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Proposed Information Collection Activity: [Claim, Authorization and Invoice for Prosthetic Items and Services]; 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 proposed revision 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 determine eligibility and authorize funding for various prosthetic services.


Written comments and recommendations on the proposed collection of information should be received on or before August 12, 2013.


Submit written comments on the collection of information through the Federal Docket Management System (FDMS) at;​ or to Cynthia Harvey-Pryor, Veterans Health Administration (10B4), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email: Please refer to “OMB Control No. 2900-0188” in any correspondence. During the comment period, comments may be viewed online through FDMS.

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Cynthia Harvey-Pryor at (202) 461-5870 or Fax (202) 495-5397.

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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) Request to Submit Quotation, Form Letter 10-90.

(b) Veterans Application for Assistance in Acquiring Home Improvement and Structural Alterations, VA Form 10-0103.

(c) Application for Adaptive Equipment Motor Vehicle, VA Form 10-1394.

(d) Prosthetic Authorization for Items or Services, VA Form 10-2421.

(e) Prosthetic Service Card Invoice, VA Form 10-2520.

(f) Prescription and Authorization for Fee Basis Eyeglasses, VA Form 10-2914.

OMB Control Number: 2900-0188.

Type of Review: Revision of a currently approved collection.

Abstract: The following forms will are used to determine eligibility, prescribe and authorize prosthetic devices:

a. VA Form Letter 10-90 is used to obtain to estimated price for prosthetic devices.

b. VA Form 10-0103 is used to determine eligibility/entitlement and reimbursement of individual claims for home improvement and structural alterations.

c. VA Form 10-1394 is used to determine eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment.

d. VA Form 10-2421 is used for the direct procurement of new prosthetic appliances and/or services. The form standardizes the direct procurement authorization process, eliminating the need for separate purchase orders, expedites patient treatment and improves the delivery of prosthetic services.

e. VA Form 10-2520 is used by the vendors as an invoice and billing document. The form standardizes repair/treatment invoices for prosthetic services rendered and standardizes the verification of these invoices. The Veteran certifies that the repairs were necessary and satisfactory. This form is furnished to vendors upon request.

f. VA Form 10-2914 is used as a combination prescription, authorization and invoice. It allows veterans to purchase their eyeglasses directly. If the form is not used, the provisions of providing eyeglasses to eligible Veterans may be delayed.

Affected Public: Individuals or households.

Estimated Total Annual Burden: 5,738.

(a) Form Letter 10-90—708.

(b) VA Form 10-0103—583.

(c) VA Form 10-1394—1,000.

(d) VA Form 10-2421—67.

(e) VA Form 10-2520—47.

(f) VA Form 10-2914—3,333.

Estimated Average Burden per Respondent:

(a) Form Letter 10-90—5 minutes.

(b) VA Form 10-0103—5 minutes.

(c) VA Form 10-1394—15 minutes.

(d) VA Form 10-2421—4 minutes.

(e) VA Form 10-2520—4 minutes.

(f) VA Form 10-2914—4 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents: 71,200.

a. Form Letter 10-90—8,500.

c. VA Form 10-0103—7,000.

d. VA Form 10-1394—4,000.

e. VA Form 10-2421—1,000.

f. VA Form 10-2520—700.

g. VA Form 10-2914—50,000.

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Dated: June 5, 2013.

By direction of the Secretary:

Crystal Rennie,

VA Clearance Officer, Office of Information and Technology, U.S. Department of Veterans Affairs.

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[FR Doc. 2013-13723 Filed 6-10-13; 8:45 am]