OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability

ICR 201211-2900-001 · OMB 2900-0219 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form Modified Repair queued
Memo on revisions to 2900-0219.doc Justification for No Material/Nonsubstantive Change Uploaded 2013-08-01 Available
10-7959a WHITE Paper correction_1.docx Justification for No Material/Nonsubstantive Change Uploaded 2012-11-27 Available
2900-0219 Justification A 8-22-13.docx Supporting Statement A Uploaded 2013-08-22 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28467 CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form Modified
ICR Details
2900-0219 201211-2900-001
Historical Active 201001-2900-009
VA 2900-0219
CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability
Revision of a currently approved collection   No
Regular
Approved without change 09/30/2013
Retrieve Notice of Action (NOA) 08/23/2013
  Inventory as of this Action Requested Previously Approved
09/30/2016 36 Months From Approved 09/30/2013
339,619 0 339,619
56,570 0 56,570
0 0 0
Used by CHAMP VA claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.
US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   US Code: 10 USC Section 1079 Name of Law: Contracts for medical care for spouses and children: plans
   US Code: 10 USC Section 1086 Name of Law: Contracts for health benefits for certain members, former members, and their dependents
   US Code: 42 USC Section 2651 Name of Law: Recovery by United States
   US Code: 38 USC Section 501 Name of Law: Rules and regulations
   US Code: 42 USC Section 2652 Name of Law: Regulations
   US Code: 42 USC Section 2653 Name of Law: Limitation or repeal of other provisions for recovery of hospital and medical care costs
   EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons
  
None
Not associated with rulemaking
  78 FR 111 06/10/2013
78 FR 159 08/16/2013
No
1
IC Title Form No. Form Name
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability VA Form 10-7959a, VA Form 10-10d, VA Form 10-7959c, VA Form 10-7959d, VA Form 10-7959e CHAMPVA Claim Form ,   CHAMPVA Other Health Insurance (OHI) Certification ,   Potential Liability Claim Form ,   Claim for Miscellaneous Expenses ,   Application for Benefits
  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 339,619 339,619 0 0 0 0
Annual Time Burden (Hours) 56,570 56,570 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$589,334
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [email protected]
  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.
08/23/2013