Continued Health Care Benefit Program (CHCBP) Application

ICR 202305-0720-002

OMB: 0720-0066

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Unchanged
Supporting Statement A
2023-08-31
Supplementary Document
2023-06-15
IC Document Collections
ICR Details
0720-0066 202305-0720-002
Received in OIRA 202008-0720-001
DOD/DODOASHA
Continued Health Care Benefit Program (CHCBP) Application
Extension without change of a currently approved collection   No
Regular 08/31/2023
  Requested Previously Approved
36 Months From Approved 08/31/2023
1,475 1,475
369 369
2,670 2,670

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.

US Code: 10 USC 1078a Name of Law: Continued Health Benefits Coverage
  
None

Not associated with rulemaking

  88 FR 40792 06/22/2023
88 FR 58573 08/28/2023
No

1
IC Title Form No. Form Name
Continued Health Care Benefit Program (CHCBP) Application DD Form 2837 Continued Health Care Benefit Program (CHCBP) Application

  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
No
No

$8,503
No
    Yes
    Yes
No
No
No
No
Sandra Dennis 703 681-8818 [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.
08/31/2023


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