OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Dental Record Authorization and Invoice for Outpatient Service

ICR 201211-2900-002 · 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 A (v2).docx Supporting Statement A Uploaded 2013-05-23 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28546 Dental Record Authorization and Invoice for Outpatient Service Form Modified
ICR Details
2900-0335 201211-2900-002
Historical Active 200909-2900-003
VA 2900-0335
Dental Record Authorization and Invoice for Outpatient Service
Reinstatement with change of a previously approved collection   No
Regular
Approved with change 07/02/2013
Retrieve Notice of Action (NOA) 03/05/2013
  Inventory as of this Action Requested Previously Approved
07/31/2016 36 Months From Approved
11,000 0 0
3,666 0 0
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
  77 FR 223 11/19/2012
78 FR 21 01/31/2013
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 0 0 0 0 11,000
Annual Time Burden (Hours) 3,666 0 0 0 0 3,666
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$352,363
No
No
No
No
No
Uncollected
Crystal Rennie 202 632-7492 [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.
03/05/2013