Information Collection

10-10143a Veterans Community Care Health Insurance Certification

IC 213636 under ICR 202008-2900-001 · OMB 2900-0823.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10143a 10-10143a Veterans Community Care Health Insurance Certification	Form and Instruction
10-10143a Veterans Community Care Health Insurance Certification VA Form 10-10143a_revised 2020.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0823

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.1510(d)

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	10-10143a	Veterans Community Care Health Insurance Certification	VA Form 10-10143a_revised 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: 3,665,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,665,000	3,665,000
Annual IC Time Burden (Hours)	610,833	610,833
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.