Information Collection

Request For Health Benefits Under The Champus Program For The Handicapped And The Basic Program

IC 108656 under ICR 198910-0704-001 · OMB 0704-0099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FOR HEALTH BENEFITS UNDER THE CHAMPUS PROGRAM FOR THE HANDICAPPED AND THE 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	(FORMERLY	No	No
Form	2533	No	No
Form	190A)	No	No
Form	CHAMPUS 190	No	No
Form	DD 2532	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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