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

CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form
VA Form 10-7959a CHAMPVA Claim Form 10-7959a-fill AUG 2013 FIX 2015.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-7959c CHAMPVA Other Health Insurance (OHI) Certification vha-10-7959c-fill AUG 2013 FIX 2015.pdf www.gov/vaforms/Search_action.asp Form and Instruction
VA Form 10-7959d Potential Liability Claim Form vha-10-7959d-fill AUG 2013 FIX 2015.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-7959e Claim for Miscellaneous Expenses vha-10-7959e-fill AUG 2013 FIX 2015.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-10d Application for Benefits vha-10-10d-fill 2014 FIX 2015.pdf www.gov/vaforms/Search_action.asp Form

Information Collection (IC) Details

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: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17.900 through 17.905 38 CFR 1.900

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-7959a	CHAMPVA Claim Form	10-7959a-fill AUG 2013 FIX 2015.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form and Instruction	VA Form 10-7959c	CHAMPVA Other Health Insurance (OHI) Certification	vha-10-7959c-fill AUG 2013 FIX 2015.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959d	Potential Liability Claim Form	vha-10-7959d-fill AUG 2013 FIX 2015.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959e	Claim for Miscellaneous Expenses	vha-10-7959e-fill AUG 2013 FIX 2015.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-10d	Application for Benefits	vha-10-10d-fill 2014 FIX 2015.pdf	http://www.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: 339,619	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	339,619	-339,643	339,643	339,619
Annual IC Time Burden (Hours)	56,570	-56,576	56,576	56,570
Annual IC Cost Burden (Dollars)	0	0	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.