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 September 19, 2003.Start Further Info
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, (202) 273-8130 or FAX (202) 273-5981, or e-mail: firstname.lastname@example.org. Please refer to “OMB Control No. 2900—New—Foreign Medical.”
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—New—Foreign Medical” in any correspondence.End Further Info End Preamble Start Supplemental Information
Title: Claim Cover Sheet for Foreign Medical Program, VA Form 10-7959f.
OMB Control Number: 2900—New—Foreign Medical.
Type of Review: New collection.
Abstract: VA Form 10-7959f will be used to submit claims for payment/reimbursement of expenses related to veterans who are residing or traveling overseas (except for Canada and the Philippines) with a service-connected disability. The form outlines the basic veteran information necessary for consideration of claims for reimbursement. Use of this form by providers or veteran is optional. VA accepts provider generated billing statement, Uniform Billing-Forms (UB) 92, HCFA 1500, Medicare Health Start Printed Page 50219Insurance Claims Form. This information collection is needed to carry out the health care benefits allowed by the Foreign Medical Program.
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 3, 2003, at pages 33228-33229.
Affected Public: Individuals or households, Business or other for profit, and Not for profit institutions.
Estimated Total Annual Burden: 3,652 hours.
Estimated Average Burden Per Respondent: 11 minutes.
Frequency of Response: On occasion.
Estimated Number of Respondents: 1,660.
Estimated Total Annual Responses: 19,920.Start Signature
Dated: August 8, 2003.
By direction of the Secretary.
IT Specialist, Records Management Service.
[FR Doc. 03-21233 Filed 8-19-03; 8:45 am]
BILLING CODE 8320-01-P