OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

VA Health Benefits Application and Update - VA Forms 10-10EZ and 10-10EZR

ICR 201909-2900-005 · OMB 2900-0091 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 10-10HS Application and Renewal for Health Benefits Form and Instruction Removed Repair queued
Form 10-10EZR VA Form 10-10EZR -- Health Benefits Update Form Form and Instruction New Repair queued
Form 10-10EZ VA Form 10-10EZ -- Application for Health Benefits Form and Instruction New Available
Form 10-10EZ Applications and Renewal for Health Benefits Form and Instruction Removed Available
Summary of Updates to VA Forms 10-10EZ and 10-10EZR_Sept 2019.docx Supplementary Document Uploaded 2019-10-11 Available
Non-Substantive Change Memorandum_2900-0091_Sept 2019.pdf Supplementary Document Uploaded 2019-10-01 Repair queued
20180614 Non Substantive Change Memo - 10-10EZ Spanish Version.pdf Justification for No Material/Nonsubstantive Change Uploaded 2018-07-10 Repair queued
2900-0091 White Paper_August 2017.docx Supplementary Document Uploaded 2017-08-24 Repair queued
2900-0091 60dayFRN VACO-0001-0021.pdf Supplementary Document Uploaded 2017-02-09 Repair queued
White Paper_VA Form 10-10EC_10.24.16.doc Justification for No Material/Nonsubstantive Change Uploaded 2017-02-09 Available
2900-0091_Justification Statement A_20180614.doc Supporting Statement A Uploaded 2018-07-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
28251 Application and Renewal for Health Benefits Form and Instruction Removed
237785 VA Form 10-10EZR -- Health Benefits Update Form Form and Instruction New
237784 VA Form 10-10EZ -- Application for Health Benefits Form and Instruction New
212005 Applications and Renewal for Health Benefits Form and Instruction Removed
ICR Details
2900-0091 201909-2900-005
Historical Active 201807-2900-003
VA 2900-0091
VA Health Benefits Application and Update - VA Forms 10-10EZ and 10-10EZR
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 01/21/2020
Retrieve Notice of Action (NOA) 10/01/2019
  Inventory as of this Action Requested Previously Approved
12/31/2020 12/31/2020 12/31/2020
1,010,000 0 1,017,000
454,000 0 455,750
0 0 0
Non-substantive updates have been made to VA Forms 10-10EZ and 10-10EZR to bring these forms into compliance with the MISSION Act of 2018. The forms collect information to enroll for health care benefits, establish basic eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission or yearly financial updates. A signed Non-substantive Change Memorandum has been added to the supplementary documents section.
US Code: 38 USC Chapter 17 Name of Law: HOSPITAL, NURSING HOME, DOMICILIARY,
   US Code: 38 USC 111(c)(1) Name of Law: Payments or allowances for beneficiary travel
  
PL: Pub.L. 115 - 182 101 Name of Law: MISSION Act of 2018
Not associated with rulemaking
  82 FR 8971 02/01/2017
82 FR 19313 04/26/2017
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 1,010,000 1,017,000 -1,010,000 1,010,000 -7,000 0
Annual Time Burden (Hours) 454,000 455,750 -454,000 454,000 -1,750 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Non-substantive updates have been made to VA Forms 10-10EZ and 10-10EZR to bring these forms into compliance with the MISSION Act of 2018. The burden has not changed for either form as a result of these updates.
$4,263,550
No
    Yes
    Yes
No
No
No
Uncollected
Frances O'Donnell 703 405-2449 [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.
10/01/2019