 2569 SSN Justification Memo.pdf	Supplementary Document	Uploaded 2022-08-16	Repair queued

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
5378	Third Party Collection Program (Insurance Information)	Form	Modified
255333	e2569 Module	Other-Screenshots	New

ICR Details

OMB Control No: 0720-0055	ICR Reference No: 202205-0720-001
Status: Historical Inactive	Previous ICR Reference No: 201908-0720-002
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: Improperly submitted and continue	Conclusion Date: 10/17/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/08/2022
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	10/31/2022
Responses	5,910,000	0	5,910,000
Time Burden (Hours)	394,000	0	394,000
Cost Burden (Dollars)	10,933,500	0	10,933,500

---

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 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
   US Code: 10 USC 1095 Name of Law: Health Care Services Incurred on Behalf of Covered Beneficiaries: Collection from Third-Party Payers
  

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:
	87 FR 31541	05/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 54984	09/08/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

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
e2569 Module

---

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The number of respondents slightly decreased and the burdens of the collection instruments were separated, causing the burden of the DD Form 2569 to decrease. However, the annual burden cost increased since the previous approval due to an increase in the hourly wage of the respondents.

---

Annual Cost to Federal Government: $8,159,015

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? No

---

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: 09/08/2022

---