Continued Health Care Benefit Program (CHCBP) Application

ICR 202007-0704-001

OMB: 0704-0364

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2020-07-02
Supplementary Document
2020-07-01
IC Document Collections
ICR Details
0704-0364 202007-0704-001
Historical Active 200905-0704-006
DOD/DODDEP
Continued Health Care Benefit Program (CHCBP) Application
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/05/2020
Retrieve Notice of Action (NOA) 07/02/2020
DOD must report this collection in its Information Collection Budget submission.
  Inventory as of this Action Requested Previously Approved
08/31/2023 36 Months From Approved
1,475 0 0
369 0 0
2,670 0 0

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

  85 FR 18569 04/02/2020
85 FR 39891 07/02/2020
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 Approved 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 0 0 -1,025 0 2,500
Annual Time Burden (Hours) 369 0 0 -256 0 625
Annual Cost Burden (Dollars) 2,670 0 0 2,670 0 0
No
Yes
Miscellaneous Actions
Revised estimate of the number of respondents.

$8,503
No
    Yes
    Yes
No
No
No
No
Kira Starks 571 372-4529 danikquia.k.starks.ctr@mail.mil

  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.
07/02/2020


© 2024 OMB.report | Privacy Policy