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 September 29, 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. 2900-0080.”

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. 2900-0080” in any correspondence.

SUPPLEMENTARY INFORMATION:

Titles:

a. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583.

b. Funeral Arrangements, VA Form 10-2065.

c. Authority and Invoice for Travel by Ambulance or Other Hired Vehicle, VA Form 10-2511.

d. Authorization and Invoice for Medical and Hospital Services, VA Form 10-7078.

OMB Control Number: 2900-0080.

Type of Review: Extension of a currently approved collection.

Abstract:

a. VA Form 10-583 is used by non-Department health care providers as a claim for the cost of unauthorized hospital and medial care they have provided and by veterans as a claim for reimbursement of such cost.

b. VA Form 10-2065 is completed during the interview with relatives of the deceased, and identifies the funeral home to which the remains are to be released. It is used as a control document when VA is requested to arrange for the transportation of the deceased from the place of death to the place of burial, and/or when burial is requested in a National Cemetery.

c. VA Form 10-7078 is used by administrative personnel in VA medical facilities to authorize expenditures from the medical care account and process payment of medical and hospital services provided by other than Federal health providers to VA beneficiaries.

d. VA Form 10-2511 is used by administrative personnel in VA facilities to authorize expenditures from the beneficiary travel account and to process payment for ambulance or other hired vehicular forms of transportation for eligible veterans to and from VA health care facilities for examination, treatment or care.

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 June 2, 2004, at page 31158.

Affected Public: Business or other for profit, Individuals or households, and Not for profit institutions.

Estimated Total Annual Burden: 31,546 hours.

a. VA Form 10-583—17,188.

b. VA Form 10-2065—3,625.

c. VA Form 10-2511—2,333.

d. VA Form 10-7078—8,400.

Estimated Average Burden per Respondent:

a. VA Form 10-583—15 minutes.

b. VA Form 10-2065—5 minutes.

c. VA Form 10-2511—2 minutes.

d. VA Form 10-7078—2 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 434,250.

a. VA Form 10-583—68,750 respondents.

b. VA Form 10-2065—43,500 respondents.

c. VA Form 10-2511—70,000 respondents.

d. VA Form 10-7078—252,000 respondents.