Information Collection

Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption

IC 257252 under ICR 202212-2900-002 · OMB 2900-0920.

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Information Collection (IC) Details

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IC Title:	Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption	Agency IC Tracking Number:	2900-NEW

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.108 38 CFR 17.110 38 CFR 17.111 38 CFR 17.4600

Information Collection 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: 24VA19 âPatient Medical Record â VA"	FR Citation: 74 FR 60040

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	6,250	6,250
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.