Veterans Health Administration, Department of Veterans Affairs.
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.
Comments must be submitted on or before October 15, 2004.
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) 273-8030, fax (202) 273-5981 or e-mail to: email@example.com. Please refer to “OMB Control No. 2900-0260.”
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. 2900-0260” in any correspondence.End Preamble Start Supplemental Information
Title: Request for and Authorization to Release Medical Records or Health Information, VA Form 10-5345.
OMB Control Number: 2900-0260.
Type of Review: Extension of a currently approved collection.
Abstract: VA Form 10-5345 is used to obtain prior written consent from a patient before information concerning treatment for alcoholism or alcohol abuse, drug abuse, sickle cell anemia, or infection with the human immunodeficiency virus (HIV) can be disclosed from his or her medical record. This special consent must indicate the name of the facility permitted to make the disclosure, name of the individual or organization to whom the information is being released, specify the particular records or information to be released, and be under the signature of the veteran and dated. It must reflect the purpose the information is to be used, and include a statement that the consent is subject to revocation and the date, event or condition upon which the consent will expire if not revoked before.
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 8, 2004, at page 32096.
Affected Public: Business or other for profit, Individuals or households.
Estimated Total Annual Burden: 16,667 hours.
Estimated Average Burden Per Respondent: 2 minutes.
Frequency of Response: One time.
Estimated Number of Respondents: 500,000.Start Signature
Dated: September 1, 2004.
By direction of the Secretary.
Director, Records Management Service.
[FR Doc. 04-20744 Filed 9-14-04; 8:45 am]
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