Information Collection

10-10143b Submission of Medical Record Information under the Veterans Community Care Program

IC 213637 under ICR 202008-2900-001 · OMB 2900-0823.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

10-10143b Submission of Medical Record Information under the Veterans Community Care Program

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 1730(b) (To search for a specific CFR, visit the Code of Federal Regulations.)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 366,823

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	12,471,982	12,471,982
Annual IC Time Burden (Hours)	1,039,332	1,039,332
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.