This PDF is the current document as it appeared on Public Inspection on 04/25/2017 at 08:45 am.
Veterans Health Administration, Department of Veterans Affairs.
In compliance with the Paperwork Reduction Act (PRA) of 1995, 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; it includes the actual data collection instrument.
Comments must be submitted on or before May 26, 2017.
Submit written comments on the collection of information through www.Regulations.gov, 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 firstname.lastname@example.org. Please refer to “OMB Control No. 2900-0091” in any correspondence.Start Further Info
FOR FURTHER INFORMATION CONTACT:
Cynthia Harvey-Pryor, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 461-5870 or email email@example.com. Please refer to “OMB Control No. 2900-0091.”End Further Info End Preamble Start Supplemental Information
1. Enrollment Application for VA Health Care—VA Form 10-10EZ.
2. Application for Renewal of Health Care Benefits—VA Form 10-10EZR.
3. Request for Hardship Determination—VA Form 10-10HS.
OMB Control Number: 2900-0091.
Type of Review: Reinstatement.
a. VA Form 10-10EZ collects information only from new applicants for VA medical care, nursing home, domiciliary, dental benefits, and new enrollees in the VA health care system.
b. VA Form 10-10EZR, Health Benefits Renewal Form, is used to collect data from those veterans who wish to update their application data.
c. VA Form 10-10HS collects information only from veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits.
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 February 1, January 19, 2017, Volume 82, No. 20, page 8971.
Affected Public: Individuals or households.
Estimated Annual Burden:
a. Enrollment Application for VA Health Care—VA Form 10-10EZ—270,000 hours.
b. Application for Renewal of Health Care Benefits—VA Form 10-10EZR—343,600 hours.
c. Request for Hardship Determination—VA Form 10-10HS—1,750 hours.
Estimated Average Burden per Respondent:
a. Enrollment Application for VA Health Care—VA Form 10-10EZ—30 minutes.
b. Application for Renewal of Health Care Benefits—VA Form 10-10EZR—24 minutes.
c. Request for Hardship Determination—VA Form 10-10HS—15 minutes.
Frequency of Response: Annually.
Estimated Annual Responses:
a. Enrollment Application for VA Health Care—VA Form 10-10EZ—540,000.
b. Application for Renewal of Health Care Benefits—VA Form 10-10EZR—859,000.
c. Request for Hardship Determination—VA Form 10-10HS—7,000.Start Signature
By direction of the Secretary.
Department Clearance Officer, Enterprise Records Service, Office of Quality and Compliance, Department of Veterans Affairs.
[FR Doc. 2017-08441 Filed 4-25-17; 8:45 am]
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