Claim, Authorization & Invoice for Prosthetic Items & Services

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 10-2520 Prosthetic Service Card Invoice	Form	Removed	Available
Form VA Form 10-2914 Prescription and Authorization for Glasses	Form	Removed	Available
Form FL 10-90 Request to submit Quotation	Form	Removed	Available
Form 10-2421 PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	Form and Instruction	Removed	Available
Form 10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	Form	Removed	Available
Form 10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations	Form	Removed	Available
Form 10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	Form	New	Available
Form 10-2520 PROSTHETIC SERVICE CARD INVOICE	Form	New	Available
Form FL 10-90 REQUEST TO SUBMIT QUOTATION	Form	New	Available
Form 10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvements and Structural Alterations	Form	New	Available
Form 10-2421 PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	Form	New	Available
Form 10-2914 PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES	Form	New	Available
Memo on revisions to VA Form 10-0103_20140313.doc	Supplementary Document	Uploaded 2014-03-13	Available
10-2501-fill (3).pdf	Supplementary Document	Uploaded 2010-12-21	Available
supplemental document statement for 10-2501.pdf	Supplementary Document	Uploaded 2010-12-21	Available
Justification 2900-0188_3-2014 (CR 3 11 14)_GO.docx	Supporting Statement A	Uploaded 2014-03-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form	Removed	Prosthetic Service Card Invoice
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form	Removed	Prescription and Authorization for Glasses
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form	Removed	Request to submit Quotation
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form and Instruction	Removed	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form	Removed	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE
28432	Claim, Authorization & Invoice for Prosthetic Items & Services	Form	Removed	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations
210614	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	Form	New	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE
210613	PROSTHETIC SERVICE CARD INVOICE	Form	New	PROSTHETIC SERVICE CARD INVOICE
210612	REQUEST TO SUBMIT QUOTATION	Form	New	REQUEST TO SUBMIT QUOTATION
210611	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvements and Structural Alterations	Form	New	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvements and Structural Alterations
210610	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	Form	New	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES
210609	PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES	Form	New	PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES

ICR Details

OMB Control No: 2900-0188	ICR Reference No: 201305-2900-018
Status: Historical Inactive	Previous ICR Reference No: 201007-2900-001
Agency/Subagency: VA	Agency Tracking No: 2900-0188
Title: Claim, Authorization & Invoice for Prosthetic Items & Services
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 06/03/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/13/2014
Terms of Clearance: VA has requested to withdraw this information collection request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	10/31/2014
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:
2900-AO17	Proposed rulemaking	78 FR 69614	11/20/2013

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 112	06/11/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 58609	09/24/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	10-1394	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE
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
PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES	10-2914	PRESCRIPTION AND AUTHORIZATION FOR FEE BASIS EYEGLASSES
PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	10-2421	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES
PROSTHETIC SERVICE CARD INVOICE	10-2520	PROSTHETIC SERVICE CARD INVOICE
REQUEST TO SUBMIT QUOTATION	FL 10-90	REQUEST TO SUBMIT QUOTATION
VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvements and Structural Alterations	10-0103	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvements and Structural Alterations

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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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: ROCIS will not let us submit this to OMB for approval without this being checked. Please note, the burden hours and number of responses has not changed. Please refer to the Supporting Statement for accurate information.

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Annual Cost to Federal Government: $167,113

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: 03/13/2014

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