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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Claim, Authorization & Invoice for Prosthetic Items & Services
Agency IC Tracking Number:
2900-0188
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
10-0103
VETERANS APPLICATION FOR ASSISTANCE In Acquiring Home Improvement and Structural Alterations
10-0103-fill.pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form
10-1394
APPLICATION FOR ADAPTIVE EQUIPMENT MOTOR VEHICLE
10-1394-fill.pdf
www.va.gov/vaforms
Yes
No
Fillable Printable
Form and Instruction
10-2421
PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES
10-2421-fill.pdf
Yes
No
Fillable Printable
Form
10-2520
PROSTHETIC SERVICE CARD INVOICE
10-2520-fill.pdf
Yes
No
Fillable Printable
Form
10-2914
PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES
10-2914-fill.pdf
Yes
No
Fillable Printable
Form
Form Letter 10-90
REQUEST TO SUBMIT ESTIMATE
FL 10-90-fill.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
71,200
Number of Respondents for Small Entity:
1
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
71,200
0
0
-626,000
0
697,200
Annual IC Time Burden (Hours)
5,738
0
0
-42,784
0
48,522
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.