Memorandum For Emergency PRA Clearance Request - CHAMPVA Forms - March 2021

Department of
Veterans Affairs

Memorandum

Date:

March 19, 2021

From:

Edward B. Bernard, Executive Director, Business Operations and Administration

Subj:

Request for OMB review and consideration of emergency clearance for “CHAMPVA
Benefits - Application, Claim, Other Health Insurance & Potential Liability – OMB
Control Number 2900-0219”

To:

Paul J. Ray
Administrator, Office of Information and Regulatory Affairs (OIRA)

Cc:

VA Desk Officer, James Crowe
Office of Management and Budget (OMB)
VA is requesting an emergency Paperwork Reduction Act (PRA) clearance of the
following Civilian Health and Medical Program of the Department of Veterans Affairs
(CHAMPVA) forms: 10-7959a, CHAMPVA Claim Form, VHA 10-10d, CHAMPVA
Application for Benefits, VHA 10-7959c, CHAMPVA Other Health Insurance form, VHA
10-7959d, CHAMPVA Potential Liability Claim, and form VHA 10-7959e, CHAMPVA
Misc. Expenses.
Emergency clearance is requested because VA needs to continue providing benefit
administration, to include enrollment and medical claims processing, for the 553,878
CHAMPVA beneficiaries and to continue to process the 20+ million medical claims
submitted by beneficiaries or on behalf of beneficiaries by their health care providers.
The use of regular OMB clearance procedures will not allow for completion of the PRA
clearance process by the current expiration date for this information collection. OMB
PRA approval is respectfully requested by March 31, 2021.
Questions may be addressed to Christopher Mercer via phone at 303-398-5146 or via
email at [email protected].

Thank you for your consideration of this matter.
Digitally signed by Bernard, Edward B.
Bernard,
Edward
B.
Date: 2021.03.19 10:53:11 -04'00'
____________________________________

Edward B. Bernard
Executive Director, Business Operations and Administration