Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption

Copayment Exemption for Indian Veterans (AR48) - Documentation of Indian or Urban Indian Status

Documents and Forms

Document Name Document Type
Form 10-334 Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption Form and Instruction
10-334 Tribal Documentation Form VA Form 10-334_Tribal Documentation Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Documentation of Indian or Urban Indian Status for Veteran Copayment Exemption	Agency IC Tracking Number:	2900-0920

Is this a Common Form? No		IC Status: Modified

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
Form and Instruction	10-334	Tribal Documentation Form	VA Form 10-334_Tribal Documentation Form.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 24VA19 “Patient Medical Record – 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: 0 %

	Approved	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

Documents for IC

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.