e2569 Module

OMB CONTROL NUMBER: 0720-0055
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information is estimated to average 4 minutes
per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing the burden, to the Department of
Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other
provision of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 USC, Sections 1079b, Procedures for charging fees for care provided to
civilian; retention and use of fees collected;1095, Health care services incurred on behalf of
covered beneficiaries: collection from thirdparty payers; 42 USC. Chapter 32, Third Party
Liability For Hospital and Medical Care; EO 9397 (SSN) as amended.
PURPOSE(S): Your information is collected to allow recovery from third parties for medical care
provided to you in a Military Treatment Facility
ROUTINE USE(S): Your records may be disclosed outside of DoD to healthcare clearinghouses,
commercial insurances providers, and other third parties in order to collect amounts owed to
the Department of Defense. Your records may also be used and disclosed in accordance with 5
USC 552a(b) of the Privacy Act of 1974, a amended, which incorporates the DoD Blanket
Routine Uses published at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. Any protected health
information (PHI) in your records may be used and disclosed generally as permitted by the
HIPAA Privacy Rule (45 CFR Parts 160 and 164), as implemented within DoD. Permitted uses
and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare
operations.
DISCLOSURE: Voluntary. Failure to provide complete and accurate information may result in
disqualification for health care services from MTFs.