Claim, Authorization & Invoice for Prosthetic Items & Services

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0188 can be found here:

Documents and Forms

Document Name Document Type
Form 10-0103 Claim, Authorization & Invoice for Prosthetic Items & Services Form
10-0103 VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Im 10-0103-fill.pdf www.va.gov/vaforms Form
10-1394 APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE 10-1394_081417.pdf www.va.gov/vaforms Form
10-2421 PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES VA Form 10-2421.pdf Form and Instruction
FL 10-90 Request to submit Quotation FL 10-90-fill.pdf vaww.va.gov/vaforms/medical/pdf/vha-FL-10-90-fill.pdf Form
VA Form 10-2914 Prescription and Authorization for Glasses VA Form 10-2914.pdf vaww.va.gov/vaforms/medical/pdf/vha-10-2914-fill.pdf Form
VA Form 10-2520 Prosthetic Service Card Invoice 10-2520-fill.pdf vaww.va.gov/vaforms/medical/pdf/vha-10-2520-fill.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim, Authorization & Invoice for Prosthetic Items & Services	Agency IC Tracking Number:	2900-0188

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0103	VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations	10-0103-fill.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-1394	APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE	10-1394_081417.pdf	www.va.gov/vaforms	Yes	No	Fillable Printable
Form and Instruction	10-2421	PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES	VA Form 10-2421.pdf		Yes	No	Fillable Printable
Form	FL 10-90	Request to submit Quotation	FL 10-90-fill.pdf	http://vaww.va.gov/vaforms/medical/pdf/vha-FL-10-90-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-2914	Prescription and Authorization for Glasses	VA Form 10-2914.pdf	http://vaww.va.gov/vaforms/medical/pdf/vha-10-2914-fill.pdf	Yes	No	Fillable Printable
Form	VA Form 10-2520	Prosthetic Service Card Invoice	10-2520-fill.pdf	http://vaww.va.gov/vaforms/medical/pdf/vha-10-2520-fill.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 71,200	Number of Respondents for Small Entity: 1

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	71,200	71,200
Annual IC Time Burden (Hours)	5,738	5,738
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.