Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)

ICR 202404-2900-008

OMB: 2900-0858

Federal Form Document

ICR Details
2900-0858 202404-2900-008
Received in OIRA 202009-2900-020
VA VBA-COMP-YA
Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)
Revision of a currently approved collection   No
Regular 07/09/2024
  Requested Previously Approved
36 Months From Approved 07/31/2024
440,246 127,397
36,687 10,616
0 0

VA Form 21-4142 is used to authorize the disclosure of information to the VA and VA Form 21-4142a is used to gather the necessary information to request medical provider information to the VA. Without the information solicited by these forms, VA would be unable to determine eligibility, and benefits would not be properly paid.

PL: Pub.L. 104 - 191 203 Name of Law: Health Insurance Portability And Accountability Act
   US Code: 42 USC 290dd-2 Name of Law: Confidentiality of records
   US Code: 38 USC Section 5101(a) (1) Name of Law: Claims and Forms
  
None

Not associated with rulemaking

  89 FR 35308 05/01/2024
89 FR 56024 07/08/2024
No

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 440,246 127,397 0 312,849 0 0
Annual Time Burden (Hours) 36,687 10,616 0 26,071 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
The respondent burden has increased due to the estimated number of receivables averaged over the past year.

$11,785,760
No
    Yes
    Yes
No
No
No
No
Maribel Aponte 202 266-4688 maribel.aponte@va.gov

  No

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.
07/09/2024


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