Federal Medical Care Recovery Act Bill Requests

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-XXXXX Request for VA Billing for Care Related to Personal Injury or Workers Compensation	Form and Instruction	New	Available
Justification A_Federal Medical Care Recovery Act Bill Requests_Revised_July 2019.doc	Supporting Statement A	Uploaded 2019-07-02	Available
30 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-07-11	Available
60 Day FRN - Published.pdf	Supplementary Document	Uploaded 2018-05-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
230962	Request for VA Billing for Care Related to Personal Injury or Workers Compensation	Form and Instruction	New

ICR Details

OMB Control No: 2900-0869	ICR Reference No: 201804-2900-002
Status: Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No:
Title: Federal Medical Care Recovery Act Bill Requests
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 with change	Conclusion Date: 07/10/2019
	Date Received in OIRA: 10/11/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2022	36 Months From Approved
Responses	3,300	0	0
Time Burden (Hours)	385	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of collecting this information is to provide basic information from which potential liability can be assessed for VA to recover the cost of care from the liable party instead of the American taxpayer and Veteran paying for the care. Failure to provide any or all of the requested information may delay or result in VA’s inability to create accident-related billing, assert a claim for reimbursement, and assist the Veteran in their personal injury or workers compensation claim. Without a third party paying for the care, the Veteran may owe VA co-payments. [With regards to the CHAMPVA form alone: Failure to provide any or all of the requested information may delay or result in VA’s inability to provide CHAMPVA benefits.] -- THE CHAMPVA FORM HAS BEEN WITHDRAWN FROM THIS ICR

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Authorizing Statute(s): US Code: 38 USC 501 Name of Law: Rules and regulations
  

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:
	83 FR 16922	04/17/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 31256	07/03/2018
Did the Agency receive public comments on this ICR? Yes

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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
Request for VA Billing for Care Related to Personal Injury or Workers Compensation	10-XXXXX	Request for VA Billing for Care Related to Personal Injury or Workers Compensation

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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	3,300	0	0	3,300	0	0
Annual Time Burden (Hours)	385	0	0	385	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 new information collection request. All hours are considered a burden increase.

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Annual Cost to Federal Government: $9,833

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: 10/11/2018

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