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Agency Information Collection Activities Under OMB Review

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Information about this document as published in the Federal Register.

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Veterans Health Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C., 3501 et seq.), 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; it includes the actual data collection instrument.


Comments must be submitted on or before February 12, 2001.

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Denise McLamb, Information Management Service (045A4), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 273-8030 or FAX (202) 273-5981. Please refer to “OMB Control No. 2900-0219.”

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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. Start Printed Page 2484

e. VA Spina Bifida Healthcare Benefits—Claim for Miscellaneous Expenses, VA Form 10-7959E.

OMB Control Number: 2900-0219.

Type of Review: Reinstatement, with change, of a previously approved collection for which approval has expired.

Abstract: The following forms are used by Civilian Health and Medical Program-VA (CHAMP-VA) and spina bifida claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.

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 adjudicate claims for CHAMPVA.

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 recover costs associated with healthcare services related to injury or illness caused by a third party.

e. VA Form 10-7959E is used by VA Spina Bifida Healthcare beneficiaries to claim payment or reimbursement for healthcare services and related travel expenses.

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 7, 2000, at pages 36219 and 36220.

Affected Public: Individuals or households, Business or Other for-Profit.

Estimated Annual Burden: 60,600 hours.

a. VA Form 10-10D—1,500 hours.

b. VA Form 10-7959A—50,000 hours.

c. VA Form 10-7959C—10,333 hours.

d. VA Form 10-7959D—1,167 hours.

e. VA Form 10-7959E—1,600 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—4 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 405,000.

a. VA Form 10-10D—9,000.

b. VA Form 10-7959A—300,000.

c. VA Form 10-7959C—62,000.

d. VA Form 10-7959D—10,000.

e. VA Form 10-7959E—24,000.

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. 2900-0219” in any correspondence.

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Dated: November 28, 2000.

By direction of the Secretary.

Barbara H. Epps,

Management Analyst, Information Management Service.

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[FR Doc. 01-824 Filed 1-10-01; 8:45 am]