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

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

OMB: 2900-0219

IC ID: 28467

Information Collection (IC) Details

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CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability 2900-0219
 
No Removed
 
Required to Obtain or Retain Benefits
 
38 CFR 17.900 through 17.905 38 CFR 1.900

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

Health Health Care Services

 

177,225 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 0 -177,225 0 177,225
Annual IC Time Burden (Hours) 0 0 0 -46,176 0 46,176
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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