10-7959e CHAMPVA Claim for Miscellaneous Expenses

OMB Number: 2900-0219

Estimated Burden: 10 minutes Expiration Date: 9/20/2016

Claim for Miscellaneous Expenses

Department of Veterans Affairs
Chief Business Office Purchased Care

1-888-820-1756

Attention: After reviewing the following information, complete the form in its entirety (print or type only) and return with the
required documentation. Receipts must be provided with this form to ensure proper payment. Failure to provide the requested
information will result in a delay or denial of reimbursement. If more space is needed, continue in the same format on a
separate sheet.
Note: This form is required for all claims for reimbursement of miscellaneous expenses related to the treatment of spina
bifida and other covered birth defects and associated covered conditions. Regardless of the type of expense being claimed,
completion of Sections I, II, and IV are mandatory. Completion of Section III is required only for claims involving travel.
Reimbursement for approved expenses (including attendant travel/miscellaneous expenses) will be made payable to
the beneficiary.
Section I - Patient Information

Last Name

First Name

MI

Social Security Number

Date of Birth (mm/dd/yyyy)

Street Address

City

State

ZIP Code

Telephone Number (include area code)

Section II - Sponsor Information
Last Name

MI

First Name

Social Security Number

Section III - Travel

Attach required receipts for expenses claimed (receipts for privately owned vehicle mileage [POV] excluded)

Will the provider be billing for services? (Check one)

Yes

No

Certification of Medical Service (required for all travel claims)

Date of Service (mm/dd/yyyy) Provider Tax ID Number

Provider signature certifying service on service date (type if electronic)

X

Patient Travel Information
Mode of Travel

444
44444

Airline

Taxi

POV (round trip) mileage

Bus

Train

Other (specify)

Date(s) of travel (mm/dd/yyyy)
City

Date(s) of travel (mm/dd/yyyy)

Departure

Time (e.g. 0815)

City

Time (e.g. 0815)

City

Departure
State

City

Last Name

Arrival

State

First Name

Attendant Information

MI

Arrival

State

Time (e.g. 0815)

State

Time (e.g. 0815)

Relationship to Patient

Patient/Attendant Miscellaneous Expenses
Lodging $

Other (parking, tolls, etc.) $

Meals $

Section IV - Certification

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

Release of Medical Information: Signature in this section authorizes the patient's providers to release medical record documentation related to the
services associated with this claim. This consent pertains to all medical records, including records related to treatment for psychological and psychiatric
conditions, drug and alcohol abuse, acquired immune deficiency syndrome, human immunodeficiency virus infection, and sickle cell disease.
Date
I certify that the above information and attachments are correct Signature (type if electronic)
and represent actual services, dates, and fees charged. (Sign and
date on right.) If certification is signed by a person other than the
patient, complete the information, signature and date.

4

Last Name

First Name

MI

Relationship to Patient

Street Address

State

City

VA FORM
AUG 2013

10-7959e

ZIP Code

Telephone Number (include area code)

Claim for Miscellaneous Expenses
Privacy Act Information: Information on this form is collected in accordance with the System of Records Notice
54VA10NB3, Veterans and Beneficiaries Purchased Care Community Health Care Claims, Correspondence,
Eligibility, Inquiry and Payment Files-VA (Published March 3, 2015, FR 80, number 41). Category: Records
maintained in the system include program applications, eligibility information concerning the Veteran, family
members, caregivers, other health insurance information to include information regarding eligibility or entitlement
to other federal medical programs. Authority: 38 USC 501 and 1781. Purpose: Records may be used for
purposes of establishing and monitoring eligibility to receive VA benefits, processing claims for medical care and
services, and processing stipends. Routine Use: The Privacy Act permits VA to disclose information about
individuals without their consent under the Privacy Act Routine Use Disclosure when the information will be used
for a purpose that is compatible with the purpose for which VA collected the information. Disclosure: Voluntary.
You do not have to provide the requested information on this form 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.
Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of Title
44 U.S.C. Section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of
information is estimated to average 10 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 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.

Spina Bifida Health Care Program

Children of Women Vietnam Veterans

Chief Business Office Purchased Care
Spina Bifida Health Care Benefits
PO Box 469065
Denver CO 80246-9065

Chief Business Office Purchased Care
Children of Women Vietnam Veterans
PO Box 469065
Denver CO 80246-9065

Phone:

1-888-820-1756

Phone:

1-888-820-1756

Fax:

1-303-331-7807

Fax:

1-303-331-7807

VA FORM
AUG 2013

10-7959e