Supporting statement for ADDP Claim Form

SUPPORTING STATEMENT FOR PAPERWORK

REDUCTION ACT SUBMISSION — 0720-0022

Active Duty Dental Program (ADDP) Claim Form

1. Need and Use. This form will be used by private sector dental professionals that provide dental care to Active Duty Service Members under the Active Duty Dental Program (ADDP). Many of these Service Members are not located near a military dental clinic and receive their dental care in the private sector. The new form is needed to update the dental readiness of Service Members treated in this program so that they can maintain worldwide deployment status and reduces paperwork by combining the dental claim and dental readiness into one form.

2. Purpose and Users of the Information. The information collection requirement is necessary to obtain and record the dental readiness of Service Members using the ADDP and at the same time submit the claim for reimbursement for dental procedures provided. The ADDP contractor will use the information on the claim to reimburse the dental provider for the dental care rendered and will forward the dental readiness classification of the Service Member to the government.

3. Information Collection Techniques. When Active Duty Service members receive dental care from civilian dentists, the dentists record the dental health status on this form. Dentists also record the treatment completed by code – Current Dental Terminology (CDT) so that they can be reimbursed for dental care rendered. Civilian dentists return the form to the ADDP contractor. The ADDP Claim Form will available in several electronic formats. Civilian dentists can access the form and submit it electronically to the ADDP contractor as well.

4. Duplication. Personnel dental health status is unique data that is not tracked in other data collection systems.

5. Small Businesses. This information collection does not have a significant economic impact on small businesses or entities.

6. Consequences of Not Collecting the Information. A member’s dental health status can quickly deteriorate to an unacceptable level and must be updated continuously to ensure the overall readiness of our forces.

7. Special Circumstances. None. This collection of information is consistent with the guidelines in 5 CFR 1320.5(d)(2).

8. Notice and Comment. The 60-day notice was published in the Federal Register (74 FR 48232-48233). No comments were received.

9. Payment/Gifts. No payment or gift will be provided to the respondents. Individual dentists will decide if they require an additional fee for completing the form, or whether they will factor it into their cost of doing business.

10. Confidentiality. The form will be utilized by the ADDP dental contractor. All electronic submissions are protected as the contractor has received DoD Information Assurance Certification and Accreditation Process (DIACAP). The ADDP contractor also is fully aware and compliant with HIPAA and the government Privacy Act.

11. Sensitive Questions. There are no questions of a sensitive nature asked on the attached forms.

12. Burden and Annualized Cost Information:

Estimated Respondents: 59,000

Response Time: 5 minutes

Response frequency: 3

Burden hours: 14,750 hours

The individual cost to the provider is the part of the cost of doing business.

13. Cost to Respondents. There will be no additional cost burden to respondents.

14. Cost to the Government. There will be a minimal cost to the government as the form is designed to be electronically distributed and printed by the military organizations that use the form.

15. Change. New collection of information.

16. Publication. There is no plan to publish or tabulate the information collected in an independent report. Data will be entered into an electronic database.

17. Expiration Date.

Approval not to display the expiration date is not being sought.

18. Exceptions.

No exceptions to the certification statement are requested.

B. Collections of Information Employing Statistical Methods.

This collection of information does not employ statistical methods.