Expanded Acess to Non-VA Care Through the Veterans Choice Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-10143e SAR for VA Community Care	Form	New	Available
Form 10-10143a Health Care Plan Information for the Veterans Choice Program	Form and Instruction	Unchanged	Available
Form 10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program Script	Form and Instruction	Modified	Repair queued
Justification 2900-0823_form 10_10143e.docx	Supporting Statement A	Uploaded 2017-01-22	Available
052316 SAR_OMBWhitePaper_Version 7.docx	Supplementary Document	Uploaded 2016-05-23	Available
VA Form 10-10143c (Statement Question # 1d on Credentialing).jpg	Supplementary Document	Uploaded 2015-08-17	Available
VA Form 10-10143b (Statement Question #1c on Documentation - TriWest).msg.PNG	Supplementary Document	Uploaded 2015-08-17	Available
VA Form 10-10143b (Statement Question #1c on Documentation - HealthNet).msg.docx	Supplementary Document	Uploaded 2015-08-17	Available
VA Form 10-10143 - TriWest Call Script (Non-VA Election Document).pdf	Supplementary Document	Uploaded 2015-08-17	Available
VA Form 10-10143 - HealthNet Call Script (Non-VA Election Document).pdf	Supplementary Document	Uploaded 2015-08-17	Available
60Day FRN VA-2016-VACO-0001-0077.pdf	Supplementary Document	Uploaded 2017-01-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221260	Secondary Authorization Request (SAR) for VA Community Care	Form	New	SAR for VA Community Care
213638	10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers		Unchanged
213637	10-10143b Submission of Medical Record Information under the Veterans Choice Program		Unchanged
213636	10-10143a Health-Care Plan Information for the Veterans Choice Program	Form and Instruction	Unchanged	Health Care Plan Information for the Veterans Choice Program
213635	10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program	Form and Instruction	Modified	Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program Script

ICR Details

OMB Control No: 2900-0823	ICR Reference No: 201604-2900-018
Status: Historical Active	Previous ICR Reference No: 201502-2900-004
Agency/Subagency: VA	Agency Tracking No: 2900-0823
Title: Expanded Acess to Non-VA Care Through the Veterans Choice Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/27/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/22/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	09/30/2018
Responses	12,729,667	0	11,860,189
Time Burden (Hours)	1,786,557	0	1,496,731
Cost Burden (Dollars)	0	0	0

---

Abstract: The Veterans Access, Choice, and Accountability Act of 2014 (the Act) requires implementing measures to allow the Secretary of Veterans Affairs to improve health care for veterans who have not been seen within established wait-time goals or who experience challenges based on their place of residence. The Act directs VA to provide hospital care and medical services to eligible veterans through agreements with eligible non-VA health care entities or providers.

---

Authorizing Statute(s): PL: Pub.L. 113 - 146 101 Name of Law: Veterans, Access, Choice, and Accountability Act of 2014
  

Citations for New Statutory Requirements: PL: Pub.L. 113 - 146 101 Name of Law: Veterans, Access, Choice, and Accountability Act of 2014

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 33738	05/27/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 70278	10/11/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program	10-10143	Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program Script
10-10143a Health-Care Plan Information for the Veterans Choice Program	10-10143a	Health Care Plan Information for the Veterans Choice Program
10-10143b Submission of Medical Record Information under the Veterans Choice Program
10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers
Secondary Authorization Request (SAR) for VA Community Care	10-10143e	SAR for VA Community Care

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	12,729,667	11,860,189	0	869,478	0	0
Annual Time Burden (Hours)	1,786,557	1,496,731	0	289,826	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: VA Form 10-10434e is now required to provide a communication tool for secondary authorization requests from VA Community providers directly to VA staff. This need presented with the implementation of VA Provider Agreement and Alaska Scheduling implementation, both of which now necessitate communication directly between community provider and VA staff. This form was not included in the original information collection as there was not a need for it at that time. Because of this additional form, there has been a burden increase.

---

Annual Cost to Federal Government: $146,584

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

---

Common Form ICR:  No

---

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: 01/22/2017

---