95-23412. Notice of Request for Expedited Review of a Revised Information Collection OPM Form 2809-EZ2

[Federal Register Volume 60, Number 183 (Thursday, September 21, 1995)]
[Notices]
[Pages 49027-49028]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-23412]



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OFFICE OF PERSONNEL MANAGEMENT


Notice of Request for Expedited Review of a Revised Information 
Collection OPM Form 2809-EZ2

AGENCY: Office of Personnel Management.

ACTION: Notice.

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SUMMARY: In accordance with the Paperwork Reduction Act of 1980 (title 
44, U.S. Code, chapter 35), this notice announces a request for 
expedited review of a revised information collection. OPM Form 2809-
EZ2, Open Season Health Benefits Enrollment Change Form, is used by 
annuitants only at Open Season to elect a change in health benefits 
coverage.
    Approximately 35,345 OPM Forms 2809-EZ2 are completed annually. 
Each form takes approximately 30 minutes to complete. The annual burden 
is 17,672 hours.
    A copy of this proposal is appended to this notice.

DATES: Comments on this proposal should be received on or before 
September 26, 1995. OMB has been requested to take action within eight 
(8) calendar days from the date of this publication.

ADDRESSES: Send or deliver comments to--

Lorraine E. Dettman, Chief, Retirement and Insurance Group, Operations 
Support Division, U.S. Office of Personnel Management, 1900 E Street, 
NW, Room 3349, Washington, DC 20415

      and

Joseph Lackey, OPM Desk Officer, Office of Information and Regulatory 
Affairs, Office of Management and Budget, New Executive Office Building 
NW., Room 10235, Washington, DC 20503.

FOR INFORMATION REGARDING ADMINISTRATIVE COORDINATION--CONTACT:
Mary Beth Smith-Toomey, Management Services Division, [phone], 
U.S. Office of Personnel Management.
Lorraine A. Green,
Deputy Director.

    The content of draft OPM Form 2809-EZ2 is set out below:

DRAFT OPM Form 2809-EZ2
1995 FEHB Open Season
Revised October 1995

Federal Employee Health Benefits Program
United States Office of Personnel Management

Civil Service Retirement System/Federal Employees Retirement System


[[Page 49028]]

Enrollment Change Form
Form Approved: OMB 3206-0200

    Use this form to change your health benefits enrollment during the 
1995 Open Season. This form has been personalized with your name, 
retirement claim number and health benefits plans available to persons 
residing in your address area. Do Not use someone else's form. Fill in 
Sections A, B, and C on the reverse side of this form. If You Do Not 
Want To Change Your Health Plan Or Type Of Coverage, Do Not Return This 
Form. If you need assistance in completing this form, call the Office 
of Personnel Management at [phone]. For the hearing impaired: 
Call the Retirement Information Office TTD number [phone].

Important Directions For Marking Answers & Signing This Form
--Fill out form on hard surface
--Make heavy black marks that fill the circle completely
--Erase any changes completely
--Make no stray marks
--Do not write in margins
[  ]  Right
[  ]  Wrong

Brochure Requested:
Claim Number:
ADDRESS CORRECTION
[  ] Address Change. If your permanent mailing address is incorrect, 
darken the Address Change circle and make the necessary corrections in 
the space provided below.
Street Address (include Apartment No. or Lot no.)
City, State and ZIP Code
Country (if not United States)
Section A--Choose a Self Only or Self and Family enrollment. DARKEN 
ONLY ONE CIRCLE.
[  ]  Self Only      or[  ]  Self and Family
Section B--PLAN CHOICES
Listed are the health plans in your state.
(Select only one--Darken the circle between the two-character 
enrollment code and the name of the plan you want.)
GOVERNMENT WIDE PLANS
[  ]
[  ]
Fee-for Service--PLANS OPEN TO ALL
[  ]
[  ]*
*There are 8 selections available for ``Fee-for-Service--PLANS OPEN TO 
ALL''
Fee-for-Service--RESTRICTED PLANS
(You must be a member of a specific group to enroll in a plan below.)
[  ]
[  ]**
**There are 7 selections available for ``Fee-for-Service--RESTRICTED 
PLANS''
PREPAID PLANS:
[  ]
[  ]***
***There are 41 selections available for ``PREPAID PLANS''.

SECTION C--You must SIGN, date and give your telephone number below. 
Your Signature (must be signed by the addressee, an OPM approved 
representative, or person holding power of attorney).
Today's Date
Your daytime telephone number & area code (      )

[FR Doc. 95-23412 Filed 9-20-95; 8:45 am]
BILLING CODE 6325-01-M