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Agency Information Collection (Claim, Authorization and Invoice for Prosthetic Items and Services); 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. 3501-3521), 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 and includes the actual data collection instrument.


Comments must be submitted on or before October 24, 2013.


Submit written comments on the collection of information through, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW., Washington, DC 20503 or sent through electronic mail to Please refer to “OMB Control No. 2900-0188” in any correspondence.

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Crystal Rennie, Enterprise Records Start Printed Page 58610Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW,, Washington, DC 20420, (202) 632-7492 or email Please refer to “OMB Control No. 2900-0188.”

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(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.

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 11, 2013, at page 35099.

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: September 19, 2013.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, U.S. Department of Veterans Affairs.

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[FR Doc. 2013-23137 Filed 9-23-13; 8:45 am]