Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-4142 Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)	Form	New	Available
2017-21433, 30-Day FRN (VAFs 21-4142-4142a).pdf	Supplementary Document	Uploaded 2017-10-20	Available
2900-NEW, Supporting Statement (4142-4142a).docx	Supporting Statement A	Uploaded 2017-09-28	Available
2017-13731, 60-Day FRN (VAFs 21-4142, 21-4142a).pdf	Supplementary Document	Uploaded 2017-09-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
228502	Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)	Form	New

ICR Details

OMB Control No: 2900-0858	ICR Reference No: 201709-2900-024
Status: Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-DJ
Title: Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142a and 21-4142)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/05/2018
	Date Received in OIRA: 11/16/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved
Responses	132,400	0	0
Time Burden (Hours)	11,033	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-4142, is used to authorize the disclosure of information to the Department of Veterans Affairs (VA). VA Form 21-4142a, is used to gather private provider information from the claimant to the VA. Without this information, determination of entitlement would not be possible. This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned. VA Forms 21-4142 and 21-4142a are being revised to include new standardization data points; to include optical character recognition boxes. VA Form 21-4142a has been further revised to include patient identification information. This addition does not increase the burden.

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Authorizing Statute(s): US Code: 38 USC Section 5101(a) Name of Law: Claims and Forms
  

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:
	82 FR 30004	06/30/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 46614	10/05/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Authorization to Disclose Information to the VA, General Release of Medical Provider Information to the VA (VA Forms 21-4142 and 21-4142a)	21-4142, 21-4142a	General Release for Medical Provider Information to the VA ,   General Release for Medical Provider Information to the VA

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ICR Summary of Burden

table that charts list 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	132,400	0	0	132,400	0	0
Annual Time Burden (Hours)	11,033	0	0	11,033	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a request for a new control number. VA Forms 21-4142 and 21-4142a were previously approved under control number 2900-0001. They have been separated from this control group so a new control number can be assigned.

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Annual Cost to Federal Government: $7,169,467

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/16/2017

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