VA Form 10-7959d CHAMPVA Potential Liability Claim

OMB Number: 2900-0219
Estimated Burden: 7 minutes
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CHAMPVA Potential Liability Claim
VA Health Administration Center

CHAMPVA

PO Box 65023

Denver CO 80206-9023

1.303.331.7519

Attention: After reviewing the following, complete form in its entirety (print or typewritten only) and return.
Do NOT exceed the designated space (i.e. do NOT extend last name into First Name area).
Purpose: Based on recent claim information, medical services have been received for the treatment of an injury or potential work-related
illness. Because the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such
services when the injury/illness was caused or is covered by a third party, the following information is required.
Section I - Patient Information
1. Last Name

2. First Name

Ml

4. Street Address

3. Social Security Number

5. Date of Birth (mm/dd/yyyy)

6. City

7. State

8. Zip Code

Section II - Injury/Illness Information

9. Telephone Number (include area code)

Section III - Third Party Claim Information

If more space needed, continue in the same format on separate sheet.

If more space needed, continue in the same format on separate sheet.
20. Based on location of incident identified in Section II, provide insurance information for:

10. Diagnosis

Auto Insurance

a. When

Home Owner Insurance

Other (specify)

11. Circumstances
(mm/dd/yyyy)

Employer

21. Name of Insurance Company/Employer

b. Where
Work
Home
Auto Accident
Other (specify)

22. Street Address

12. Describe What Happened

23. City

13. Last Name of Witness

24. State 25. Zip Code

14. First Name of Witness

Ml

26. Insurance Co/Employer Phone No.
(include area code)

27. Insurance Policy Number

15. Witness Phone Number (include area code)

28. Is patient represented by an attorney or contemplating representation?
Yes (complete attorney information below)
No (proceed to Section IV)

16. Last Name of Investigator (i.e. police)

29. Last Name of Attorney

17. First Name of Investigator

MI

30. First Name of Attorney

31. Street Address

18. Title

32. City

19. Investigator Phone Number (include area code)

33. State

34. Zip Code

35. Attorney Phone Number (include area code)

Section IV - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, ficticious, or fraudulent statements or claims.

36. I certify that the above information and attachments are correct
to the best of my knowledge and belief. (Sign and date on right.) If
signed by a person other than patient, complete the following.
37. Last Name

Signature

38. First Name

Date

Ml

39. Relationship to Patient

40. Street Address

41. City

VA FORM
NOV 2006

42. State

10-7959d

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43. Zip Code

44. Phone Number (include area code)

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CHAMPVA Potential Liability Claim

Appendix

PRIVACY ACT: The authority for collection of the requested information 38 U.S.C. 501, 38 C.F.R. 1.900 et. seq; 42 U.S.C.
2651-2653; and E.O. 9397. The purpose of collecting this information is to provide basic information from which potential
liability can be assessed. You do not have to provide the requested information but if any or all of the requested information
is not provided, it may delay or result in denial of your request for CHAMPVA benefits. Failure to furnish the requested
information will have no adverse impact on any other VA benefit to which you may be entitled. The responses you submit
are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act,
including the routine uses identified in the VA system of records 54VA16, titled "Health Administration Center Civilian Health
and Medical Program records - VA". For example, information on this form may be disclosed to contractors, trading
partners, health care providers and other suppliers of health care services to determine your eligibility for medical benefits
and payment for services. 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 voluntary. 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.
Paperwork Reduction Act: This information is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 7
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed and completing and reviewing the collection of information. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number. Based on recent claim information, medical services
have been received for the treatment of an injury or potential work-related illness. Because of the Federal Medical Care
Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such services when the injury/illness
was caused or is covered by a third party, the following information is required.
VA FORM
NOV 2006

10-7959d