Application and Renewal for Health Benefits

ICR 200911-2900-008

OMB: 2900-0091

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2009-04-23
IC Document Collections
IC ID
Document
Title
Status
28251 Modified
ICR Details
2900-0091 200911-2900-008
Historical Active 200807-2900-003
VA 2900-0091
Application and Renewal for Health Benefits
Revision of a currently approved collection   No
Regular
Approved without change 03/07/2010
Retrieve Notice of Action (NOA) 11/25/2009
  Inventory as of this Action Requested Previously Approved
03/31/2013 36 Months From Approved 07/31/2010
2,075,312 0 2,071,812
1,114,740 0 1,113,865
0 0 0

Collects information to enroll for health care benefits, establishes basic eligibility, identifies 3rd party health insurance coverage, identifies prescription copayment, provides for income verification and serves as a mechanism to make changes upon admission or yearly financial updates.

US Code: 38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
   US Code: 38 USC 111(c)(1) Name of Law: Payments or allowances for beneficiary travel
  
None

2900-AM97 Final or interim final rulemaking 74 FR 81 04/29/2009

No

1
IC Title Form No. Form Name
Application and Renewal for Health Benefits VA Form 10-10EZR, VA Form 10-10HS, 10-10EZ Application for Health Benefits ,   Request for Hardship Determination ,   Health Benefits Renewal Form

  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 2,075,312 2,071,812 0 3,500 0 0
Annual Time Burden (Hours) 1,114,740 1,113,865 0 875 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The increase in burden hours is due to the inclusion of VA Form 10-10HS.

$10,941,125
No
No
Uncollected
Uncollected
No
Uncollected
Denise McLamb 202-565-8374 [email protected]

  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.
11/25/2009


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