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Proposed Information Collection Activity: Proposed Collection; Comment Request

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Veterans Health Administration, Department of Veterans Affairs.




The Veterans Health Administration (VHA) is announcing an opportunity for public comment on the proposed collection of certain information by the agency. Under the Paperwork Reduction Act (PRA) of 1995, Federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each extension of a currently approved collection, and allow 60 days for public comment in response to the notice. This notice solicits comments on information needed to initiate and document expenditures, claim reimbursement as well as make funeral arrangements and authorize burial benefits.


Written comments and recommendations on the proposed collection of information should be received on or before August 2, 2004.


Submit written comments on the collection of information to Ann Bickoff, Veterans Health Administration (193B1), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420 or e-mail Please refer to “OMB Control No. 2900-0080” in any correspondence.

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Ann Bickoff at (202) 273-8310.

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Under the PRA of 1995 (Public Law 104-13; 44 U.S.C. 3501-3521), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to section 3506(c)(2)(A) of the PRA.

With respect to the following collection of information, VHA invites comments on: (1) Whether the proposed collection of information is necessary for the proper performance of VHA's functions, including whether the information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology.


a. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583.

b. Funeral Arrangements, 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.

OMB Control Number: 2900-0080.

Type of Review: Extension of a currently approved collection.


a. VA Form 10-583 is used by health care providers as a claim for the cost of unauthorized hospital care and by veterans as a claim for reimbursement of such cost.

b. VA Form 10-2065 is completed by clerical staff upon the death of a veteran in a VA medical care facility. It is used primarily in VA medical facilities and serves as an official record of the Funeral Director to which the person making funeral arrangements wishes the remains to be released. It 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 10-7078 is used by administrative personnel in VA medical facilities 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.

d. VA Form 10-2511 is used by administrative personnel in VA facilities to authorize expenditures from the beneficiary travel account. It is also 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.

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

Estimated Total Annual Burden: 31,546 hours.

a. VA Form 10-583—17,188.

b. VA Form 10-2065—3,625.

c. VA Form 10-2511—2,333.

d. VA Form 10-7078—8,400.

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.

Frequency of Response: On occasion.

Estimated Number of Respondents: 434,250.

a. VA Form 10-583—68,750 respondents.

b. VA Form 10-2065—43,500 respondents.

c. VA Form 10-2511—70,000 respondents.

d. VA Form 10-7078—252,000 respondents.

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Dated: May 19, 2004.

By direction of the Secretary.

Loise Russell,

Director, Records Management Service.

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[FR Doc. 04-12390 Filed 6-1-04; 8:45 am]