Information Collection

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

IC 230962 under ICR 201804-2900-002 · OMB 2900-0869.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-XXXXX Request for VA Billing for Care Related to Personal Injury or Workers Compensation	Form and Instruction
10-XXXXX Request for VA Billing for Care Related to Personal Inju Request_for_VA_Billing_NEW_July 2019_v3.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-XXXXX	Request for VA Billing for Care Related to Personal Injury or Workers Compensation	Request_for_VA_Billing_NEW_July 2019_v3.pdf	TBD	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,300	3,300
Annual IC Time Burden (Hours)	385	385
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.