Agency Information Collection Activity Under OMB Review: General Release for Medical Provider Information to the Department of Veterans Affairs (VA) and Authorization and Consent To Release Information to the Department of Veterans Affairs

DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-NEW]

Agency Information Collection Activity Under OMB Review: General Release for Medical Provider Information to the Department of Veterans Affairs (VA) and Authorization and Consent To Release Information to the Department of Veterans Affairs

AGENCY:

Veterans Benefits Administration, Department of Veterans Affairs.

ACTION:

Notice.

SUMMARY:

In compliance with the Paperwork Reduction Act (PRA) of 1995, this notice announces that the Veterans Benefits Administration, Department of Veterans Affairs, will submit the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and it includes the actual data collection instrument.

DATES:

Comments must be submitted on or before November 6, 2017.

ADDRESSES:

Submit written comments on the collection of information through

www.Regulations.gov

, or to Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW., Washington, DC 20503 or sent through electronic mail to

oira_submission@omb.eop.gov.

Please refer to “OMB Control No. 2900-NEW” in any correspondence.

FOR FURTHER INFORMATION CONTACT:

Cynthia Harvey-Pryor, Enterprise Records Service (005R1B), Department of Veterans Affairs, 811 Vermont Avenue NW., Washington, DC 20420, (202) 461-5870 or email

cynthia.harvey-pryor@va.gov.

Please refer to “OMB Control No. 2900-NEW” in any correspondence.

SUPPLEMENTARY INFORMATION:

Authority:

44 U.S.C. 3501-21.

Title:

General Release for Medical Provider Information to the Department of Veterans Affairs (VA) (VA Form 21-4142) and Authorization and Consent to Release Information to the Department of Veterans Affairs (VA Form 21-4142a).

OMB Control Number:

2900-NEW.

Type of Review:

New collection.

Abstract:

VA Forms 21-4142 will be used to authorize the disclosure of information to the VA and 21-4142a will be used to gather the necessary information to request medical provider information to the VA.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The

Federal Register

Notice with a 60-day comment period soliciting comments on this collection of information was published at 82 FR 125 on June 30, 2017, page 30004.

Affected Public:

Individuals or Households.

Estimated Annual Burden:

11,033.

Estimated Average Burden per Respondent:

5 minutes.

Frequency of Response:

One time.

Estimated Number of Respondents:

132,400.

By direction of the Secretary.

Cynthia Harvey-Pryor,

Department Clearance Officer, Office of Quality, Privacy and Risk, Department of Veterans Affairs.

[FR Doc. 2017-21433 Filed 10-4-17; 8:45 am]

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