CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-10d Application for Benefits	Form	Modified	Available
Form VA Form 10-7959e Claim for Miscellaneous Expenses	Form	Modified	Available
Form VA Form 10-7959d Potential Liability Claim Form	Form	Modified	Available
Form VA Form 10-7959c CHAMPVA Other Health Insurance (OHI) Certification	Form and Instruction	Modified	Available
Form VA Form 10-7959a CHAMPVA Claim Form	Form	Modified	Available
CHAMPVA Benefits - White Paper - 022316.docx	Supplementary Document	Uploaded 2016-02-23	Available
Memo on revisions to 2900-0219.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2013-08-01	Available
10-7959a WHITE Paper correction_1.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-11-27	Available
2900-0219 Justification A_FINAL_092016.docx	Supporting Statement A	Uploaded 2016-09-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form	Modified	Application for Benefits
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form	Modified	Claim for Miscellaneous Expenses
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form	Modified	Potential Liability Claim Form
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form and Instruction	Modified	CHAMPVA Other Health Insurance (OHI) Certification
28467	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form	Modified	CHAMPVA Claim Form

ICR Details

OMB Control No: 2900-0219	ICR Reference No: 201602-2900-032
Status: Historical Active	Previous ICR Reference No: 201211-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/12/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/01/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	09/30/2016	09/30/2016
Responses	339,619	0	339,619
Time Burden (Hours)	56,570	0	56,570
Cost Burden (Dollars)	0	0	0

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Abstract: Used by CHAMP VA claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.

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Authorizing Statute(s): US Code: 42 USC Section 2652 Name of Law: Regulations
   US Code: 42 USC Section 2653 Name of Law: Limitation or repeal of other provisions for recovery of hospital and medical care costs
   EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons
   US Code: 38 USC Section 501 Name of Law: Rules and regulations
   US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   US Code: 42 USC Section 2651 Name of Law: Recovery by United States
   US Code: 10 USC Section 1079 Name of Law: Contracts for medical care for spouses and children: plans
   US Code: 10 USC Section 1086 Name of Law: Contracts for health benefits for certain members, former members, and their dependents
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
2900-AP09	Final or interim final rulemaking	81 FR 19887	04/06/2016

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 111	06/10/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 159	08/16/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	VA Form 10-7959a, VA Form 10-10d, VA Form 10-7959c, VA Form 10-7959d, VA Form 10-7959e	CHAMPVA Claim Form ,   CHAMPVA Other Health Insurance (OHI) Certification ,   Potential Liability Claim Form ,   Claim for Miscellaneous Expenses ,   Application for Benefits

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ICR Summary of Burden

table that charts list of burden

	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	339,619	339,619	0	-339,643	339,643	0
Annual Time Burden (Hours)	56,570	56,570	0	-56,576	56,576	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $589,334

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/01/2016

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