Information Collection

Application for Physicians, Dentists, Podiatrists, Optometrists and Chiropractors - VA Form 10-2850

IC 257916 under ICR 202301-2900-008 · OMB 2900-0205.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-2850 Application for Physicians, Dentists, Podiatrists, Optometrists and Chiropractors - VA Form 10-2850	Form and Instruction
10-2850 Application for Physicians, Dentists, Podiatrists, Optom vha-2850-fill.pdf	Form and Instruction
10-2850 Application for Physicians, Dentists, Podiatrists, Optom VA Form 10-2850.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-0205

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	10-2850	Application for Physicians, Dentists, Podiatrists, Optometrists and Chiropractors - VA Form 10-2850	VA Form 10-2850.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,128

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	16,128	16,128
Annual IC Time Burden (Hours)	8,064	8,064
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.