REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM

ICR 198307-0704-004

OMB: 0704-0099

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0704-0099 198307-0704-004
Historical Active 197809-0704-005
DOD/DODDEP
REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM
Revision of a currently approved collection   No
Regular
Approved without change 09/28/1983
Retrieve Notice of Action (NOA) 07/20/1983
  Inventory as of this Action Requested Previously Approved
09/30/1986 09/30/1986 09/30/1983
8,400 0 7,000
8,400 0 7,000
0 0 0

THE INFORMATION REQUESTED IS FOR THE PURPOSE OF DETERMINING ELIGIBILITY FOR BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED AND FOR EXTENDED HOSPITALIZATION UNDER THE BASIC PROGRAM, CHAMPUS. USED TO ESTABLISH BENEFICIARY IDENTIFYING INFORMATION; APPROPRIATENESS, SOURCE AND COST OF CARE; AND VALIDATE WHETHER SERVICES REQUESTED ARE PROGRAM BENEFITS.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM

  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 8,400 7,000 0 0 1,400 0
Annual Time Burden (Hours) 8,400 7,000 0 0 1,400 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
07/20/1983


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