Continued Health Care Benefit Program (CHCBP) Application

ICR 199905-0704-001

OMB: 0704-0364

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
0704-0364 199905-0704-001
Historical Active 199404-0704-002
DOD/DODDEP
Continued Health Care Benefit Program (CHCBP) Application
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 06/30/1999
Retrieve Notice of Action (NOA) 05/03/1999
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002
600 0 0
150 0 0
0 0 0

The Continued Health Care Benefit Program (CHCBP) application is used by a Third-Party Administrator (TPA) to obtain beneficiary information to make enrollment decisions. The information requested allows the TPA to review eligibility family information and coverage issues as outlined in 10 U.S.C. 1078a.

None
None


No

1
IC Title Form No. Form Name
Continued Health Care Benefit Program (CHCBP) Application DD-X384

  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 600 0 0 600 0 0
Annual Time Burden (Hours) 150 0 0 150 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
05/03/1999


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