Information Collection

Dental Record Authorization and Invoice for Outpatient Service

IC 28546 under ICR 201211-2900-002 · OMB 2900-0335.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient Service	Form
VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient S 2900-0335 VA Form 10-2570d-fill.pdf vaww.va.gov/vaforms/	Form

IC Title:

Agency IC Tracking Number:

2900-0335

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	VA Form 10-2570d	Dental Record Authorization and Invoice for Outpatient Service	2900-0335 VA Form 10-2570d-fill.pdf	http://vaww.va.gov/vaforms/	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	11,000	11,000
Annual IC Time Burden (Hours)	3,666	3,666
Annual IC Cost Burden (Dollars)	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.