FEHB_IVR_PAS_PBS_2023_Revised

Privacy Act Statement

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to collect the information requested pursuant to Title 5, U.S. Code, Chapter 89, Sections 8905 and 8905a, which, specifies the opportunities and conditions under which a retiree, survivor annuitant, or former spouse of a retiree is eligible to enroll or to change enrollment in the Federal Employees Health Benefits Program (FEHBP). OPM is authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: OPM is requesting this information to share with the health insurance carrier you select, so that they may (1) identify your enrollment in the plan, (2) verify you and/or your family’s eligibility for payment of claims for health benefits services or supplies, and (3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits. Routine Uses: The information requested on this form may be shared as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application. For example, OPM may share your information with other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your disability retirement benefits, or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information is voluntary. However, failure to provide this information may result in OPM’s noncompliance of the provisions of title 5, U.S. Code, Chapter 89. Individuals who do not provide this information via this online system can also request changes via telephone or letter. The information collected can only be obtained from the respondents.

An annuitant may access his or her own Personally Identifiable Information (PII) by logging in to the AHBOSS web system. The PII entered into AHBOSS is restricted in AHBOSS using federal government standards (National Institute of Standards and Technology Special Publications 800-53 Rev. 4).

Public Burden Statement

The public reporting burden to complete this information collection is estimated at 10 minutes per response, including for reviewing instructions, searching data sources, gathering and maintaining the data needed, and the completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to the Office of Personnel Management, RS Publications Team at [email protected].  Current information regarding this collection of information – including all background materials -- can be found at https:/www.reginfo.gov/public/do/PRAMain by using the search function to enter either the title of the collection or 3206-0201.

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