Provider Dispute Notice

Expanded Access to Non-VA Care through the MISSION Program: Establishing a Process for Certification, Discontinuance, and Disputes for Veterans Care Agreements (VCAs) - AQ45

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Provider Dispute Notice	Agency IC Tracking Number:	2900-NEW

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 38 CFR 17.4100

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA	FR Citation: 74 FR 34398

Number of Respondents: 803	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	803	803
Annual IC Time Burden (Hours)	268	268
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.