[Federal Register Volume 78, Number 185 (Tuesday, September 24, 2013)]
[Notices]
[Pages 58609-58610]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-23137]


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DEPARTMENT OF VETERANS AFFAIRS

[OMB Control No. 2900-0188]


Agency Information Collection (Claim, Authorization and Invoice 
for Prosthetic Items and Services); Activity 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. 3501-3521), this notice announces that the Veterans Health 
Administration, Department of Veterans Affairs, will submit 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 24, 2013.

ADDRESSES: Submit written comments on the collection of information 
through www.Regulations.gov, or to Office of Information and Regulatory 
Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 
17th St. NW., Washington, DC 20503 or sent through electronic mail to 
[email protected]. Please refer to ``OMB Control No. 2900-
0188'' in any correspondence.

FOR FURTHER INFORMATION CONTACT: Crystal Rennie, Enterprise Records

[[Page 58610]]

Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue 
NW,, Washington, DC 20420, (202) 632-7492 or email 
[email protected]. Please refer to ``OMB Control No. 2900-0188.''

SUPPLEMENTARY INFORMATION:
    Titles:
    (a) Request to Submit Quotation, Form Letter 10-90.
    (b) Veterans Application for Assistance in Acquiring Home 
Improvement and Structural Alterations, VA Form 10-0103.
    (c) Application for Adaptive Equipment Motor Vehicle, VA Form 10-
1394.
    (d) Prosthetic Authorization for Items or Services, VA Form 10-
2421.
    (e) Prosthetic Service Card Invoice, VA Form 10-2520.
    (f) Prescription and Authorization for Fee Basis Eyeglasses, VA 
Form 10-2914.
    OMB Control Number: 2900-0188.
    Type of Review: Revision of a currently approved collection.
    Abstract: The following forms will are used to determine 
eligibility, prescribe and authorize prosthetic devices:
    a. VA Form Letter 10-90 is used to obtain to estimated price for 
prosthetic devices.
    b. VA Form 10-0103 is used to determine eligibility/entitlement and 
reimbursement of individual claims for home improvement and structural 
alterations.
    c. VA Form 10-1394 is used to determine eligibility/entitlement and 
reimbursement of individual claims for automotive adaptive equipment.
    d. VA Form 10-2421 is used for the direct procurement of new 
prosthetic appliances and/or services. The form standardizes the direct 
procurement authorization process, eliminating the need for separate 
purchase orders, expedites patient treatment and improves the delivery 
of prosthetic services.
    e. VA Form 10-2520 is used by the vendors as an invoice and billing 
document. The form standardizes repair/treatment invoices for 
prosthetic services rendered and standardizes the verification of these 
invoices. The Veteran certifies that the repairs were necessary and 
satisfactory. This form is furnished to vendors upon request.
    f. VA Form 10-2914 is used as a combination prescription, 
authorization and invoice. It allows veterans to purchase their 
eyeglasses directly. If the form is not used, the provisions of 
providing eyeglasses to eligible Veterans may be delayed.
    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 11, 2013, at page 35099.
    Affected Public: Individuals or households.
    Estimated Total Annual Burden: 5,738.
    (a) Form Letter 10-90--708.
    (b) VA Form 10-0103--583.
    (c) VA Form 10-1394--1,000.
    (d) VA Form 10-2421--67.
    (e) VA Form 10-2520--47.
    (f) VA Form 10-2914--3,333.
    Estimated Average Burden Per Respondent:
    (a) Form Letter 10-90--5 minutes.
    (b) VA Form 10-0103--5 minutes.
    (c) VA Form 10-1394--15 minutes.
    (d) VA Form 10-2421--4 minutes.
    (e) VA Form 10-2520--4 minutes.
    (f) VA Form 10-2914--4 minutes.
    Frequency of Response: On occasion.
    Estimated Number of Respondents: 71,200.
    a. Form Letter 10-90--8,500.
    c. VA Form 10-0103--7,000.
    d. VA Form 10-1394--4,000.
    e. VA Form 10-2421--1,000.
    f. VA Form 10-2520--700.
    g. VA Form 10-2914--50,000.

    Dated: September 19, 2013.

    By direction of the Secretary.
Crystal Rennie,
VA Clearance Officer, U.S. Department of Veterans Affairs.
[FR Doc. 2013-23137 Filed 9-23-13; 8:45 am]
BILLING CODE 8320-01-P