The purpose of collecting this
information is to provide basic information from which potential
liability can be assessed for VA to recover the cost of care from
the liable party instead of the American taxpayer and Veteran
paying for the care. Failure to provide any or all of the requested
information may delay or result in VA’s inability to create
accident-related billing, assert a claim for reimbursement, and
assist the Veteran in their personal injury or workers compensation
claim. Without a third party paying for the care, the Veteran may
owe VA co-payments. [With regards to the CHAMPVA form alone:
Failure to provide any or all of the requested information may
delay or result in VA’s inability to provide CHAMPVA benefits.] --
THE CHAMPVA FORM HAS BEEN WITHDRAWN FROM THIS ICR
US Code:
38
USC 501 Name of Law: Rules and regulations
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.