Agency Information Collection (Application for CHAMPVA Benefits) Activities Under OMB Review, 25320 [2010-10796]

Download as PDF 25320 Federal Register / Vol. 75, No. 88 / Friday, May 7, 2010 / Notices DEPARTMENT OF VETERANS AFFAIRS [OMB Control No. 2900–0219] Agency Information Collection (Application for CHAMPVA Benefits) 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. Comments must be submitted on or before June 7, 2010. ADDRESSES: Submit written comments on the collection of information through 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– 0219’’ in any correspondence. jlentini on DSKJ8SOYB1PROD with NOTICES DATE: FOR FURTHER INFORMATION CONTACT: Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461– 7485, fax (202) 273–0443 or e-mail denise.mclamb@va.gov. Please refer to ‘‘OMB Control No. 2900–0219.’’ SUPPLEMENTARY INFORMATION: Titles: a. Application for CHAMPVA Benefits, VA Form 10–10d. b. CHAMPVA Claim Form, VA Form 10–7959a. c. CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10–7959c. d. CHAMPVA Potential Liability Claim, VA Form 10–7959d. e. Claim for Miscellaneous Expenses, VA Form 10–7959e. OMB Control Number: 2900–0219. Type of Review: Revision of a currently approved collection. Abstracts: a. VA Form 10–10d is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program. b. VA Form 10–7959a is used to accurately adjudicate and process VerDate Mar<15>2010 19:19 May 06, 2010 Jkt 220001 beneficiaries claims for payment/ reimbursement of related healthcare expenses. c. VA Form 10–7959c is used to systematically obtain other health insurance information and to correctly coordinate benefits among all liable parties. d. VA Form 10–7959d is used to gather additional information relative to the injury or illness as well as third party claim information. e. Beneficiaries complete VA Form 10–7959e to claim payment/ reimbursement of expenses related to spina bifida and certain covered birth defects. 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 March 1, 2010, at pages 9276–9277. Affected Public: Individuals or households, business or other for-profit, and not-for-profit institutions. Estimated Annual Burden: a. VA Form 10–10d—4,411 hours. b. VA Form 10–7959a—37,336 hours. c. VA Form 10–7959c—13,456 hours. d. VA Form 10–7959d—467 hours. e. VA Form 10–7959e—725 hours. Estimated Average Burden Per Respondent: a. VA Form 10–10d—10 minutes. b. VA Form 10–7959a—10 minutes. c. VA Form 10–7959c—10 minutes. d. VA Form 10–7959d—7 minutes. e. VA Form 10–7959e—10 minutes. Frequency of Response: On occasion. Estimated Number of Respondents: a. VA Form 10–10d—26,468. b. VA Form 10–7959a—224,018. c. VA Form 10–7959c—80,733. d. VA Form 10–7959d—4,000. e. VA Form 10–7959e—4,400. Dated: May 4, 2010. By direction of the Secretary. Denise McLamb, Program Analyst, Enterprise Records Service. [FR Doc. 2010–10796 Filed 5–6–10; 8:45 am] BILLING CODE 8320–01–P DEPARTMENT OF VETERANS AFFAIRS [OMB Control No. 2900–0712] Agency Information Collection (Nationwide Customer Satisfaction Surveys) Activities Under OMB Review AGENCY: Veterans Health Administration, Department of Veterans Affairs. PO 00000 Frm 00136 Fmt 4703 Sfmt 4703 ACTION: Notice. 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, 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. DATES: Comments must be submitted on or before June 7, 2010. ADDRESSES: Submit written comments on the collection of information through 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– 0712’’ in any correspondence. FOR FURTHER INFORMATION CONTACT: Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461– 7485, fax (202) 273–0443 or e-mail denise.mclamb@va.gov. Please refer to ‘‘OMB Control No. 2900–0712.’’ SUPPLEMENTARY INFORMATION: Title: Nation-wide Customer Satisfaction Surveys, VA Forms 1465–2 through 1465–4. OMB Control Number: 2900–0712. Type of Review: Revision of a currently approved collection. Abstract: The Survey of Health Experience of Patients (SHEP) Survey is used to obtain information from VA patients that will be used to identify problems or compliant and to improve the quality of health care services delivered to veterans. Data will be use to measure improvement toward the goal of matching or exceeding non-VA external benchmark performance. 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 March 1, 2010, at page 9277. Affected Public: Individuals or households. Estimated Annual Burden: a. Inpatient Short Form, VA Form 10–1465–2—18,750 hours. b. Ambulatory Care Long Form, VA Form 10–1465–3—9,802 hours. c. Ambulatory Care Short Form, VA Form 10–1465–4—67,573 hours. E:\FR\FM\07MYN1.SGM 07MYN1

Agencies

[Federal Register Volume 75, Number 88 (Friday, May 7, 2010)]
[Notices]
[Page 25320]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-10796]



[[Page 25320]]

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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Agency Information Collection (Application for CHAMPVA Benefits) 
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.

DATE: Comments must be submitted on or before June 7, 2010.

ADDRESSES: Submit written comments on the collection of information 
through 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. 2900-0219'' in any correspondence.

FOR FURTHER INFORMATION CONTACT: Denise McLamb, Enterprise Records 
Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, 
NW., Washington, DC 20420, (202) 461-7485, fax (202) 273-0443 or e-mail 
denise.mclamb@va.gov. Please refer to ``OMB Control No. 2900-0219.''

SUPPLEMENTARY INFORMATION: 
    Titles:
    a. Application for CHAMPVA Benefits, VA Form 10-10d.
    b. CHAMPVA Claim Form, VA Form 10-7959a.
    c. CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10-
7959c.
    d. CHAMPVA Potential Liability Claim, VA Form 10-7959d.
    e. Claim for Miscellaneous Expenses, VA Form 10-7959e.
    OMB Control Number: 2900-0219.
    Type of Review: Revision of a currently approved collection.
    Abstracts:
    a. VA Form 10-10d is used to determine eligibility of persons 
applying for healthcare benefits under the CHAMPVA program.
    b. VA Form 10-7959a is used to accurately adjudicate and process 
beneficiaries claims for payment/reimbursement of related healthcare 
expenses.
    c. VA Form 10-7959c is used to systematically obtain other health 
insurance information and to correctly coordinate benefits among all 
liable parties.
    d. VA Form 10-7959d is used to gather additional information 
relative to the injury or illness as well as third party claim 
information.
    e. Beneficiaries complete VA Form 10-7959e to claim payment/
reimbursement of expenses related to spina bifida and certain covered 
birth defects.
    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 March 1, 2010, at pages 9276-9277.
    Affected Public: Individuals or households, business or other for-
profit, and not-for-profit institutions.
    Estimated Annual Burden:
     a. VA Form 10-10d--4,411 hours.
     b. VA Form 10-7959a--37,336 hours.
     c. VA Form 10-7959c--13,456 hours.
     d. VA Form 10-7959d--467 hours.
     e. VA Form 10-7959e--725 hours.
    Estimated Average Burden Per Respondent:
     a. VA Form 10-10d--10 minutes.
     b. VA Form 10-7959a--10 minutes.
     c. VA Form 10-7959c--10 minutes.
     d. VA Form 10-7959d--7 minutes.
     e. VA Form 10-7959e--10 minutes.
    Frequency of Response: On occasion.
    Estimated Number of Respondents:
     a. VA Form 10-10d--26,468.
     b. VA Form 10-7959a--224,018.
     c. VA Form 10-7959c--80,733.
     d. VA Form 10-7959d--4,000.
     e. VA Form 10-7959e--4,400.

    Dated: May 4, 2010.

    By direction of the Secretary.
Denise McLamb,
Program Analyst, Enterprise Records Service.
[FR Doc. 2010-10796 Filed 5-6-10; 8:45 am]
BILLING CODE 8320-01-P
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