Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
10-10143 Election to Receive Authorized Non-VA Care and Selection of Provider for the Veterans Choice Program Modified 5571636 928606 0 Form and Instruction 10-10143
10-10143a Health-Care Plan Information for the Veterans Choice Program Modified 528953 88159 0 Form and Instruction 10-10143a
10-10143b Submission of Medical Record Information under the Veterans Choice Program Modified 5572600 464383 0
10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers Unchanged 187000 15583 0
Total burden requested under this ICR: 11860189 1496731 0  
To view an IC, click on IC Title