OMB control number

OPM 2809, Health Benefits Election Form

OMB 3206-0141 · OPM.

OMB 3206-0141

OPM Form 2809 is used by annuitants and former spouses to elect, cancel, suspend, or change health benefits enrollment during periods other than open season. Note: The Privacy Act Statement has been revised due to a systematic review by our Chief Privacy Officer. Also, the term "Claim Number" has been replaced with "Beneficiary Identifier".

The latest form for OPM 2809, Health Benefits Election Form expires 2023-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form OPM 2809 Health Benefits Election Form Form and Instruction
OPM2809_30DayFRNPublished_2023_04_03.doc.pdf Supplementary Document
OPM2809_60DayFRNPublished_2023_02_06.pdf Supplementary Document
E8-5659.pdf Supplementary Document
OPM2809_OMBSupportingStatement_2023_final.docx Supporting Statement A
Health Benefits Election Form Form and Instruction

All Historical Document Collections

202304-3206-001 Approved with change	Extension without change of a currently approved collection	2023-04-21
202003-3206-002 Approved without change	Revision of a currently approved collection	2020-03-17
201603-3206-001 Approved without change	Revision of a currently approved collection	2016-03-03
201308-3206-001 Approved with change	Revision of a currently approved collection	2013-08-23
201201-3206-008 Approved without change	Extension without change of a currently approved collection	2012-01-26
201103-3206-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2011-03-14
200904-3206-009 Approved without change	Reinstatement without change of a previously approved collection	2009-04-30
200508-3206-003 Approved without change	Revision of a currently approved collection	2005-08-19
200204-3206-003 Approved without change	Revision of a currently approved collection	2002-04-12
199904-3206-001 Approved without change	Reinstatement with change of a previously approved collection	1999-04-28
199505-3206-003 Approved without change	Revision of a currently approved collection	1995-05-30
199303-3206-003 Approved without change	Revision of a currently approved collection	1993-03-29
199302-3206-007 Approved with change	No material or nonsubstantive change to a currently approved collection	1993-02-24
199301-3206-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1993-01-27
199107-3206-001 Approved without change	Revision of a currently approved collection	1991-07-01
199011-3206-001 Approved without change	Revision of a currently approved collection	1990-11-23
199008-3206-007 Approved without change	Extension without change of a currently approved collection	1990-08-14
198903-3206-011 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-03-07
198708-3206-003 Approved without change	Revision of a currently approved collection	1987-08-05
198609-3206-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1986-09-09
198407-3206-001 Approved without change	Revision of a currently approved collection	1984-07-27
198406-3206-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-06-20
198403-3206-011 Approved without change	New collection (Request for a new OMB Control Number)	1984-03-22