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

Forms and Documents

Document Name	Status
Form 21-4142 Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) Form	Modified
2024-14847, 30-Day FRN (2900-0858, VAF21-4142, 4142a).pdf Supplementary Document	2024-07-09
2024-09336, 60-Day FRN (VAF21-4142, 4142a).pdf Supplementary Document	2024-06-26
2900-0858, Supporting Statement (VAF21-4142, 4142a).docx Supporting Statement A	2024-07-09

IC Document Collections

IC ID	Document Title	Status
228502	Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a) Form	Modified

ICR Details

OMB Control No: 2900-0858	ICR Reference No: 202404-2900-008
Status: Received in OIRA	Previous ICR Reference No: 202009-2900-020
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-YA
Title: Authorization and Consent to Release Information to VA (VA Form 21-4142), General Release for Medical Provider Information to VA (VA Form 21-4142a)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/09/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2024
Responses	440,246	127,397
Time Burden (Hours)	36,687	10,616
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

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:
	89 FR 35308	05/01/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56024	07/08/2024
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
Authorization to Disclose Information to VA (VA Form 21-4142), General Release of Medical Provider Information to VA (VA Form 21-4142a)	21-4142, 21-4142a	Authorization to Disclose Information to VA ,   General Release of Medical Provider Information to VA

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

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

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Annual Cost to Federal Government: $11,785,760

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

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

Is this ICR related to the Pandemic Response? No

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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: 07/09/2024

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