[Federal Register Volume 69, Number 37 (Wednesday, February 25, 2004)]
[Notices]
[Pages 8749-8750]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-4110]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0219]


Agency Information Collection Activities Under OMB Review

AGENCY: Veterans Health Administration, Department of Veterans Affairs.

ACTION: Notice.

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SUMMARY: In compliance with the Paperwork Reduction Act (PRA) of 1995 
(44 U.S.C. 3501-21), this notice announces that the Veterans Health 
Administration (VHA), Department of Veterans Affairs, has submitted the 
collection of information abstracted below to the Office of Management 
and Budget (OMB) for review and comment. The PRA submission describes 
the nature of the information collection and its expected cost and 
burden and includes the actual data collection instrument.

DATE: Comments must be submitted on or before March 26, 2004.

FOR FURTHER INFORMATION OR A COPY OF THE SUBMISSION CONTACT: Denise 
McLamb, Records Management Service (005E3), Department of Veterans 
Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 273-8030, 
FAX (202) 273-5981 or e-mail to: [email protected]. Please 
refer to ``OMB Control No. 2900-0219.''
    Send comments and recommendations concerning any aspect of the 
information collection to VA's OMB Desk Officer, OMB Human Resources 
and Housing Branch, New Executive Office Building, Room 10235, 
Washington, DC 20503 (202) 395-7316. Please refer to ``OMB Control No. 
2900-0219'' in any correspondence.

[[Page 8750]]


SUPPLEMENTARY INFORMATION:
    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 accurately 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 solicit additional information 
relative to injury/illness as well as third party claim information.
    An agency may not conduct or sponsor, and a person is not required 
to respond to a collection of information unless it displays a 
currently valid OMB control number. The Federal Register Notice with a 
60-day comment period soliciting comments on this collection of 
information was published on November 13, 2003, at page 64429.
    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: February 12, 2004.

    By direction of the Secretary.
Loise Russell,
Director, Records Management Service.
[FR Doc. 04-4110 Filed 2-24-04; 8:45 am]
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