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Agency Information Collection (Payment and Reimbursement for Emergency Services for Non Service-Connected Conditions in Non-VA Facilities) Activity Under OMB Review

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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. 3501-21), this notice announces that the Veterans Health Administration, Department of Veterans Affairs, will submit 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 January 18, 2012.


Submit written comments on the collection of information through;​ or 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. 2900-0620” in any correspondence.

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Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7479, Fax (202) 273-0487 or email Please refer to “OMB Control No. 2900-0620.”

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Title: Payment and Reimbursement for Emergency Services for Non Service-Connected Conditions in Non-VA Facilities, 38 U.S.C. 1725.

OMB Control Number: 2900-0620.

Type of Review: Extension of a currently approved collection.

Abstract: Veterans enrolled in VA's health-care system are personally liable for emergency treatment rendered at non-VA health facilities. Veterans or their representative, and the health care provider of the emergency treatment furnished to the veteran must submit a claim in writing or complete a Health Insurance Claim Form CMS 1500 or Medical Uniform Institutional Provider Bill Form UB-04 to request payment or reimbursement for such treatment. VA uses the data collected to determine the claimant's eligibility for payment or reimbursement.

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 October 12, 2011, at page 63353.

Affected Public: Business or other for-profit.

Estimated Total Annual Burden: 51,768 hours.

Estimated Average Burden per Respondent: 15 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 207,071.

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By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

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[FR Doc. 2011-32268 Filed 12-16-11; 8:45 am]