Information Collection

VA Form 10-10143g: Non-VA Hospital Emergency Notification

IC 242010 under ICR 202005-2900-018 · OMB 2900-0823.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0823 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10143g VA Form 10-10143g: Non-VA Hospital Emergency Notification	Form
10-10143g Non-VA Hospital Emergency Notification Non-VA Hospital Emergency Notification_VA Form 10-10143g_May 2020.pdf	Form

IC Title:

VA Form 10-10143g: Non-VA Hospital Emergency Notification

Agency IC Tracking Number:

2900-0823

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.4020

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	10-10143g	Non-VA Hospital Emergency Notification	Non-VA Hospital Emergency Notification_VA Form 10-10143g_May 2020.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500,000	500,000
Annual IC Time Burden (Hours)	83,333	83,333
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.