Medical Expense Report (VA Form 21P-8416)

ICR 201604-2900-020

OMB: 2900-0161

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2016-09-08
Supplementary Document
2016-09-06
Supplementary Document
2016-05-25
Supplementary Document
2016-05-12
IC Document Collections
IC ID
Document
Title
Status
28397 Modified
ICR Details
2900-0161 201604-2900-020
Historical Active 201310-2900-004
VA VBA-P&F-NK
Medical Expense Report (VA Form 21P-8416)
Revision of a currently approved collection   No
Regular
Approved without change 01/10/2017
Retrieve Notice of Action (NOA) 09/08/2016
  Inventory as of this Action Requested Previously Approved
01/31/2020 36 Months From Approved 09/30/2017
96,400 0 96,400
48,200 0 48,200
974,845 0 0

VA Form 21P-8416 is used to gather information about unreimbursed medical expenses paid by beneficiaries in receipt of income-based benefits. This collection of information allows VA to authorize and properly pay benefits.

US Code: 38 USC 1503(a)(8) Name of Law: Determinations with respect to annual income
  
None

Not associated with rulemaking

  81 FR 12032 05/23/2016
81 FR 21032 09/01/2016
No

1
IC Title Form No. Form Name
Medical Expense Report VA Form 21P-8416 Medical Expense Report

  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 96,400 96,400 0 0 0 0
Annual Time Burden (Hours) 48,200 48,200 0 0 0 0
Annual Cost Burden (Dollars) 974,845 0 0 974,845 0 0
No
No

$6,385,536
No
No
No
No
No
Uncollected
Cynthia Harvey - Pryor 202 461-5870 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/08/2016


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