Agency Information Collection Activities Under OMB Review

AGENCY:

Veterans Health Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-21), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has submitted the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.

DATES:

Comments must be submitted on or before March 3, 2004.

FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT:

Denise McLamb, Records Management Service (005E3), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 273-8030, Fax (202) 273-5981 or e-mail to: denise.mclamb@mail.va.gov. Please refer to “OMB Control No. 2900-0335.”

Send comments and recommendations concerning any aspect of the information collection to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503, (202) 395-7316. Please refer to “OMB Control No. 2900-0335” in any correspondence.

SUPPLEMENTARY INFORMATION:

Title: Dental Record Authorization and Invoice for Outpatient Services, VA Form 10-2570d.

OMB Control Number: 2900-0335.

Type of Review: Extension of a currently approved collection.

Abstract: VA Form 10-2570b, Examination Procedure Instructions for Participating Fee Dentist, and VA Form 10-2570c, Treatment Procedure Instructions for the Participating Fee Dentist, have been combined with VA Form 10-2570d, Dental Record Authorization and Invoice for Outpatient Services. VA Form 10-2570d is essential to the proper administration of VA outpatient fee dental program. The associated instructions make it possible to communicate with clarity the required procedures, peculiarities, and precautions associated with VA authorizations for contracting with private dentists for the provision of dental treatment for eligible veteran beneficiaries. Since most of the veterans who are authorized fee dental care are geographically inaccessible to VA dental clinics, it is necessary to request information as to the veteran's oral condition, treatment needs and the usual customary fees for these services from the private fee dentist whom the veteran has selected. The form lists the dental treatment needs of the veteran patient, the cost to VA to provide such services, and serves as an invoice for payment.

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. The Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on October 14, 2003, at pages 59243-59244.

Affected Public: Business and other for profit.

Estimated Total Annual Burden: 4,153 hours.

Estimated Average Burden Per Respondent: 20 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 12,460.