Claim, Authorization & Invoice for Prosthetic Items & Services

Forms and Documents

Document Name	Status
Form 10-0103 Claim, Authorization & Invoice for Prosthetic Items & Services Form	Modified
2900-0188 updates to VA Forms10-2914, 10-2520, FL 10-90.doc Justification for No Material/Nonsubstantive Change	2009-10-05

IC Document Collections

IC ID	Document Title	Status
28432	Claim, Authorization & Invoice for Prosthetic Items & Services Form	Modified

ICR Details

OMB Control No: 2900-0188	ICR Reference No: 200907-2900-001
Status: Historical Active	Previous ICR Reference No: 200707-2900-035
Agency/Subagency: VA	Agency Tracking No: 2900-0188
Title: Claim, Authorization & Invoice for Prosthetic Items & Services
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/12/2009
	Date Received in OIRA: 10/05/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	12/31/2010	12/31/2010
Responses	71,200	0	71,200
Time Burden (Hours)	5,738	0	5,738
Cost Burden (Dollars)	0	0	0

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Abstract: Used to determine eligibility, prescribe, authorize and pay for prosthetic devices and glasses, obtain estimates, allow direct purchase and obtain information on loaned devices.

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Authorizing Statute(s): US Code: 38 USC 3901 Name of Law: Definitions
   US Code: 38 USC 3902 Name of Law: Assistance for providing automobile and adaptive equipment
   US Code: 38 USC 3903 Name of Law: Limitations on assistance; special training courses
   US Code: 38 USC 3904 Name of Law: Research and development
   US Code: 38 USC 1701(6) Name of Law: Definitions
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 152	08/08/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 199	10/16/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim, Authorization & Invoice for Prosthetic Items & Services	10-2421, 10-1394, 10-0103, FL 10-90, VA Form 10-2914, VA Form 10-2520	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations ,   APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE ,   PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES ,   Request to submit Quotation ,   Prescription and Authorization for Glasses ,   Prosthetic Service Card Invoice

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ICR Summary of Burden

	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	71,200	71,200	0	0	0	0
Annual Time Burden (Hours)	5,738	5,738	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 10-1394 - Using FY06 and FY07 1st and 2nd quarter data, Prosthetics can better estimate the number of automobile adaptive claims filed on 10-1394. There has been no significant change in workload or procedure, but rather more accurate data collection over the years. 10-2421 - Since our last request, Prosthetics services have moved towards the goal of 100% purchase card use; however, we cannot mandate that all vendors accept purchase cards. Due to this, we anticipate a sharp decline in the use of 10-2421. 10-2914 - Since our last request, eyeglass consults have been standardized in the VA’s Computerized Patient Record System. VA uses fee basis or contract providers to meet their eyeglass prescription needs. These fee basis/contract prescriptions must still be provided on 10-2914. 10-426 - Loan Follow-up Letter, is no longer used because the loan program has been discontinue.

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Annual Cost to Federal Government: $113,736

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/05/2009

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