Medical Expense Report (VA Form 21P-8416)

Forms and Documents

Document Name	Status
Form VA Form 21P-8416 Medical Expense Report Form	Modified
SupportingStatement(2900-0161).docx Supporting Statement A	2016-09-08
2900-0161 30-Day FRN.pdf Supplementary Document	2016-09-06
2900-0161 60-Day FRN.pdf Supplementary Document	2016-05-25
2900-0161 Revisions Description.docx Supplementary Document	2016-05-12

IC Document Collections

IC ID	Document Title	Status
28397	Medical Expense Report Form	Modified

ICR Details

OMB Control No: 2900-0161	ICR Reference No: 201604-2900-020
Status: Historical Active	Previous ICR Reference No: 201310-2900-004
Agency/Subagency: VA	Agency Tracking No: VBA-P&F-NK
Title: Medical Expense Report (VA Form 21P-8416)
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: 01/10/2017
	Date Received in OIRA: 09/08/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	09/30/2017
Responses	96,400	0	96,400
Time Burden (Hours)	48,200	0	48,200
Cost Burden (Dollars)	974,845	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 38 USC 1503(a)(8) Name of Law: Determinations with respect to annual income
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 12032	05/23/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 21032	09/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary 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	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $6,385,536

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

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Common Form ICR:  No

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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: 09/08/2016

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