Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 21-4142a General Release of Medical Provider Information to VA	Form	Modified	Available
Form 21-4142 Authorization to Disclose Information to VA	Form	Modified	Available
Form 21-4142 Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	Form	Modified	Repair queued
2024-14847, 30-Day FRN (2900-0858, VAF21-4142, 4142a).pdf	Supplementary Document	Uploaded 2024-07-09	Repair queued
2024-09336, 60-Day FRN (VAF21-4142, 4142a).pdf	Supplementary Document	Uploaded 2024-06-26	Repair queued
2900-0858, Supporting Statement (VAF21-4142, 4142a).docx	Supporting Statement A	Uploaded 2024-07-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
228502	Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	Form	Modified	General Release of Medical Provider Information to VA
228502	Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	Form	Modified	Authorization to Disclose Information to VA
228502	Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	Form	Modified

ICR Details

OMB Control No: 2900-0858	ICR Reference No: 202404-2900-008
Status: Active	Previous ICR Reference No: 202009-2900-020
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/12/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/09/2024
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	08/31/2027	36 Months From Approved	08/31/2024
Responses	440,246	0	127,397
Time Burden (Hours)	36,687	0	10,616
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather the necessary information to request medical provider information to the VA. Without the information solicited by these forms, VA would be unable to determine eligibility, and benefits would not be properly paid.

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Authorizing Statute(s): US Code: 42 USC 290dd-2 Name of Law: Confidentiality of records
   US Code: 38 USC Section 5101(a) (1) Name of Law: Claims and Forms
   PL: Pub.L. 104 - 191 203 Name of Law: Health Insurance Portability And Accountability Act
  

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:
	89 FR 35308	05/01/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56024	07/08/2024
Did the Agency receive public comments on this ICR? No

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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
Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	21-4142, 21-4142a	Authorization to Disclose Information to VA ,   General Release of Medical Provider Information to VA

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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	440,246	127,397	0	312,849	0	0
Annual Time Burden (Hours)	36,687	10,616	0	26,071	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: The respondent burden has increased due to the estimated number of receivables averaged over the past year.

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Annual Cost to Federal Government: $11,785,760

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: 07/09/2024

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