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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Application and Renewal for Health Benefits
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
38 CFR 70.20
38 CFR 70.31(c)
38 CFR 70.31(e)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
VA form 10-10EZ
Application for Health Benefits
VHA-1010EZ-new-fill V2v1_07302013.pdf
http://www.va.gov/healtheligibility/application/
Yes
Yes
Fillable Fileable
Form and Instruction
VA Form 10-10HS
Request for Hardship Determination
10-10HS-fill.pdf
http://www.va.gov/vaforms/medical/pdf/vha-10-10HS.pdf
Yes
No
Fillable Printable
Form
VA Form 10-10EZR
Health Benefits Renewal Form
VHA-10-10EZR-fill.pdf
http://www.va.gov/vaforms
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
24VA19 Patient Medical Record - VA
FR Citation:
72 FR 15
Number of Respondents:
1,017,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
3 %
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
1,017,000
0
-1,058,312
0
0
2,075,312
Annual IC Time Burden (Hours)
455,750
0
-658,990
0
0
1,114,740
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.