Information Collection

Authorization And Invoice For Medical And Hospital Services, Claim For Payment Of Unauthorized Medical Services, Authority & Invoice For Travel By Ambulance Or...

IC 174212 under ICR 199408-2900-004 · OMB 2900-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0080 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES, CLAIM FOR PAYMENT OF UNAUTHORIZED MEDICAL SERVICES, AUTHORITY & INVOICE FOR TRAVEL BY AMBULANCE OR...	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	VA 10-7078	No	No
Form	10-583	No	No
Form	10-2511	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 443,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	443,250	443,250
Annual IC Time Burden (Hours)	29,500	29,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.