HEALTH BENEFITS REGISTRATION FORM (FEHBP), HEALTH BENEFITS ENROLLMENT CHANGE FORM, ENROLLMENT CODE FORM & BROCHURE REQUEST FORM, & ENROLLMENT CHANGE FORM
ICR 198708-3206-003 · OMB 3206-0141 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 3206-0141 can be found here:
HEALTH BENEFITS REGISTRATION FORM (FEHBP), HEALTH BENEFITS ENROLLMENT CHANGE FORM, ENROLLMENT CODE FORM & BROCHURE REQUEST FORM, & ENROLLMENT CHANGE FORM
TITLE 5, USC CHAPTER 89 SPECIFIES THE OPPORTUNITIES AND CONDITION UNDE WHICH AN ANNUITANT, SURVIVOR ANNUITANT OR FORMER SPOUSE OF AN ANNUITAN IS ELIGIBLE TO ENROLL OR TO CHANGE ENROLLMENT IN THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM. DEPENDING ON THE CIRCUMSTANCES ONE OF THE FOUR FORMS IN THIS CLEARANCE PACKAGE IS USED BY THE ABOVE PERSONS TO ELECT TO ENROLL, CHANGE ENROLLMENT OR CANCEL ENROLLMENT IN THE PROGRAM
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:
(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;
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.
HEALTH BENEFITS REGISTRATION FORM (FEHBP), HEALTH BENEFITS ENROLLMENT CHANGE FORM, ENROLLMENT CODE FORM & BROCHURE REQUEST FORM, & ENROLLMENT CHANGE FORM