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 Community Care Program Unchanged 3665000 610833 0 Other-Script
10-10143a Health-Care Plan Information for the Veterans Choice Program Unchanged 3665000 610833 0 Form and Instruction 10-10143a
10-10143b Submission of Medical Record Information under the Veterans Community Care Program Unchanged 12471982 1039332 0
10-10143c Submission of Information on Credentials and Licenses by Eligible Entities and Providers Unchanged 122274 10190 0
10-10143e Secondary Authorization Request (SAR) for VA Community Care Unchanged 1834115 611372 0 Form 10-10143e
10-10143f - Community Care Document Cover Sheet Modified 500000 41667 0 Form and Instruction 10-10143f
VA Form 10-10143g: Non-VA Hospital Emergency Notification New 500000 83333 0 Form 10-10143g
Total burden requested under this ICR: 22758371 3007560 0  
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