Privacy Act Statement

Pursuant to 5 U.S.C. § 552a (e)(3), this Privacy Act Statement explains why OPM is requesting information for Postal Service Health Benefits (PSHB) Program enrollment. 

Authority

OPM is authorized to collect the information requested on this form pursuant to Title 5, U.S.C. Chapter 89 and Title 5 of the Code of Federal Regulations, Part 890 pertaining to enrollment in the Federal Employees Health Benefits (FEHB) Program or the Postal Service Health Benefits (PSHB) Program. OPM is authorized to collect your Social Security Number (SSN) by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008), and section 6055 of the Internal Revenue Code (reporting requirements for minimum essential coverage). OPM is also authorized to collect both your Social Security Number and Medicare Number pursuant to the Mandatory Insurer Reporting Law (section 111 of Public Law 110-173). 

Purpose

The principal use of this information will be to share it with the health insurance carrier you select so that it may (1) record your enrollment in the plan, (2) verify your or your family’s eligibility for payment of claims for health benefits; and (3) coordinate payment of claims with other carriers with whom you might also make a claim for payment of benefits.

Routine Uses

The information you provide for enrollment may also be disclosed externally with other Federal agencies or Congressional offices which may have a need to know it in connection with an inquiry or a determination of eligibility for your health benefits. It may also be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or Social Security administrative agencies to determine and issue benefits under their programs or to obtain information necessary for determination or continuation of benefits under this program. In addition, to the extent this information indicates a possible violation of civil or criminal law, it may be shared and verified, as noted above, with an appropriate Federal, state, or local law enforcement agency. A list of routine uses associated with this form can be found in the Privacy Act System of Records Notice (SORN), OPM/Central-23, FEHB Program Enrollment Records.

Consequences of Failure to Provide Information

Providing this information is voluntary, however failure to provide it may result in a delay in processing your enrollment. We request that you provide your and your family member’s Social Security Number so that it may be used as an individual identifier in the FEHB or PSHB Program, and for other purposes. Your health insurance carrier also needs to report your Social Security Number or your Medicare Number in order to properly coordinate benefits between your health plan and Medicare. Failure to furnish your Social Security Number or Medicare Number may result in OPM’s inability to ensure the prompt payment of your or your family’s claims for health benefits, the proper coordination with Medicare, and the proper health insurance status reporting to the Internal Revenue Service. Additionally, for USPS employees, annuitants, or their family members it may result in OPM’s inability to determine eligibility for PSHB coverage. 

Public Burden Statement

The public reporting burden to complete this information collection is estimated at 30 minutes per response, including time for reviewing instructions, searching data sources, gathering and maintaining the data needed, and the completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number and expiration date. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to the Office of Personnel Management, ATTN: Enrollment and Member Support Program Office at HIPRA@opm.gov.  Current information regarding this collection of information – including all background materials -- can be found at reginfo.gov’s Information Collection Review webpage by using the search function to enter either the title of the collection (SF 2809 Health Benefits Election Form) or the OMB Control Number (3206-0160). OPM may not collect this information, and you are not required to respond, unless this number is displayed.