E5-5780. 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.

DATE:

Comments must be submitted on or before November 21, 2005.

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, [phone], FAX [phone] or e-mail to: [e-mail]. Please refer to “OMB Control No. 2900-0620.”

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, [phone]. Please refer to “OMB Control No. 2900-0620” in any correspondence.

SUPPLEMENTARY INFORMATION:

Title: Payment and Reimbursement for Emergency Services for Non Service-Connected Conditions in Non-VA Facilities.

OMB Control Number: 2900-0620.

Type of Review: Extension of a currently approved collection.

Abstract: Veterans enrolled in VA's health-care system are personally liable for emergency treatment rendered at non-VA health facilities. Veterans or their representative, and the health care provider of the emergency treatment to the veteran must submit a claim in writing or complete a Health Insurance Claim Form HCFA 1450 and 1500 or Medical Uniform Institutional Provider Bill Form UB-82 and 92 to request payment or reimbursement for such treatment. VA uses the data collected to determine the claimant's eligibility for payment or reimbursement.

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 22, 2005, at page 36234.

Affected Public: Business or other for-profit, individuals or households, and not-for-profit institutions.

Estimated Total Annual Burden: 147,187 hours.

Estimated Average Burden Per Respondent: 30 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 294,373.

Dated: October 6, 2005.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Records Management Service,