Information Collection

Dental Record Authorization and Invoice for Outpatient Service

IC 28546 under ICR 201211-2900-002 · OMB 2900-0335.

Documents and Forms

Document Name Document Type
Form VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient Service Form
VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient S 2900-0335 VA Form 10-2570d-fill.pdf vaww.va.gov/vaforms/ Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Dental Record Authorization and Invoice for Outpatient Service	Agency IC Tracking Number:	2900-0335

Is this a Common Form? No		IC Status: Modified

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	VA Form 10-2570d	Dental Record Authorization and Invoice for Outpatient Service	2900-0335 VA Form 10-2570d-fill.pdf	http://vaww.va.gov/vaforms/	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	11,000	11,000
Annual IC Time Burden (Hours)	3,666	3,666
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.