OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Dental Record Authorization and Invoice for Outpatient Service

ICR 200909-2900-003 · OMB 2900-0335 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient Service Form Modified Available
2900-0335 justification.DOC Supporting Statement A Uploaded 2009-12-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28546 Dental Record Authorization and Invoice for Outpatient Service Form Modified
ICR Details
2900-0335 200909-2900-003
Historical Active 200612-2900-013
VA 2900-0335
Dental Record Authorization and Invoice for Outpatient Service
Extension without change of a currently approved collection   No
Regular
Approved without change 02/01/2010
Retrieve Notice of Action (NOA) 12/10/2009
  Inventory as of this Action Requested Previously Approved
02/28/2013 36 Months From Approved 02/28/2010
11,000 0 12,460
3,666 0 4,153
0 0 0
VA Form 10-2570d lists the veteran's dental treatment needs, the cost to the VA to provide these services, authorizes this treatment and serves as an invoice for payment.
US Code: 38 USC Section 1712(a) and (b) Name of Law: Veterans' Benefits
   US Code: 38 USC Section 1710(4)(c) Name of Law: Veterans' Benefits
  
None
Not associated with rulemaking
  74 FR 187 09/29/2009
74 FR 235 12/09/2009
No
1
IC Title Form No. Form Name
Dental Record Authorization and Invoice for Outpatient Service VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient Service
  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 11,000 12,460 0 0 -1,460 0
Annual Time Burden (Hours) 3,666 4,153 0 0 -487 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There is an estimation of 44,000 dental treatment cases authorized annually for fee dental treatment. It has been estimated that only 25% of fee dentists will VA form 10-2570d, the remainder will use forms auto generated by their office automation software.
$319,803
No
No
Uncollected
Uncollected
No
Uncollected
Denise McLamb 202-565-8374 [email protected]
  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.
12/10/2009