Skip to Content


Proposed Information Collection (Claim for Payment of Cost of Unauthorized Medical Services) Activity: Comment Request

Document Details

Information about this document as published in the Federal Register.

Document Statistics
Document page views are updated periodically throughout the day and are cumulative counts for this document including its time on Public Inspection. Counts are subject to sampling, reprocessing and revision (up or down) throughout the day.
Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble Start Printed Page 60170


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, to 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 November 29, 2010.


Submit written comments on the collection of information through;​ or to Cynthia Harvey-Pryor, Veterans Health Administration (193E1), 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. During the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at

Start Further Info


Cynthia Harvey-Pryor at (202) 461-5870 or FAX (202) 273-9381.

End Further Info End Preamble Start Supplemental Information


Under the PRA of 1995 (Pub. L. 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 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: Extension of a currently approved collection.


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.

Affected Public: Business or other for profit.

Estimated Total Annual Burden:

a. VA Form 10-583—19,376.

b. VA Form 10-2065—2,053.

c. VA Form 10-2511—2,333.

d. VA Form 10-7078—8,900.

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—77,504 respondents.

b. VA Form 10-2065—24,630 respondents.

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

d. VA Form 10-7078—267,021,000 respondents.

e. Request for Payment of Beneficiary Travel After the Date of Service—25,000

Start Signature

Dated: September 24, 2010.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Records Management Service.

End Signature End Supplemental Information

[FR Doc. 2010-24438 Filed 9-28-10; 8:45 am]