Request for Payment of Bowel and Bladder Services (VA Form 10-314)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-314 Request for Payment of Bowel and Bladder Services	Form	New	Available
Form 10-314b VA Form 10-314b - Request for Payment of Bowel and Bladder Services	Form	New	Repair queued
Form 10-314a Bowel and Bladder Services Preauthorization Form	Form	New	Repair queued
Department of Veterans Affairs_VA Form 314B Comment_PO Response_Signed_02282023.pdf	Supplementary Document	Uploaded 2023-03-01	Repair queued
30-day FRN - 2900-NEW - Preauthorization & Request for Payment of Bowel & Bladder Services - published 03012023.pdf	Supplementary Document	Uploaded 2023-03-01	Repair queued
60-day FRN - 2900-NEW - Preauthorization & Request for Payment of Bowel & Bladder Services - published 12152022.pdf	Supplementary Document	Uploaded 2023-01-11	Repair queued
Supporting Statement A_Preauthorization Request for Payment of Bowel Bladder Services_10-314a 10-314b_2900-NEW_updated Feb 2023.docx	Supporting Statement A	Uploaded 2023-03-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
256605	VA Form 10-314 - Request for Payment of Bowel and Bladder Services	Form	New	Request for Payment of Bowel and Bladder Services
256605	VA Form 10-314b - Request for Payment of Bowel and Bladder Services	Form	New
256604	Bowel and Bladder Services Preauthorization Form	Form	New

ICR Details

OMB Control No: 2900-0924	ICR Reference No: 202207-2900-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: VA	Agency Tracking No: 2900-NEW
Title: Request for Payment of Bowel and Bladder Services (VA Form 10-314)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/25/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/01/2023
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time the agency will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2026	36 Months From Approved
Responses	40,800	0	0
Time Burden (Hours)	6,800	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Legal authority for this information collection is found in 38 U.S.C., Chapter 17, for Veterans seeking health care services. Data collected may be used to establish, determine, and monitor eligibility to receive VA benefits and for authorizing and paying Non-VA healthcare services furnished to Veterans and beneficiaries. VA Form 10-314 will be required to request reimbursement for bowel and bladder care services. The form is used to list the dates and times the care was rendered to the Veteran and is then submitted monthly to VA to request payment for those services.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 76695	12/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 13013	03/01/2023
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
VA Form 10-314 - Request for Payment of Bowel and Bladder Services	10-314	Request for Payment of Bowel and Bladder Services

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	40,800	0	0	40,800	0	0
Annual Time Burden (Hours)	6,800	0	0	6,800	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new collection, and all burden hours are considered a program increase.

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Annual Cost to Federal Government: $0

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

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Common Form ICR:  No

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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: 03/01/2023

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