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Agency Information Collection Activity Under OMB Review: Authorization and Consent To Release Information to the Department of Veterans Affairs (VA), and General Release for Medical Provider Information to the Department of Veterans Affairs (VA)

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Veterans Benefits Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Benefits Administration (VBA), 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 it includes the actual data collection instrument.


Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to​public/​do/​PRAMain. Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function. Refer to “OMB Control No. 2900-0858”.

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Maribel Aponte, Office of Enterprise and Integration, Data Governance Analytics (008), 1717 H Street NW, Washington, DC 20006, (202) 266-4688 or email Please refer to “OMB Control No. 2900-0858” in any correspondence.

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Authority: 38 U.S.C. 5101(a)(1).

Title: Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) (VA Form 21-4142), and General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA Form 21-4142a).

OMB Control Number: 2900-0858.

Type of Review: Reinstatement of a previously approved collection.

Abstract: VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather the necessary information to request medical provider information to the VA. Without the information solicited by these forms, VA would be unable to determine eligibility, and benefits would not be properly paid.

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 at 86 FR 50 on March 17, 2021, page 14687.

Affected Public: Individuals or Households.

Estimated Annual Burden: 10,616.

Estimated Average Burden per Respondent: 5 minutes.

Frequency of Response: One time.

Estimated Number of Respondents: 127,397.

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By direction of the Secretary.

Maribel Aponte,

VA PRA Clearance Officer, Office of Enterprise and Integration, Data Governance Analytics, Department of Veterans Affairs.

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[FR Doc. 2021-10638 Filed 5-19-21; 8:45 am]