2900-0858, Supporting Statement (VAF21-4142, 4142a)

Supporting Statement - Part A

Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) and General Release for Medical Provider Information

to the Department of Veterans Affairs (VA)

Control # 2900-0858

Summary of Changes from Previously Approved Collection

• No changes have been made to these forms.

• This request is a “revision” due to the respondent burden increasing due to the estimated number of receivables averaged over the past year.

• No comments were received during the 60-Day comment period.

1. Need for the Information Collection

The Department of Veterans Affairs (VA) through its Veterans Benefits Administration (VBA) administers an integrated program of benefits and services, established by law, for Veterans, service personnel, and their dependents and/or beneficiaries. Information is requested by VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA). These collections of information were developed to comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 ("HIPAA") and 42 U.S.C. 290dd-242. Regulatory authority is found under 38 C.F.R. Part 2, 45 C.F.R. Parts 160 and 164.

2. Use of the Information

The respondent population for VA Forms 21-4142 and 21-4142a is composed of individuals who are allowing the VA to gather the necessary information to request medical provider information to the VA.

As such, 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.

3. Use of Information Technology

VA Forms 21-4142 and 21-4142a are available on the One-VA Website in a fillable electronic format. VBA is currently hosting this form on a secure server and does have the technology in place to allow for the complete submission of both forms. Validation edits are performed to assure data integrity. There currently is no utility process in place that will allow the data submitted on the form to be incorporated with an existing centralized legacy database.

4. Non-Duplication

The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.

5. Burden on Small Businesses

This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.

6. Less Frequent Collection

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.

7. Paperwork Reduction Act Guidelines

This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).

8. Consultation and Public Comments

Part A: PUBLIC NOTICE

A 60-Day Federal Register Notice (FRN) for the collection published on Wednesday, May 1, 2024. The 60-Day FRN citation is Vol. 89 FRN 35308.

No comments were received during the 60-Day comment period.

A 30-Day FRN for the collection published on Monday, July 8, 2024. The 30-Day FRN citation is 89 FRN 56024.

Part B: CONSULTATION

No additional consultation apart from soliciting public comments through the Federal Register was conducted for this submission.

9. Gifts or Payment

No payments or gifts are being offered to respondents as an incentive to participate in the collection.

10. Confidentiality

The records are maintained in the appropriate Privacy Act System of Records identified as “Compensation, Pension, Education, and Veteran Readiness and Employment Records-VA (58VA21/22/28),” published at 74 FR 29275 on June 19, 2009, and last amended at 87 FR 8740 (February 16, 2022).

11. Sensitive Questions

No questions considered sensitive are being asked in this collection.

12. Respondent Burden and its Labor Costs

1. Number of Respondents is estimated at 440,246 per year.

2. Frequency of Response is one time.

3. Annual burden hours are 36,687 hours.

4. The estimated completion time for this form is 5 minutes.

5. VA cannot make further assumptions about the population of respondents because of the variability of factors such as the educational background and wage potential of respondents. Therefore, VBA uses general wage data to estimate the respondents’ costs associated with completing the information collection.

The Bureau of Labor Statistics (BLS) gathers information on full-time wage and salary workers. According to the latest available BLS data, the mean hourly wage is $31.48 based on the BLS wage code – “00-0000 All Occupations.” This information was taken from the following website: https://www.bls.gov/oes/current/oes_nat.htm.

Legally, respondents may not pay a person or business for assistance in completing the information collection. Therefore, there are no expected overhead costs for completing the information collection. VBA estimates the total cost to all respondents to be $1,154,906.70 (36,687 burden hours x $31.48 per hour).

13. Respondent Costs Other Than Burden Hour Costs

There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.

14. Costs to the Federal Government

Grade	Step	Burden Time	Fraction of Hour	Hourly Rate	Cost Per Response	Total Responses	Total
7	3	10	0.17	$21.45	3.575	440,246	$ 1,573,879.45
Overhead at 100% Salary							$ 1,573,879.45
9	3	10	0.17	$26.24	4.373	440,246	$ 1,925,342.51
Overhead at 100% Salary							$ 1,925,342.51
11	3	10	0.17	$31.74	5.290	440,246	$ 2,328,901.34
Overhead at 100% Salary							$ 2,328,901.34
Processing / Analyzing Costs							$ 11,656,246.59
Printing and Production Cost							$ 129,513.85
Total Cost to Government							$ 11,785,760.44

Overhead costs are 100% of salary and are the same as the wage listed above and the amounts are included in the total. 

Printing and production costs approximates the cost of printing this information collection per year.  (Processing/Analyzing Cost total divided by $90).

Note: The hourly wage information above is based on the hourly 2024 General Schedule (Base) Pay (Pay & Leave : Salaries & Wages - OPM.gov). This rate does not include any locality adjustment as applicable.

The processing time estimates above are based on the actual amount of time employees of each grade level spend to process to completion a claim received on this form. The within-grade step (3) of each employee represents the average experience of employees within each grade.

15. Reason for Change in Burden

The respondent burden has increased due to the estimated number of receivables averaged over the past year.

16. Publication of Results

The results of this information collection will not be published.

17. Non-Display of OMB Expiration Date

We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.

18. Exceptions to “Certification for Paperwork Reduction Submissions”

We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.