[Federal Register Volume 69, Number 178 (Wednesday, September 15, 2004)]
[Notices]
[Page 55661]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-20744]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0260]


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.

DATES: Comments must be submitted on or before October 15, 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. 2900-0260.''
    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. 
2900-0260'' in any correspondence.

SUPPLEMENTARY INFORMATION:
    Title: Request for and Authorization to Release Medical Records or 
Health Information, VA Form 10-5345.
    OMB Control Number: 2900-0260.
    Type of Review: Extension of a currently approved collection.
    Abstract: VA Form 10-5345 is used to obtain prior written consent 
from a patient before information concerning treatment for alcoholism 
or alcohol abuse, drug abuse, sickle cell anemia, or infection with the 
human immunodeficiency virus (HIV) can be disclosed from his or her 
medical record. This special consent must indicate the name of the 
facility permitted to make the disclosure, name of the individual or 
organization to whom the information is being released, specify the 
particular records or information to be released, and be under the 
signature of the veteran and dated. It must reflect the purpose the 
information is to be used, and include a statement that the consent is 
subject to revocation and the date, event or condition upon which the 
consent will expire if not revoked before.
    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 June 8, 2004, at page 32096.
    Affected Public: Business or other for profit, Individuals or 
households.
    Estimated Total Annual Burden: 16,667 hours.
    Estimated Average Burden Per Respondent: 2 minutes.
    Frequency of Response: One time.
    Estimated Number of Respondents: 500,000.

    Dated: September 1, 2004.
    By direction of the Secretary.
Loise Russell,
Director, Records Management Service.
[FR Doc. 04-20744 Filed 9-14-04; 8:45 am]
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