Dental Record Authorization and Invoice for Outpatient Service

Forms and Documents

Document Name	Status
Form VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient Service Form	Modified
2900-0335 justification.DOC Supporting Statement A	2009-12-10

IC Document Collections

IC ID	Document Title	Status
28546	Dental Record Authorization and Invoice for Outpatient Service Form	Modified

ICR Details

OMB Control No: 2900-0335	ICR Reference No: 200909-2900-003
Status: Historical Active	Previous ICR Reference No: 200612-2900-013
Agency/Subagency: VA	Agency Tracking No: 2900-0335
Title: Dental Record Authorization and Invoice for Outpatient Service
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/01/2010
	Date Received in OIRA: 12/10/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2013	36 Months From Approved	02/28/2010
Responses	11,000	0	12,460
Time Burden (Hours)	3,666	0	4,153
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 10-2570d lists the veteran's dental treatment needs, the cost to the VA to provide these services, authorizes this treatment and serves as an invoice for payment.

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Authorizing Statute(s): US Code: 38 USC Section 1712(a) and (b) Name of Law: Veterans' Benefits
   US Code: 38 USC Section 1710(4)(c) Name of Law: Veterans' Benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 187	09/29/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 235	12/09/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Dental Record Authorization and Invoice for Outpatient Service	VA Form 10-2570d	Dental Record Authorization and Invoice for Outpatient Service

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ICR Summary of Burden

	Total Approved	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	11,000	12,460	0	0	-1,460	0
Annual Time Burden (Hours)	3,666	4,153	0	0	-487	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is an estimation of 44,000 dental treatment cases authorized annually for fee dental treatment. It has been estimated that only 25% of fee dentists will VA form 10-2570d, the remainder will use forms auto generated by their office automation software.

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Annual Cost to Federal Government: $319,803

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/10/2009

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