Agency Information Collection (Claim for Payment of Cost of Unauthorized Medical Services) Activity Under OMB Review, 76080-76081 [2010-30551]

Agencies

• DEPARTMENT OF VETERANS AFFAIRS

[Federal Register Volume 75, Number 234 (Tuesday, December 7, 2010)]
[Notices]
[Pages 76080-76081]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-30551]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0080]


Agency Information Collection (Claim for Payment of Cost of 
Unauthorized Medical Services) Activity Under OMB Review

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: In compliance with the Paperwork Reduction Act (PRA) of 1995 
(44 U.S.C. 3501-3521), this notice announces that the Veterans Health 
Administration (VHA), Department of Veterans Affairs, will submit 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.

DATE: Comments must be submitted on or before January 6, 2011.

ADDRESSES: Submit written comments on the collection of information 
through https://www.Regulations.gov or 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.

FOR FURTHER INFORMATION CONTACT: Denise McLamb, Enterprise Records 
Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue,

[[Page 76081]]

NW., Washington, DC 20420, (202) 461-7485, fax (202) 273-0443 or e-mail 
denise.mclamb@va.gov. Please refer to ``OMB Control No. 2900-0080.''

SUPPLEMENTAL INFORMATION:
    Titles:
    a. Claim for Payment of Cost of Unauthorized Medical Services, VA 
Form 10-583.
    b. Funeral Arrangements Form for Disposition of Remains of the 
Deceased, 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.
    e. Request for Payment of Beneficiary Travel after the Date of 
Service.
    OMB Control Number: 2900-0080.
    Type of Review: Revision of a currently approved collection.
    Abstract:
    a. VA Form 10-583 is used to request payment or reimbursement of 
the cost of unauthorized non-VA medical services.
    b. VA Form 10-2065 is completed by VA personnel during an interview 
with relatives of the deceased, and to identify the funeral home to 
which the remains are to be released. The form is also 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 10-2511 is used 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.
    d. VA uses VA Form 10-7078 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.
    e. Claimants who request payment for beneficiary travel after the 
time of service may do so in writing or in person.
    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 September 29, 2010, at page 60170.
    Affected Public: Business or other for profit.
    Estimated Total Annual Burden:
    a. VA Form 10-583--17,188.
    b. VA Form 10-2065--2,053.
    c. VA Form 10-2511--2,333.
    d. VA Form 10-7078--8,400.
    e. Request for Payment of Beneficiary Travel after the Date of 
Service--417.
    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.
    e. Request for Payment of Beneficiary Travel after the Date of 
Service--1 minute.
    Frequency of Response: Annually.
    Estimated Number of Respondents:
    a. VA Form 10-583--68,750 respondents.
    b. VA Form 10-2065--24,630 respondents.
    c. VA Form 10-2511--70,000 respondents.
    d. VA Form 10-7078--252,000 respondents.
    e. Request for Payment of Beneficiary Travel after the Date of 
Service--25,000.

    Dated: December 1, 2010.

    By direction of the Secretary.
Denise McLamb,
Program Analyst, Enterprise Records Service.
[FR Doc. 2010-30551 Filed 12-6-10; 8:45 am]
BILLING CODE 8320-01-P