OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

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

ICR 202009-2900-020 · OMB 2900-0858 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form VA Form 21-4142 Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a) Form Modified Missing upstream
2021-10638, 30-Day FRN (VAF21-4142 series).pdf Supplementary Document Uploaded 2021-05-20 Repair queued
2021-05458, 60-Day FRN (VAF21-4142 series).pdf Supplementary Document Uploaded 2021-05-06 Repair queued
2900-0858, Supporting Statement (VAF21-4142 series).docx Supporting Statement A Uploaded 2021-05-06 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
228502 Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a) Form Modified
ICR Details
2900-0858 202009-2900-020
Received in OIRA 201709-2900-024
VA VBA-COMP-NK
Authorization to Disclose Information to the VA (VA Form 21-4142), General Release of Medical Provider Information to the VA (VA Form 21-4142a)
Reinstatement with change of a previously approved collection   No
Regular 05/24/2021
  Requested Previously Approved
36 Months From Approved
127,397 0
10,616 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.
US Code: 38 USC Section 5101(a) (1) Name of Law: Claims and Forms
   PL: Pub.L. 104 - 191 203 Name of Law: Health Insurance Portability And Accountability Act
   US Code: 42 USC 290dd-2 Name of Law: Confidentiality of records
  
None
Not associated with rulemaking
  86 FR 14687 03/17/2021
86 FR 27502 05/20/2021
No
  Total Request 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 127,397 0 0 -5,003 0 132,400
Annual Time Burden (Hours) 10,616 0 0 -417 0 11,033
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
The respondent burden has decreased due to the estimated number of receivables averaged over the past two years.
$3,369,091
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 [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.
05/24/2021