Application for Extended Care
Services, VA Form 10-10EC
Reinstatement without change of a previously approved
collection
No
Regular
03/11/2022
Requested
Previously Approved
36 Months From Approved
2,000
0
3,000
0
0
0
Collects information to establish
eligibility for extended care benefits, establishes financial
liability veteran to pay if accepted for placement in Extended Care
Services, and establishes veteran has agreed to make any applicable
copayment.
US Code:
38
USC 1710B Name of Law: Eligibility for hospital, nursing home,
and domiciliary
US Code: 38
USC 1722A Name of Law: Determination of inability to defray
necessary expenses;
US Code: 38
USC 1729 Name of Law: Recovery by the United States of the cost
of certain
US Code: 38
USC 1705 Name of Law: Management of health care: patient
enrollment system
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.