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Federal forms, ICRs, and supporting documents

Information Collection Request

Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....

ICR 200203-2900-014 · OMB 2900-0080 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
42186 Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical.... Form Migrated
ICR Details
2900-0080 200203-2900-014
Historical Active 200108-2900-007
VA
Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 03/12/2002
Retrieve Notice of Action (NOA) 03/12/2002
  Inventory as of this Action Requested Previously Approved
11/30/2004 11/30/2004 10/31/2004
480,100 0 480,100
32,742 0 32,742
0 0 0
These forms are used to initiate and document expenditures, to claim reimbursement as well as make funeral arrangements and authorize burial benefits.
None
None
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 480,100 480,100 0 0 0 0
Annual Time Burden (Hours) 32,742 32,742 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/12/2002