Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization and Consent to Release Info to the Dept of VA
ICR 201403-2900-010 · OMB 2900-0001 · Historical Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0001 can be found here:
Veteran's Application for C&P, Veteran's Supplemental Claim Application, General Release for Med Provider Info to the Dept of VA, Authorization and Consent to Release Info to the Dept of VA
VA Forms 21-526 and 21-526b are used to gather the necessary information to determine a veteran's eligibility, dependency, and income, as applicable, for the compensation and/or pension benefit sought. Without this information, determination of entitlement would not be possible.
VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA).
VA Form 21-4142a, is used to gather private provider information from the claimant to the VA.
Burden increased because VA's Compensation Service added a new form to the icr 2900-0001. VA has newly created the VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). The new VA Form 21-4142a is created to gather Private Health Provider information from the claimant and is filled out in conjunction with the VA Form 21-4142 as this form does not require a signature. It is solely used by VA to gather information to be used to develop for private medical records.
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.
Form VA Form 21-526 Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application
Suppl Stmt - DOMA, 21-526, 21-526b (non-sub).docx
Veteran's Application for Compensation and/ or Pension; Authorization and Consent to Release Information to the DVA, Veteran's Supplemental Claim Application