Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form VA Form 29-0975 AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	Form	Modified	Repair queued
White Paper 29-0975e.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-06-23	Repair queued
2021-02650.pdf	Supplementary Document	Uploaded 2021-02-09	Repair queued
SupportingState(2900-0856).docx	Supporting Statement A	Uploaded 2021-02-09	Repair queued
2020-24308.pdf	Supplementary Document	Uploaded 2020-12-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220731	AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	Form	Modified

ICR Details

OMB Control No: 2900-0856	ICR Reference No: 202206-2900-018
Status: Received in OIRA	Previous ICR Reference No: 202010-2900-011
Agency/Subagency: VA	Agency Tracking No: VBA-INS-NK
Title: Authorization to Disclose Information to a Third Party (Insurance) (VA Form 29-0975)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/24/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	04/30/2024	04/30/2024
Responses	1,200	1,200
Time Burden (Hours)	100	100
Cost Burden (Dollars)	0	0

---

Abstract: This form will be used by the Department of Veterans Affairs Insurance Center (VAIC) to enable a third party to act on behalf of the insured Veteran/beneficiary. Many of our customers are of advanced age or suffer from limiting disabilities and need assistance from a third party to conduct their affairs. The information collected provides an optional service and is not required to receive insurance benefits.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 24308	11/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 2650	02/09/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION	29-0975e, VA Form 29-0975	Authorization to Disclose Personal Information to a Third Party (Insurance) ,   Authorization to Disclose Information to a Third Party Insurance

---

ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,200	1,200	0	0	0	0
Annual Time Burden (Hours)	100	100	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a small increase due to an increase in use of this form.

---

Annual Cost to Federal Government: $6,630

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/24/2022

---