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Agency Information Collection (VA Meds by Mail Order Form, VA Form 10-0426) Activities: 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 January 22, 2015.


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-NEW (VA Meds by Mail Order Form)” 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-NEW (VA Meds by Mail)” 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.

Titles: VA Meds by Mail Order Form.

OMB Control Number: 2900-NEW (VA Meds by Mail Order Form, VA Form 10-0426).

Type of Review: New collection.

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 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.Start Printed Page 77098

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.

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 8, 2014, at page 60896.

Affected Public: Individuals or households.

Estimated Annual Burden: 9,167 burden hours.

Estimated Average Burden Per Respondent: 5 minutes.

Frequency of Response: Yearly.

Estimated Number of Respondents: 110,000.

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Dated: December 17, 2014.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, Department of Veterans Affairs.

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[FR Doc. 2014-29934 Filed 12-22-14; 8:45 am]