CHAMPVA Potential Liability Claim Form

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

⚠️ Notice: This information collection may be referencing outdated material.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 10-7959d CHAMPVA Potential Liability Claim Form Form
10-7959d CHAMPVA Potential Liability Claim Form vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf www.gov/vaforms/Search_action.asp Form
10-7959d CHAMPVA Potential Liability Claim Form vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf www.gov/vaforms/Search_action.asp Form

Information Collection (IC) Details

IC Title:	CHAMPVA Potential Liability Claim Form	Agency IC Tracking Number:	2900-0219

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 1.900 38 CFR 17.900 through 17.905

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-7959d	CHAMPVA Potential Liability Claim Form	vha-10-7959d-fill_CHAMPVA_Potential Liability Claim.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,045	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,045	2,045
Annual IC Time Burden (Hours)	239	239
Annual IC Cost Burden (Dollars)	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.