Information Collection

Claim, Authorization & Invoice for Prosthetic Items & Services

IC 28432 under ICR 200707-2900-035 · OMB 2900-0188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-2914 Claim, Authorization & Invoice for Prosthetic Items & Services	Form
10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Im 10-0103-fill.pdf www.va.gov/vaforms	Form
10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE 10-1394-fill.pdf www.va.gov/vaforms	Form
10-2421 PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES 10-2421-fill.pdf	Form and Instruction
10-2520 PROSTHETIC SERVICE CARD INVOICE 10-2520-fill.pdf	Form
10-2914 PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES 10-2914-fill.pdf	Form
Form Letter 10-90 REQUEST TO SUBMIT ESTIMATE FL 10-90-fill.pdf	Form

IC Title:

Claim, Authorization & Invoice for Prosthetic Items & Services

Agency IC Tracking Number:

2900-0188

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-2914	PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES	10-2914-fill.pdf		Yes	No	Fillable Printable
Form	Form Letter 10-90	REQUEST TO SUBMIT ESTIMATE	FL 10-90-fill.pdf		Yes	No	Fillable Printable
Form	10-0103	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations	10-0103-fill.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-1394	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	10-1394-fill.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-2421	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	10-2421-fill.pdf		Yes	No	Fillable Printable
Form	10-2520	PROSTHETIC SERVICE CARD INVOICE	10-2520-fill.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 71,200

Number of Respondents for Small Entity: 1

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	71,200	-626,000	697,200
Annual IC Time Burden (Hours)	5,738	-42,784	48,522
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.