VA Form 10-314 - Request for Payment of Bowel and Bladder Services

Preauthorization and Request for Payment of Bowel and Bladder Services (VA Forms 10-314a and 10-314b)

Documents and Forms

Document Name Document Type
Form 10-314b VA Form 10-314b - Request for Payment of Bowel and Bladder Services Form
10-314b Request for Payment of Bowel and Bladder Services 10-314b_Request for Payment of Bowel and Bladder Services.pdf Form
10-314 Request for Payment of Bowel and Bladder Services VA Form 10-314_rev April 2023.pdf Form

Information Collection (IC) Details

IC Title:	VA Form 10-314 - Request for Payment of Bowel and Bladder Services	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-314	Request for Payment of Bowel and Bladder Services	VA Form 10-314_rev April 2023.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40,800	40,800
Annual IC Time Burden (Hours)	6,800	6,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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