Agency Information Collection Activities Under OMB Review

DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0091]

Agency Information Collection Activities Under OMB Review

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: In compliance with the Paperwork Reduction Act (PRA) of 1995

(44 U.S.C. 3501 et seq.), this notice announces that the Veterans

Health Administration (VHA), Department of Veterans Affairs, has

submitted 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; it includes the actual data collection

instrument.

DATES: Comments must be submitted on or before October 14, 1997.

FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT: Ron

Taylor, Information Management Service (045A4), Department of Veterans

Affairs, 810 Vermont Avenue, NW, Washington, DC 20420, (202) 273-8015

or FAX (202) 273-5981. Please refer to ``OMB Control No. 2900-0091.''

SUPPLEMENTARY INFORMATION:

Title and Form Numbers: Application for Medical Benefits, VA Forms

10-10 and 10-10T; Insurance Information, VA Form 10-10I; Financial

Worksheet, VA Form 10-10F; and Funeral Arrangements, VA Form 10-2065.

OMB Control Number: 2900-0091.

Type of Review: Revision of a currently approved collection.

Abstract: The OMB approvals for use of these forms is due to expire

on August 31, 1997. Many of these forms will be redesigned to meet the

requirements of Public Law 104-262, Veterans' Health Care Eligibility

Reform Act of 1996. VHA is requesting an extension until such time as

these forms

[[Page 47880]]

are designed and the enrollment process is implemented.

Title 38, U.S.C., Chapter 17, authorized VA to provide hospital

care, medical services, domiciliary care and nursing home care to

eligible veterans. Public Law 99-272 amending Title 38, U.S.C., Section

1729, established new eligibility assessment procedures, based on

income levels, for determining whether nonservice-connected veterans

are eligible for cost-free VA medical care and authorizes VA to recover

the cost of care furnished to veterans from their health insurance

carriers. Public Law 99-272 codified at Title 38, U.S.C., Section 1722,

authorized VA to provide care to nonservice-connected veterans who are

unable to defray the necessary expenses of care if the veteran's

attributable income is not greater than the maximum annual pension

rate. Title 38 U.S.C., Section 1722a, authorizes collection of a co-

payment for medications. Public Law 104-262 requires VA to design,

establish and operate a system of annual patient enrollment in

accordance with a series of priorities stipulated in the law. A

consequence of this law is that many groups of veterans who are in a

lower priority group (W.W.I veterans, veterans with disabilities rated

as 0% service-connected seeking treatment for other than their service

connected conditions, veterans exposed to a toxic substance, radiation,

or environmental hazard and nonservice-connected veterans) may request

that they be allowed to be income tested in order to gain a higher

priority. Title 38, U.S.C., Chapters 23 and 24, authorizes VA to

provide burial benefits and to bury the remains of an eligible deceased

veteran in a National Cemetery.

VA Forms 10-10, 10-10T, 10-10F, and 10-10I are generally completed

by clerical staff at the VHA medical facility where the applicant

applies for medical care benefits; however, the forms may be completed

by veterans in the convenience of their home. If the veteran is

completing the forms at home and it is the first time application is

made, the forms are submitted to the nearest VA health care facility

for processing. VA Form 10-2065 is generally completed by clerical

staff at the medical center upon the death of a veteran in a VA medical

care facility.

VA Form 10-10 is used to establish a system of records on veterans

applying for medical care benefits. The information collected is used

to identify the veteran applying for medical care, emergency contact

data, employment information, military service data, and income

screening data for pharmacy co-payment authorized under Title 38,

U.S.C., Section 1722A. This also includes the ``missing'' VA Form 10-

10T data collected at a later date.

VA Form 10-10T is a simplified version of VA Form 10-10 and was

created to shorten the application process. VA Form 10-10T is used to

identify the veteran applying for medical care, establish a veteran's

initial eligibility and establish a system of records on veterans

applying for medical care benefits. If the veteran is eligible for

care, any missing data which in the past would have been collected on

VA Form 10-10, such as an emergency contacts, employment information,

military service data, and income screening data for pharmacy co-

payment authorized under Title 38, U.S.C., Section 1722A is collected

at a later date.

VA Form 10-10F is used in the information collection process to

obtain financial information on all veterans whose eligibility for VA

health care benefits is based on income. Nonservice-connected veterans

and noncompensable service-connected veterans rated 0% seeking care for

their nonservice-connected conditions complete the form to establish

their eligibility for cost-free health care, mileage reimbursement and

prescription co-payment exemption benefits. Veterans with compensable

service-connected disabilities rated 0, 10 or 20%, may provide their

income information to establish their eligibility for prescription co-

payment exemption and mileage reimbursement. Veterans with service-

connected disabilities rated 30 or 40% may provide their income

information to determine their eligibility for prescription co-payment

exemption.

VA Form 10-10I is used in the information collection process to

collect health insurance information and to bill health insurance

carriers to recover the cost of medical care furnished to veterans for

treatment on nonservice-connected conditions.

VA Form 10-2065 is used primarily in VA medical facilities and

serves as an official record of the funeral director to which the

person making funeral arrangements wishes the remains to be released.

It is used as a control document when VA is requested to arrange for

the transportation of the deceased from the place of death to the place

of burial, and/or when burial is requested in a National Cemetery. This

information is requested under the authority of Title 38, U.S.C.,

Chapters 23 and 24.

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 on May 27, 1997 at page 28757-28758.

Affected Public: Individuals or households.

Estimated Annual Burden: 2,766,738 hours.

VA Form 10-10--1,631,250 hours

VA Form 10-10T--60,417 hours

VA Form 10-10F--492,000 hours

VA Form 10-10I--480,000 hours

VA Form 10-2065--3,071 hours

Estimated Average Burden Per Respondent.

VA Form 10-10--45 minutes

VA Form 10-10T--5 minutes

VA Form 10-10F--20 minutes

VA Form 10-10I--12 minutes

VA Form 10-2064--5 minutes

Frequency of Response: On occasion.

Estimated Number of Respondents: 7,336,850.

VA Form 10-10--2,175,000

VA Form 10-10T--725,000

VA Form 10-10F--1,500,000

VA Form 10-10I--2,900,000

VA Form 10-2064--34,850

Send commends and recommendations concerning any aspect of the

information collection to VA's OMB Desk Officer, Allison Eydt, OMB

Human Resources and Housing Branch, New Executive Office Building, Room

10235, Washington, DC 20503, (202) 395-4650. Please refer to ``OMB

Control No. 2900-0091'' in any correspondence.

Dated: August 12, 1997.

By direction of the Secretary.

Donald L. Neilson,

Director, Information Management Service.

[FR Doc. 97-24063 Filed 9-10-97; 8:45 am]

BILLING CODE 82320-01-M