2010-30551. 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.

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 http://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 [phone]. 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, NW., Washington, DC 20420, [phone], fax [phone] or e-mail [e-mail]. 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.