Information Collection

10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program

IC 213635 under ICR 202008-2900-001 · OMB 2900-0823.

Documents and Forms

Document Name Document Type
10-10143_Election to Non-VA Care_Telephone Script - 2021.docx Other-Script

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Community Care Program	Agency IC Tracking Number:	2900-0823

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.1515

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Script			10-10143_Election to Non-VA Care_Telephone Script - 2021.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,665,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,665,000	3,665,000
Annual IC Time Burden (Hours)	610,833	610,833
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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