DENTAL RECORD, AUTHORIZATION AND INVOICE FOR OUTPATIENT SERVICES

ICR 198906-2900-013

OMB: 2900-0335

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
2900-0335 198906-2900-013
Historical Active 198610-2900-013
VA
DENTAL RECORD, AUTHORIZATION AND INVOICE FOR OUTPATIENT SERVICES
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/19/1989
Approved with change 06/19/1989
Retrieve Notice of Action (NOA) 06/19/1989
  Inventory as of this Action Requested Previously Approved
07/31/1989 07/31/1989 07/31/1989
43,113 0 43,113
14,371 0 14,371
0 0 0

VETERANS BENEFITS, DENTAL SERVICES, PROFESSIONAL FEES, MEDICAL RECORD AUTHORIZE VETERANS TO SEEK PRIVATE DENTISTS FOR DENTAL EXAMINATION AND TREATMENT PLAN. FORM IS RETURNED TO VA FOR REVIEW AND TREATMENT AUTHORIZATION. ON COMPLETION OF TREATMENT, ORIGINAL AND COPY ARE RETURNED TO VA WHERE THEY SERVE AS A RECORD OF TREATMENT AND INVOICE FOR PAYMENT RESPECTIVELY.

None
None


No

1
IC Title Form No. Form Name
DENTAL RECORD, AUTHORIZATION AND INVOICE FOR OUTPATIENT SERVICES VA 10-2570D

  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 43,113 43,113 0 0 0 0
Annual Time Burden (Hours) 14,371 14,371 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
06/19/1989


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