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VA Meds by Mail Order Form, VA Form 10-0426

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Comment Request


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 revised collection, and allow 60 days for public comment in response to the notice. This notice solicits comments on information needed to obtain an accurate and comprehensive assessment of satisfaction of patients who receive mental health care services and on outcomes for Veterans who seek mental health treatment from VHA. Data will allow the program office to ensure that the target audience is being reached, effective treatments are being offered, and tangible, quantitative results are being measured and tracked for continual program improvement.


Written comments and recommendations on the proposed collection of information should be received on or before. December 8, 2014.


Submit written comments on the collection of information through the Federal Docket Management System (FDMS) at;​ or to Audrey Revere, Office of Regulatory and Administrative Affairs, Veterans Health Administration (10B4), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email: Please refer to “OMB Control No. 2900-NEW, VA Meds by Mail Order Form, VA Form 10-0426” in any correspondence. During the comment period, comments may be viewed online through FDMS.

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Audrey Revere at (202) 461-5694.

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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 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: Meds By Mail Order Form, VA Form 10-0426.

OMB Control Number: 2900-NEW.

Type of Review: New Collection (Request for a new OMB Control Number).

Abstract: VA Form 10-0426, Meds by Mail (MbM) Order Form, is used by eligible CHAMPVA and Spina Bifida beneficiaries (also referred to as patient) in accordance with 38 CFR Sections 17.270, 17.271 and 17.272 when submitting a paper prescription written by their medical provider for fulfillment through the Meds by Mail Program. Information collected on this form is necessary for proper patient identification and medical record review.

The provisions of VHA Handbook 1108.05, Outpatient Pharmacy Services, require that, as a condition for dispensing a prescription, the prescription must contain the following patient identifiers:

(1) Patient's Full Name

(2) Social Security Number

(3) Patient's Current Address

Local Meds by Mail Desk Procedure utilizes date of birth as an additional patient identifier.

The provisions of VHA Handbook 1108.05, Outpatient Pharmacy Services require pharmacists to review the patient medical record for the presence of allergy information and the potential for adverse drug events prior to the dispensing of medication to the patient.

Affected Public: Individuals or Households.

Estimated Total Annual Burden: 18,333 hours.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: Yearly.

Estimated Number of Respondents: 110,000.

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Dated: October 3, 2014.

By direction of the Secretary.

Crystal Rennie,

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

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[FR Doc. 2014-23995 Filed 10-7-14; 8:45 am]