[Federal Register Volume 68, Number 219 (Thursday, November 13, 2003)]
[Notices]
[Page 64429]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-28369]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Proposed Information Collection Activity: Proposed Collection; 
Comment Request

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: The Veterans Health Administration (VHA), Department of 
Veterans Affairs (VA), is announcing an opportunity for public comment 
on the proposed collection of certain information by the agency. Under 
the Paperwork Reduction Act (PRA) of 1995, Federal agencies are 
required to publish notice in the Federal Register concerning each 
proposed collection of information, including each proposed extension 
of a currently approved collection, and allow 60 days for public 
comment in response to the notice. This notice solicits comments for 
information needed to determine eligibility of persons applying for 
healthcare benefits under Civilian Health and Medical Program-VA 
(CHAMPVA) and to adjudicate claims submitted under CHAMPVA.

DATES: Written comments and recommendations on the proposed collection 
of information should be received on or before January 12, 2004.

ADDRESSES: Submit written comments on the collection of information to 
Ann W. Bickoff, Veterans Health Administration (193B1), Department of 
Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420. Please 
refer to ``OMB Control No. 2900-0219'' in any correspondence.

FOR FURTHER INFORMATION CONTACT: Ann W. Bickoff at (202) 273-8310 or 
FAX (202) 273-9381.

SUPPLEMENTARY INFORMATION: Under the PRA of 1995 (Pub. L. 104-13; 44 
U.S.C. 3501-21), Federal agencies must obtain approval from the Office 
of Management and Budget (OMB) for each collection of information they 
conduct or sponsor. This request for comment is being made pursuant to 
Section 3506(c)(2)(A) of the PRA.
    With respect to the following collection of information, VHA 
invites comments on: (1) Whether the proposed collection of information 
is necessary for the proper performance of VHA's functions, including 
whether the information will have practical utility; (2) the accuracy 
of VHA's estimate of the burden of the proposed collection of 
information; (3) ways to enhance the quality, utility, and clarity of 
the information to be collected; and (4) ways to minimize the burden of 
the collection of information on respondents, including through the use 
of automated collection techniques or the use of other forms of 
information technology.
    Titles:
    a. Application for CHAMPVA Benefits, VA Form 10-10d.
    b. CHAMPVA Claim Form, VA Form 10-7959a.
    c. CHAMPVA--Other Health Insurance (OHI) Certification, VA Form 10-
7959c.
    d. CHAMPVA Potential Liability Claim, VA Form 10-7959d.
    OMB Control Number: 2900-0219.
    Type of Review: Extension of a currently approved collection.
    Abstract:
    a. VA Form 10-10d is used to determine eligibility of persons 
applying for healthcare benefits under the CHAMPVA program.
    b. VA Form 10-7959a is used to accurate adjudicate and process 
beneficiaries claims for payment/reimbursement of related healthcare 
expenses.
    c. VA Form 10-7959c is used to systematically obtain other health 
insurance information and to correctly coordinate benefits among all 
liable parties.
    d. VA Form 10-7959d is used to recover costs associated with 
healthcare services related to injury or illness caused by a third 
party.
    Affected Public: Individuals or households, Business or other for-
profit.
    Estimated Annual Burden: 394,667 hours.
    a. VA Form 10-10d--3,417 hours.
    b. VA Form 10-7959a--383,333 hours.
    c. VA Form 10-7959c--5,000 hours.
    d. VA Form 10-7959d--2,917 hours.
    Estimated Average Burden Per Respondent:
    a. VA Form 10-10d--10 minutes.
    b. VA Form 10-7959a--10 minutes.
    c. VA Form 10-7959c--10 minutes.
    d. VA Form 10-7959d--7 minutes.
    Frequency of Response: On occasion.
    Estimated Number of Respondents: 2,375,500.
    a. VA Form 10-10d--20,500.
    b. VA Form 10-7959a--2,300,000.
    c. VA Form 10-7959c--30,000.
    d. VA Form 10-7959d--25,000.

    Dated: November 3, 2003.

    By direction of the Secretary.
Jacqueline Parks,
IT Specialist, Records Management Service.
[FR Doc. 03-28369 Filed 11-12-03; 8:45 am]
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