CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability

ICR 200402-2900-001

OMB: 2900-0219

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
2900-0219 200402-2900-001
Historical Active 200107-2900-018
VA
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability
Extension without change of a currently approved collection   No
Regular
Approved without change 03/23/2004
Retrieve Notice of Action (NOA) 02/20/2004
  Inventory as of this Action Requested Previously Approved
03/31/2007 03/31/2007 03/31/2004
2,375,500 0 381,000
394,667 0 63,000
0 0 0

Used by CHAMPVA claimants to claim reimbursement for medical care and by VA to determine eligibility, proces claims, detect fraud and recover costs from 3rd parties.

None
None


No

1
IC Title Form No. Form Name
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability 10-10D, 10-7959A, 10-7959C, 10-7959D

  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 2,375,500 381,000 0 1,994,500 0 0
Annual Time Burden (Hours) 394,667 63,000 0 331,667 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.
02/20/2004


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