Claim, Authorization & Invoice for Prosthetic Items & Services

Claim, Authorization & Invoice for Prosthetic Items & Services

OMB: 2900-0188

IC ID: 28432

Information Collection (IC) Details

View Information Collection (IC)

Claim, Authorization & Invoice for Prosthetic Items & Services 2900-0188
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
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 FL 10-90 Request to submit Quotation FL 10-90-fill.pdf http://vaww.va.gov/vaforms/medical/pdf/vha-FL-10-90-fill.pdf Yes No Fillable Printable
Form VA Form 10-2914 Prescription and Authorization for Glasses 10-2914-fill.pdf http://vaww.va.gov/vaforms/medical/pdf/vha-10-2914-fill.pdf Yes No Fillable Printable
Form VA Form 10-2520 Prosthetic Service Card Invoice 10-2520-fill.pdf http://vaww.va.gov/vaforms/medical/pdf/vha-10-2520-fill.pdf Yes No Fillable Printable

Health Health Care Services

 

71,200 1
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 71,200 0 0 0 0 71,200
Annual IC Time Burden (Hours) 5,738 0 0 0 0 5,738
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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