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Federal forms, ICRs, and supporting documents

Information Collection Request

CHAMPVA CLAIM FORM AND APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS

ICR 199308-2900-007 · OMB 2900-0219 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
147624 CHAMPVA CLAIM FORM AND APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS Form Migrated
ICR Details
2900-0219 199308-2900-007
Historical Active 198811-2900-003
VA
CHAMPVA CLAIM FORM AND APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/24/1993
Retrieve Notice of Action (NOA) 08/12/1993
  Inventory as of this Action Requested Previously Approved
06/30/1996 06/30/1996
329,600 0 0
27,467 0 0
0 0 0
ELIGIBLE BENEFICIARIES USE VA FORM 10-10D TO APPLY FOR MEDICAL BENEFIT AVAILABLE TO THE THROUGH VA. VA FORM 10-7959A IS USED BY CHAMPVA BENEFICIARIES TO SUBMIT CLAIMS FOR COVERED MEDICAL TREATMENT.
None
None
No
1
IC Title Form No. Form Name
CHAMPVA CLAIM FORM AND APPLICATION FOR MEDICAL BENEFITS FOR DEPENDENTS OR SURVIVORS VA 10-10D, 10-7959A
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 329,600 0 0 329,600 0 0
Annual Time Burden (Hours) 27,467 0 0 27,467 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  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:
 
 
 
 
 
 
 
    (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.
08/12/1993