Information Collection

10-10143a Veterans Community Care Health Insurance Certification

IC 213636 under ICR 202008-2900-001 · OMB 2900-0823.

Documents and Forms

Document Name Document Type
Form 10-10143a 10-10143a Veterans Community Care Health Insurance Certification Form and Instruction
10-10143a Veterans Community Care Health Insurance Certification VA Form 10-10143a_revised 2020.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	10-10143a Veterans Community Care Health Insurance Certification	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 17.1510(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-10143a	Veterans Community Care Health Insurance Certification	VA Form 10-10143a_revised 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: 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
No associated records found

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