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

Federal Medical Care Recovery Act Bill Requests

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Request for VA Billing for Care Related to Personal Injury or Workers Compensation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	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

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.