OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)

ICR 201709-2900-024 · OMB 2900-0858 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 21-4142 Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a) Form New Available
2017-21433, 30-Day FRN (VAFs 21-4142-4142a).pdf Supplementary Document Uploaded 2017-10-20 Repair queued
2900-NEW, Supporting Statement (4142-4142a).docx Supporting Statement A Uploaded 2017-09-28 Available
2017-13731, 60-Day FRN (VAFs 21-4142, 21-4142a).pdf Supplementary Document Uploaded 2017-09-28 Available
IC Document Collections
IC IDCollectionTypeStatusForm
228502 Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a) Form New
ICR Details
2900-0858 201709-2900-024
Active
VA VBA-COMP-DJ
Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 03/05/2018
Retrieve Notice of Action (NOA) 11/16/2017
  Inventory as of this Action Requested Previously Approved
03/31/2021 36 Months From Approved
132,400 0 0
11,033 0 0
0 0 0
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. Without this information, determination of entitlement would not be possible. This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned. VA Forms 21-4142 and 21-4142a are being revised to include new standardization data points; to include optical character recognition boxes. VA Form 21-4142a has been further revised to include patient identification information. This addition does not increase the burden.
US Code: 38 USC Section 5101(a) Name of Law: Claims and Forms
  
None
Not associated with rulemaking
  82 FR 30004 06/30/2017
82 FR 46614 10/05/2017
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 132,400 0 0 132,400 0 0
Annual Time Burden (Hours) 11,033 0 0 11,033 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned.
$7,169,467
No
    Yes
    Yes
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [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.
11/16/2017