Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice...

Claim, Authorization and Invoice for Beneficiary Travel and other Miscellaneous Medical Services

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 10-583 Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice... Form
10-583 CLAIM FOR PAYMENT OF COST OF UNAUTHORIZED MEDICAL SERVIC 10-583-fill 6 21.pdf www.va.gov/vaforms Form
10-2065 FUNERAL ARRANGEMENTS 10-2065.pdf www.va.gov/vaforms Form
10-2511 AUTHORITY AND INVOICE FOR TRAVEL BY AMBULANCE OR OTHER H 10-2511.pdf http:www.va.gov/vaforms Form
10-7078 AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVI 10-7078.pdf http:www.va.gov/vaforms Form

Information Collection (IC) Details

IC Title:	Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority and Invoice for Travel by Ambulance or Other Hired Vehicle; Authorization and Invoice...	Agency IC Tracking Number:	2900-0080

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-583	CLAIM FOR PAYMENT OF COST OF UNAUTHORIZED MEDICAL SERVICES	10-583-fill 6 21.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-2065	FUNERAL ARRANGEMENTS	10-2065.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Fileable
Form	10-2511	AUTHORITY AND INVOICE FOR TRAVEL BY AMBULANCE OR OTHER HIRED VEHICLE	10-2511.pdf	http:www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-7078	AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES	10-7078.pdf	http:www.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 440,380	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	440,380	6,130	434,250
Annual IC Time Burden (Hours)	30,391	-1,155	31,546
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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