VA Form 10-21034j Health Insurance Module 1

OMB Number 2900-new
Estimated burden: 4 min.

DEPARTMENT OF VETERANS AFFAIRS

VETERAN ENROLLEES'
HEALTH AND RELIANCE
UPON VA
Health Insurance Module 1
Privacy Act Information: The information requested is solicited under the authority of 38 U.S.C., Sections 1705, 527; P.L. 104-262,
Veterans Health Care Eligibility Reform Act of 1996; and Regulation 38 CFR Part 17. The information is being collected to enable
VA to make accurate projections for the Secretary's enrollment level decisions, i.e., who will demand enrollment in future years, what
health care services will be needed, and the ability of VA to meet this need. The information may be disclosed outside the VA as
permitted by law; possible disclosures include those described in the "routine uses" identified in the VA system of records 97VA105,
Consolidated Data Information System--VA, published in the Federal Register in accordance with the Privacy Act of 1974.
Disclosure is voluntary. Failure to furnish the information will have no adverse affect on any other benefits to which you may be
entitled. Social Security numbers will be used in the identification of veterans or persons receiving VA health care benefits and may
be used for other purposes where authorized by 38 U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by statute.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it reveals to you a valid OMB number. This information sought is solicited under the
authority of Public Law 104-262, the Veterans Health Care Eligibility Reform Act of 1996. We anticipate that the time expended by
all individuals who complete this module will average 4 minutes. This includes the time it will take to listen to instructions and
respond to the telephone interviewer. Participation in this survey is entirely voluntary. Failure to participate will have no adverse
impact on any benefits to which you may have been entitled. The information we gain from this study will help us better understand
veterans' health care needs.
VA FORM
AUG 2006

10-21034j