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Agency Information Collection (Application for Extended Care Services, VA Form 10-10EC); 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 (VHA), 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.


Written comments and recommendations on the proposed collection of information should be received on or before October 6, 2014.

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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. 2900-0629” in any correspondence. During the comment period, comments may be viewed online through the FDMS.

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Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492 or email Please refer to “OMB Control No. 2900-0629” in any correspondence.

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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.

Title: Application for Extended Care Services, VA Form 10-10EC.

OMB Control Number: 2900-0629.

Type of Review: Revision of a currently approved collection.

Abstract: Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care and nursing home care to eligible Veterans. Title 38 U.S.C. 1705 requires VA to design, establish and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. A consequence of this is that many groups of Veterans who are in a lower priority group may request that they be allowed to be income tested in order to gain a higher priority. Title 38 U.S.C. 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which will determine whether nonservice-connected and 0% service-connected noncompensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Title 38 U.S.C. 1722A establishes the eligibility assessment procedures, based on income levels, for determining Veterans' eligibility for cost-free medications and Title 38 U.S.C. 1710B defines the procedures for establishing eligibility for cost-free Extended Care benefits. Title 38 U.S.C. 1729 authorizes VA to recover from Veterans' health insurance carriers the cost of care furnished for their nonservice-connected conditions.

VA Form 10-10EC, Application for Extended Care Services, is used to collect financial information necessary to determine a Veteran's copayment obligation for extended care services, also known as long term care (LTC). VA Form 10-10EC, Application for Extended Care Services collects information to establish eligibility for extended care benefits, establishes financial liability Veteran to pay if accepted for placement in Extended Care Services, and establishes veteran has agreed to make any applicable copayment.

Affected Public: Individuals or Households.

Estimated Total Annual Burden: 3,000 hours.

Estimated Average Burden per Respondent: 90 minutes.

Frequency of Response: Yearly.

Estimated Number of Respondents: 2,000.

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Dated: September 2, 2014.

By direction of the Secretary.

Crystal Rennie,

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

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[FR Doc. 2014-21148 Filed 9-4-14; 8:45 am]