Information Collection

10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program

IC 213635 under ICR 201604-2900-018 · OMB 2900-0823.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0823 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10143 10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program	Form and Instruction
10-10143 Election to Receive Authorized Non-VA Care and Selection 10-10143 Election to Non-VA Care Telephone Script 10-30-14.docx	Form and Instruction

IC Title:

10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.1515

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 and Instruction	10-10143	Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program Script	10-10143 Election to Non-VA Care Telephone Script 10-30-14.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 440,794

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,571,636	5,571,636
Annual IC Time Burden (Hours)	928,606	928,606
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.