Application and Renewal for Health Benefits

ICR 201410-2900-005

OMB: 2900-0091

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Form and Instruction
Unchanged
Supplementary Document
2014-11-20
Justification for No Material/Nonsubstantive Change
2014-11-21
Supplementary Document
2014-10-10
Justification for No Material/Nonsubstantive Change
2014-07-03
Justification for No Material/Nonsubstantive Change
2014-06-20
Justification for No Material/Nonsubstantive Change
2014-06-20
Supporting Statement A
2014-11-21
ICR Details
2900-0091 201410-2900-005
Historical Active 201407-2900-006
VA 2900-0091
Application and Renewal for Health Benefits
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 02/26/2015
Retrieve Notice of Action (NOA) 11/24/2014
  Inventory as of this Action Requested Previously Approved
01/31/2017 01/31/2017 01/31/2017
2,034,000 0 2,034,000
455,750 0 455,750
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
  
PL: Pub.L. 112 - 154 105 Name of Law: Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012

Not associated with rulemaking

  78 FR 127 07/02/2013
78 FR 213 11/04/2013
No

  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 2,034,000 2,034,000 0 0 0 0
Annual Time Burden (Hours) 455,750 455,750 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$4,263,550
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [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.
11/24/2014


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