View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 2900-0219	ICR Reference No: 200703-2900-003
Status: Historical Active	Previous ICR Reference No: 200402-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0219
Title: CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/18/2007
	Date Received in OIRA: 03/12/2007
Terms of Clearance: OMB approves this collection consistent with the memo from VA on 6/14/07 and the revised forms attached. Upon expiration of the collection, VA will update OMB on the progress of electronic implementation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved	06/30/2007
Responses	119,200	0	2,375,500
Time Burden (Hours)	19,668	0	394,667
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): US Code: 38 USC Section 1781 Name of Law: Medical care for survivors and dependents of certain veterans
   US Code: 10 USC Section 1079 Name of Law: Contracts for medical care for spouses and children: plans
   US Code: 10 USC Section 1086 Name of Law: Contracts for health benefits for certain members, former members, and their dependents
   US Code: 42 USC Section 2651 Name of Law: Recovery by United States
   US Code: 38 USC Section 501 Name of Law: Rules and regulations
   US Code: 42 USC Section 2652 Name of Law: Regulations
   US Code: 42 USC Section 2653 Name of Law: Limitation or repeal of other provisions for recovery of hospital and medical care costs
   EO: EO 9397 Name/Subject of EO: Number System for Federal Accounts Relating to Individual Persons

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	119,200	2,375,500	-2,256,300	0
Annual Time Burden (Hours)	19,668	394,667	0	-374,999
Annual Cost Burden (Dollars)	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: The previous estimate submitted by this office made an invalid assumption that a VA Form 10-7959a was required for every medical claim that is created in the facility. A more correct estimate would be that only 15% of all claims require a VA Form 10-7959a, since this form is ONLY used by a taxpayer requesting repayment for out of pocket costs. The majority of claims are received directly from the doctor, pharmacy, or hospital, and not from the taxpayer. Thus, this is considered a routine business practice and these agencies are not required to use this form. VA Form 10-7959d usage figure has been reduced to the figure stated, based on the current conditions within the HACs department that process these. They are anticipating increasing the workforce to process more of these in the future.

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