Va Form 10-0460 - Request For Prescription Drugs From An Eligible Veteran In A State Home Page 3
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3The Paperwork Reduction Act of 1995 requires us to notify you that this information collection
is in accordance with the clearance requirements of section 3507 of this Act. We may not conduct
or sponsor, and the respondent is not required to respond to, a collection unless it displays a valid
OMB Control Number. The public reporting burden for this collection of information is estimated
to average 30 minutes per response, including the time for reviewing instructions, gather the
necessary facts and fill out the form. This information is collected under the authority of Title 38
CFR Parts 51 and 58. It is being collected under the medical benefits in the State Homes Program
and will be used for that purpose.
Privacy Act Information:
It is being collected to enable us to determine your eligibility for
medical benefits and will be used for that purpose. The income and eligibility you supply may be
verified through a computer matching program at any time and information may be disclosed
outside the VA as permitted by law; possible disclosures include those described in the "routine
uses" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in
the Federal Register in accordance with the Privacy Act of 1974. Disclosure is voluntary;
however, the information is required in order for us to determine your eligibility for the medical
benefit for which you have applied. Failure to furnish the information will have no adverse affect
on any other benefits to which you may be entitled. Disclosure of Social Security number(s) of
those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is
mandatory. Social Security numbers will be used in the administration of veterans benefits, in the
identification of veterans or persons claiming or receiving VA benefits and their records and may
be used for other purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5
U.S.C. 552a) or where required by other statute
Page 3 of 3
10-0460
VA FORM
FEB 2008
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