Information Collection

CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability

IC 28467 under ICR 200703-2900-003 · OMB 2900-0219.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0219 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-10d CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	Form
VA Form 10-10d Application for CHAMPVA Benefits 10-10d.pdf www.va.gov/vaforms/Search_action.asp	Form
VA Form 10-7959a CHAMPVA Claim Form 10-7959a.pdf www.va.gov/vaforms/Search_action.asp	Form
VA 10-7959c CHAMPVA Other Health Insurance (OHI) Certification 10-7959c.pdf www.va.gov/vaforms/Search_action.asp	Form and Instruction
VA Form 10-7959d CHAMPVA Potential Liability Claim 10-7959d.pdf www.va.gov/vaforms/Search_action.asp	Form

IC Title:

CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability

Agency IC Tracking Number:

2900-0219

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 1.900

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-10d	Application for CHAMPVA Benefits	10-10d.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959d	CHAMPVA Potential Liability Claim	10-7959d.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form and Instruction	VA 10-7959c	CHAMPVA Other Health Insurance (OHI) Certification	10-7959c.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959a	CHAMPVA Claim Form	10-7959a.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	119,200	-2,256,300	0	2,375,500
Annual IC Time Burden (Hours)	19,668	0	-374,999	394,667
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
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.