OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

OPM 2809, Health Benefits Election Form

OMB 3206-0141 ยท OPM.

OMB 3206-0141

OPM Form 2809 is used by annuitants and former spouses to elect, cancel, suspend, or change health benefits enrollment during periods other than open season. Note: The Privacy Act Statement has been revised due to a systematic review by our Chief Privacy Officer. Also, the term "Claim Number" has been replaced with "Beneficiary Identifier".

The latest form for OPM 2809, Health Benefits Election Form expires 2023-04-30 and is listed under ICR 202003-3206-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form OPM 2809 Health Benefits Election FormForm and Instruction
OPM2809_30DayFRNPublished_2023_04_03.doc.pdf Supplementary Document
OPM2809_60DayFRNPublished_2023_02_06.pdf Supplementary Document
E8-5659.pdf Supplementary Document
OPM2809_OMBSupportingStatement_2023_final.docxSupporting Statement A
Health Benefits Election Form Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202304-3206-001 Extension without change of a currently approved collection 2023-04-21 Approved with change
202003-3206-002 Revision of a currently approved collection 2020-03-17 Approved without change
201603-3206-001 Revision of a currently approved collection 2016-03-03 Approved without change
201308-3206-001 Revision of a currently approved collection 2013-08-23 Approved with change
201201-3206-008 Extension without change of a currently approved collection 2012-01-26 Approved without change
201103-3206-001 No material or nonsubstantive change to a currently approved collection 2011-03-14 Approved without change
200904-3206-009 Reinstatement without change of a previously approved collection 2009-04-30 Approved without change
200508-3206-003 Revision of a currently approved collection 2005-08-19 Approved without change
200204-3206-003 Revision of a currently approved collection 2002-04-12 Approved without change
199904-3206-001 Reinstatement with change of a previously approved collection 1999-04-28 Approved without change
199505-3206-003 Revision of a currently approved collection 1995-05-30 Approved without change
199303-3206-003 Revision of a currently approved collection 1993-03-29 Approved without change
199302-3206-007 No material or nonsubstantive change to a currently approved collection 1993-02-24 Approved with change
199301-3206-003 No material or nonsubstantive change to a currently approved collection 1993-01-27 Approved with change
199107-3206-001 Revision of a currently approved collection 1991-07-01 Approved without change
199011-3206-001 Revision of a currently approved collection 1990-11-23 Approved without change
199008-3206-007 Extension without change of a currently approved collection 1990-08-14 Approved without change
198903-3206-011 No material or nonsubstantive change to a currently approved collection 1989-03-07 Approved with change
198708-3206-003 Revision of a currently approved collection 1987-08-05 Approved without change
198609-3206-010 No material or nonsubstantive change to a currently approved collection 1986-09-09 Approved with change
198407-3206-001 Revision of a currently approved collection 1984-07-27 Approved without change
198406-3206-004 No material or nonsubstantive change to a currently approved collection 1984-06-20 Approved with change
198403-3206-011 New collection (Request for a new OMB Control Number) 1984-03-22 Approved without change