Form 10-10143 Election to Receive Authorized Non-VA Care and Selection

Election to Receive Authorized Non-VA Care and Selection of

Provider for the Veterans Choice Program Script

VA Form 10-10143

OMB Number: 2900-XXXX

Estimated Burden: 2 minutes

OMB Expiration Date: XX/XX/2014

1. Would you like to hear the Privacy and/or Paperwork Reduction Act Notice?

If no, continue to question 2. If yes read the following:

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705 and 1710in order for VA to determine your eligibility for the Veterans Choice program. Information you supply may be verified from initial submission forward through a computer matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the Notice of Privacy Practices. Providing the requested information is required for eligibility for the Veterans Choice program. If any or all of the requested information is not provided, it may delay or result in denial of your request for the Veterans Choice program. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

2. Would you like to receive non-VA care through the Veterans Choice Program?

If no, disregard question 3. If yes continue to question 3.

3. Is there a specific provider you would like receive non-VA care from through the Veterans Choice Program?