# Submission for OMB Review; Comment Request
**AGENCY:**
Office of the Assistant Secretary of Defense for Health Affairs (OASD(HA)), Department of Defense, (DoD).
**ACTION:**
30-Day information collection notice.
**SUMMARY:**
The DoD has submitted to the Office of Management and Budget (OMB) for clearance the following proposal for collection of information under the provisions of the Paperwork Reduction Act.
**DATES:**
Consideration will be given to all comments received by December 1, 2023.
**ADDRESSES:**
Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to *www.reginfo.gov/public/do/PRAMain.* Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function.
**FOR FURTHER INFORMATION CONTACT:**
Angela Duncan, 571-372-7574, *[email protected].*
**SUPPLEMENTARY INFORMATION:**
*Title; Associated Form; and OMB Number:* Third Party Collection Program (Insurance Information); DD Form 2569; OMB Control Number 0720-0055.
*Type of Request:* Extension.
*Number of Respondents:* 3,570,000.
*Responses per Respondent:* 1.5.
*Annual Responses:* 5,355,000.
*Average Burden per Response:* 4 minutes.
*Annual Burden Hours:* 357,000 hours.
*Needs and Uses:* The DoD is authorized to collect “reasonable charges” from third party payers for the cost of inpatient and outpatient services rendered at military treatment facilities (MTFs) to military retirees, all dependents, and other eligible beneficiaries who have private health insurance. The DoD may also collect the cost of trauma or other medical care provided from civilians (or their insurers), and/or the average cost of health care provided to beneficiaries at DoD MTFs from other federal agencies. For DoD to perform such collections, eligible beneficiaries may elect to provide DoD with other health insurance information. For civilian nonbeneficiary and interagency patients, DD Form 2569 is necessary and serves as an assignment of benefits, approval to submit claims to payers on behalf of the patient, and authorizes the release of medical information. This form is available to third-party payers upon request. The collection of personal information from individuals of the public for use in medical services is authorized by title 10 U.S.C. 1095, “Health Care Services Incurred on Behalf of Covered Beneficiaries: Collection from Third-Party Payers”; Title 32 CFR part 220, “Collection From Third Party Payers of Reasonable Charges for Healthcare Services”; Title 10 U.S.C. 1079b(a), “Procedures for Charging Fees for Care Provided to Civilians; Retention and Use of Fees Collected”; and Title 10 U.S.C. 1085, “Medical and Dental Care from Another Executive Department: Reimbursement.”
*Affected Public:* Individuals or households.
*Frequency:* On occasion.
*Respondent's Obligation:* Voluntary.
*OMB Desk Officer:* Mr. Matt Eliseo.
You may also submit comments and recommendations, identified by Docket ID number and title, by the following method:
• *Federal eRulemaking Portal: http://www.regulations.gov.* Follow the instructions for submitting comments.
*Instructions:* All submissions received must include the agency name, Docket ID number, and title for this *Federal Register* document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the internet at *http://www.regulations.gov* as they are received without change, including any personal identifiers or contact information.
*DoD Clearance Officer:* Ms. Angela Duncan.
Requests for copies of the information collection proposal should be sent to Ms. Duncan at *[email protected].*
Dated: October 24, 2023.
Aaron T. Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.