Information Collection

Request For Health Benefits Under The Program For The Handicapped/basic Program

IC 108655 under ICR 198609-0704-005 · OMB 0704-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0099 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUEST FOR HEALTH BENEFITS UNDER THE PROGRAM FOR THE HANDICAPPED/BASIC PROGRAM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CHAMPUS 190				No	No
Form	190A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	1,600	8,400
Annual IC Time Burden (Hours)	5,000	800	4,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.