AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES

ICR 198611-2900-011

OMB: 2900-0339

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
2900-0339 198611-2900-011
Historical Active 198610-2900-010
VA
AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES
No material or nonsubstantive change to a currently approved collection   No
Emergency 11/30/1986
Approved with change 11/30/1986
Retrieve Notice of Action (NOA) 11/30/1986
  Inventory as of this Action Requested Previously Approved
09/30/1989 09/30/1989 09/30/1989
252,000 0 252,000
10,080 0 10,080
0 0 0

THIS FORM IS USED IN VA MEDICAL FACILITIES TO AUTHORIZE AND PROCESS PAYMENT OF MEDICAL AND HOSPITAL SERVICES FOR VA BENEFICIARIES PROVIDED BY OTHER THAN FEDERAL HEALTH PROVIDERS.

None
None


No

1
IC Title Form No. Form Name
AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES 10-7078

  Total Approved 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 252,000 252,000 0 0 0 0
Annual Time Burden (Hours) 10,080 10,080 0 20 -20 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
11/30/1986


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