Request for revisions to VA forms 10-2914, 10-2520, FL 10-90

Department of Veterans Affairs
Veterans Health Administration (VHA)

From: VHA OMB Clearance Liaison (19E1)

Subj.: Request for approval and inclusion of minor revisions to OMB approved collections 2900-0188. There are no changes to the remaining forms and burden hours associated with this collection.

Revisions/updates to OMB approved forms:

FL 10-90 - Request to Submit Quotation (Title changed):

1. Cover letter text was revised for simplified verbiage and less instruction;

2. Section 1, “Stump Sock Measurements” was removed.

3. Trade discount sections Part 2 and Part 3 were combined and a column for “HCPCS” was added (Healthcare Common Procedure Coding System).

4. Bidder information was deleted.

VA Form 10-2520 - Prosthetic Service Card Invoice

1. Hydraulic Unit description section was deleted. 

2. Repair Data table - a column for HCPCS was added and the name of the section changed to HCPCS Repair Data 

3. Administrative Certification was changed to “To Be Completed by A Prosthetics Service

4. Voucher Audit Block was removed

VA Form 10-2914 - Prescription and Authorization for Glasses

1. Deleted no. 2, Claim Number

2. Renamed Special Instruction to Medical Justification

3. Added no.7, ICD-9 code box for transition and progressive lens

4. Deleted no. 10A Supply case and added Transitions and Progressive

5. Removed the “Authority for Issuance” section, thus eliminating page 2.