Application and Renewal for Health Benefits

Forms and Documents

Document Name	Status
Form VA Form 10-10HS Application and Renewal for Health Benefits Form and Instruction	Modified
Form 10-10EC Applications and Renewal for Health Benefits Form and Instruction	New
2900-0091 sub. change.docx Justification for No Material/Nonsubstantive Change	2014-06-20
2900-0091 sub. change.docx Justification for No Material/Nonsubstantive Change	2014-06-20
2900-0091 SS_20140620.doc Supporting Statement A	2014-06-20

IC Document Collections

IC ID	Document Title	Status
28251	Application and Renewal for Health Benefits Form and Instruction	Modified
212005	Applications and Renewal for Health Benefits Form and Instruction	New

ICR Details

OMB Control No: 2900-0091	ICR Reference No: 201406-2900-044
Status: Historical Active	Previous ICR Reference No: 201306-2900-006
Agency/Subagency: VA	Agency Tracking No: 2900-0091
Title: Application and Renewal for Health Benefits
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/20/2014
	Date Received in OIRA: 06/20/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	01/31/2017	01/31/2017
Responses	2,034,000	0	1,017,000
Time Burden (Hours)	455,750	0	455,750
Cost Burden (Dollars)	0	0	0

---

Abstract: Collects information to enroll for health care benefits, establishes basic eligibility, identifies 3rd party health insurance coverage, identifies prescription copayment, provides for income verification and serves as a mechanism to make changes upon admission or yearly financial updates.

---

Authorizing Statute(s): US Code: 38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
   US Code: 38 USC 111(c)(1) Name of Law: Payments or allowances for beneficiary travel
  

Citations for New Statutory Requirements: PL: Pub.L. 112 - 154 105 Name of Law: Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 127	07/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 213	11/04/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Application and Renewal for Health Benefits	VA Form 10-10HS	Request for Hardship Determination
Applications and Renewal for Health Benefits	10-10EC, 10-10d, 10-10EZ, 10-10EZR	Application for Extended Care Benefits ,   Application for CHAMPVA ,   Enrollment Application for Health Benefits ,   Health Benefits Update Form

---

ICR Summary of Burden

	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	2,034,000	1,017,000	0	1,017,000	0	0
Annual Time Burden (Hours)	455,750	455,750	0	0	0	0
Annual Cost Burden (Dollars)	0	0	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:

---

Annual Cost to Federal Government: $4,263,550

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/20/2014

---