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

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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.