Continued Health Care Benefit Program (CHCBP) Application

Forms and Documents

Document	Type	Status	Availability
Form DD Form 2837 Continued Health Care Benefit Program (CHCBP) Application	Form	Unchanged	Repair queued
0720-0066_SSA_08.31.2023.docx	Supporting Statement A	Uploaded 2023-08-31	Repair queued
0720-0066_SSNJ_6.15.2023.pdf	Supplementary Document	Uploaded 2023-06-15	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
5414	Continued Health Care Benefit Program (CHCBP) Application	Form	Unchanged

ICR Details

OMB Control No: 0720-0066	ICR Reference No: 202305-0720-002
Status: Received in OIRA	Previous ICR Reference No: 202008-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Continued Health Care Benefit Program (CHCBP) Application
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/31/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2023
Responses	1,475	1,475
Time Burden (Hours)	369	369
Cost Burden (Dollars)	2,670	2,670

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Abstract: The information collected on the Department of Defense (DD) Form 2837, Continued Health Care Benefit Program (CHCBP) Application, is needed to determine a former military beneficiary’s eligibility to purchase CHCBP coverage, which is optional continuation coverage after the former member or former beneficiary loses entitlement to military health benefits coverage under Title 10 United States Code (10 USC), Chapter 55. Provision of the information requested on the DD Form 2837 is required to obtain or retain benefits, or eligibility for CHCBP coverage cannot be determined and must be denied.

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Authorizing Statute(s): US Code: 10 USC 1078a Name of Law: Continued Health Benefits Coverage
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 40792	06/22/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 58573	08/28/2023
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Continued Health Care Benefit Program (CHCBP) Application	DD Form 2837	Continued Health Care Benefit Program (CHCBP) Application

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ICR Summary of Burden

	Total Request	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	1,475	1,475	0	0	0	0
Annual Time Burden (Hours)	369	369	0	0	0	0
Annual Cost Burden (Dollars)	2,670	2,670	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: $8,503

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 08/31/2023

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