Health Resource Center (HRC) Medical Center Payment Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-0505 VA Medical Center Payment Form	Form	New	Repair queued
Justification A_Medical Center Payment Form (V3).docx	Supporting Statement A	Uploaded 2010-05-14	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
192600	VA Medical Center Payment Form	Form	New

ICR Details

OMB Control No:	ICR Reference No: 201004-2900-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Health Resource Center (HRC) Medical Center Payment Form
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Not subject to PRA	Conclusion Date: 03/22/2011
	Date Received in OIRA: 07/27/2010
Terms of Clearance: Consistent with the memo of April 7, 2010 and with the discretion provided by 5 CFR 1320(h)(10), OMB considers this request for information to be not subject to the PRA.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information will be gathered from the Veteran or the Veteran’s family members, and input directly into the pay.gov website. The purpose of the information is to allow Veterans that have medical care co payment debts to pay their bills online with a credit card or ACH transaction.

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Authorizing Statute(s): US Code: 38 USC Part 1, Chapter 5, Section 527 Name of Law: Veterans Benefits: Evaluation and Data Collection
  

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:
	75 FR 81	04/28/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 131	07/09/2010
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
VA Medical Center Payment Form	VA Form 10-0505	VA Medical Center Payment

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new collection. All burden hours are considered an increase.

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Annual Cost to Federal Government: $452,225

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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: 07/27/2010

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