Information Collection

VA Form 10-10143g: Non-VA Hospital Emergency Notification

IC 242010 under ICR 202005-2900-018 · OMB 2900-0823.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0823 can be found here:

Documents and Forms

Document Name Document Type
Form 10-10143g VA Form 10-10143g: Non-VA Hospital Emergency Notification Form
10-10143g Non-VA Hospital Emergency Notification Non-VA Hospital Emergency Notification_VA Form 10-10143g_May 2020.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VA Form 10-10143g: Non-VA Hospital Emergency Notification	Agency IC Tracking Number:	2900-0823

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.4020

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-10143g	Non-VA Hospital Emergency Notification	Non-VA Hospital Emergency Notification_VA Form 10-10143g_May 2020.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	83,333	83,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.