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Federal Register / Vol. 85, No. 232 / Wednesday, December 2, 2020 / Notices

c. VA Form 10–10143b will collect
health records of covered Veterans from
non-VA health care entities and
providers for care authorized under the
VCCP, as required by 38 U.S.C.
1703(a)(2)(A), which requires VA to
establish a mechanism to receive
medical records from non-VA providers.
A copy of all medical and dental records
(including but not limited to images,
test results, and notes or other records
of what care was provided and why)
related to a Veteran’s care provided
under the VCCP must be submitted to
VA, including any claims for payment
for the furnishing of such care.
d. VA Form 10–10143c will collect
information from non-VA entities and
providers concerning relevant
credentials and licenses as required for
such entities or providers to furnish care
and services generally. This information
is authorized by section 133 of the
MISSION Act, which requires VA to
establish competency standards for nonVA providers, as well as 38 U.S.C.
1703C(a)(1), which requires VA to
establish certain standards of quality for
furnishing care and services (including
through non-VA providers).
e. VA Form 10–10143e will collect
secondary authorization requests from
non-VA entities and providers to
furnish care and services in addition to
or supporting the original authorization
for care. This information is required by
38 U.S.C. 1703(a)(3), which establishes
that a covered Veteran may only receive
care or services under the VCCP upon
VA’s authorization of such care or
services.
f. VA Form 10–10143f will allow for
the submission of paper documents in
support of a non-VA provider claim for
emergency care rendered in the
community when not accompanied by a
paper Health Care Claim form. This
Community Care Document Cover Sheet
will be used exclusively for the
submission of medical documentation
for unauthorized emergent services for
patients otherwise covered by VA.
g. VA Form 10–10143g will be used
to provide 72-hour notification to VA
when a Veteran receives emergent care
from a non-VA provider. This form
should be completed by the non-VA
provider within 72 hours of the
beginning of treatment.
An agency may not conduct or
sponsor, and a person is not required to
respond to, a collection of information
unless it displays a currently valid OMB
control number. The Federal Register
Notice with a 60-day comment period
soliciting comments on this collection
of information was published at 85 FR
158 on August 14, 2020, pages 49720
and 49721.

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VA Form 10–10143
Affected Public: Individuals or
households.
Estimated Annual Burden: 610,833
hours.
Estimated Average Burden per
Respondent: 10 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
3,665,000.
VA Form 10–10143a
Affected Public: Individuals or
households.
Estimated Annual Burden: 610,833
hours.
Estimated Average Burden per
Respondent: 10 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
3,665,000.
VA Form 10–10143b
Affected Public: Private Sector.
Estimated Annual Burden: 1,039,332
hours.
Estimated Average Burden per
Respondent: 5 minutes.
Frequency of Response: Average of 34
times annually.
Estimated Number of Respondents:
366,823.
VA Form 10–10143c
Affected Public: Private Sector.
Estimated Annual Burden: 10,190
hours.
Estimated Average Burden per
Respondent: 5 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
122,274.
VA Form 10–10143e
Affected Public: Private Sector.
Estimated Annual Burden: 611,372
hours.
Estimated Average Burden per
Respondent: 20 minutes.
Frequency of Response: Average of 5
times annually.
Estimated Number of Respondents:
366,823.
VA Form 10–10143f
Affected Public: Private Sector.
Estimated Annual Burden: 41,667
hours.
Estimated Average Burden per
Respondent: 5 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
500,000.
VA Form 10–10143g
Affected Public: Private Sector.

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Estimated Annual Burden: 83,333
hours.
Estimated Average Burden per
Respondent: 10 minutes.
Frequency of Response: Once
annually.
Estimated Number of Respondents:
500,000.
By direction of the Secretary.
Danny S. Green,
Interim VA Clearance Officer, Office of
Quality, Performance and Risk (OQPR),
Department of Veterans Affairs.
[FR Doc. 2020–26575 Filed 12–1–20; 8:45 am]
BILLING CODE 8320–01–P

DEPARTMENT OF VETERANS
AFFAIRS
[OMB Control No. 2900–0882]

Agency Information Collection Activity
Under OMB Review: Chapter 31
Request for Assistance
Veterans Benefits
Administration, Department of Veterans
Affairs.
ACTION: Notice.
AGENCY:

In compliance with the
Paperwork Reduction Act (PRA) of
1995, this notice announces that the
Veterans Benefits Administration,
Department of Veterans Affairs, will
submit the collection of information
abstracted below to the Office of
Management and Budget (OMB) for
review and comment. The PRA
submission describes the nature of the
information collection and its expected
cost and burden and it includes the
actual data collection instrument.
DATES: Written comments and
recommendations for the proposed
information collection should be sent
within 30 days of publication of this
notice to www.reginfo.gov/public/do/
PRAMain. Find this particular
information collection by selecting
‘‘Currently under 30-day Review—Open
for Public Comments’’ or by using the
search function. Refer to ‘‘OMB Control
No. 2900–0882.
FOR FURTHER INFORMATION CONTACT:
Danny S. Green, Enterprise Records
Service (005R1B), Department of
Veterans Affairs, 811 Vermont Avenue
NW, Washington, DC 20420, (202) 421–
1354 or email danny.green2@va.gov.
Please refer to ‘‘OMB Control No. 2900–
0882’’ in any correspondence.
SUPPLEMENTARY INFORMATION:
Authority: 38 U.S.C. 3100, 38 U.S.C.
501.
Title: Chapter 31 Request for
Assistance (VA Form 28–10212).
OMB Control Number: 2900–0882.
SUMMARY:

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Federal Register / Vol. 85, No. 232 / Wednesday, December 2, 2020 / Notices
Type of Review: Extension of a
currently approved collection.
Abstract: VA Form 28–10212 is used
to gather specific information regarding
a claimant’s request for services,
supplies, or equipment that are
necessary to participate in the Chapter
31 program.
An agency may not conduct or
sponsor, and a person is not required to
respond to a collection of information

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unless it displays a currently valid OMB
control number. The Federal Register
Notice with a 60-day comment period
soliciting comments on ≤this collection
of information was published at insert
citation date, 85 FR 182 on September,
18, 2020, pages 58428 and 58429.
Affected Public: Individuals.
Estimated Annual Burden: 83.
Estimated Average Burden per
Respondent: 10 minutes.

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Frequency of Response: One time.
Estimated Number of Respondents:
500.
By direction of the Secretary.
Danny S. Green,
VA PRA Clearance Officer, Office of Quality,
Performance and Risk, Department of
Veterans Affairs.
[FR Doc. 2020–26566 Filed 12–1–20; 8:45 am]
BILLING CODE 8320–01–P

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