VA Form 10-7959d Potential Liability Claim Form

OMB Number: 2900-0219

Expiration Date: 9/20/2016

CHAMPVA Potential Liability Claim

Department of Veterans Affairs
Chief Business Office Purchased Care

Estimated Burden: 7 minutes

CHAMPVA

PO Box 469063

Denver CO 80246-9063

1-800-733-8387

Attention: After reviewing the following information, complete this form (print or type only) in its entirety and return.
Purpose: Based on recent claim information, medical services have been received for the treatment of an injury or potential work-related illness.
Because the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such services when the
injury/illness was caused or is covered by a third party, the following information is required.

Section I - Patient Information

2. First Name (this is a mandatory field)

1. Last Name (this is a mandatory field)

MI

4. Street Address

3. Social Security Number (this is a mandatory field)

5. Date of Birth (mm/dd/yyyy)

6. City

7. State

Section II - Injury/Illness Information

If more space is needed, continue in the same format on separate sheet
10. Diagnosis

8. ZIP Code

9. Telephone Number (include area code)

Section III - Third Party Claim Information

If more space is needed, continue in the same format on separate sheet
20. Based on location of incident in Section II, provide insurance information for:

11. Circumstances
b. Where

a. When

12. Describe What Happened

Work
Home

Auto Insurance
Other (specify)

Employer

Home Owner Insurance

21. Name of Insurance Company/Employer

Auto Accident
Other (specify below)

22. Street Address

23. City

24. State

13. Last Name of Witness

14. First Name of Witness

MI

25. ZIP Code

26. Insurance Co. / Employer Phone (include area code)

27. Insurance Policy Number

15. Witness Telephone Number (include area code)

28. Is patient represented by an attorney or contemplating representation?

16. Last Name of Investigator (i.e. police)

29. Last Name of Attorney

Yes (complete attorney information below)
No (proceed to Section IV)

17. First Name of Investigator

MI

30. First Name of Attorney

31. Street Address

18. Title

32. City

19. Investigator Telephone Number (include area code)

33. State

34. ZIP Code

35. Attorney Telephone Number (include area code)

Section IV - Certification

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

36. I certify that the above information and attachments are correct
to the best of my knowledge and belief. (Sign and date on right.) If
signed by a person other than patient, complete the following.
37. Last Name

Signature

Date

38. First Name

MI

39. Relationship to Patient

40. Street Address

42. State

41. City

VA FORM
AUG 2013

10-7959d

43. ZIP Code

44. Telephone Number (include area code)

CHAMPVA Potential Liability Claim Form
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 is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 7
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. Comments regarding this burden
estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by calling
the CHAMPVA Help Line, 1-800-733-8387. Respondents should be aware that notwithstanding any other provision of law,
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. Based on recent claim information, medical services have been received for the treatment of an
injury or potential work-related illness. Because of the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the
recovery of VA costs associated with such services when the injury/illness was caused or is covered by a third party, this
information is required.
VA FORM
AUG 2013

10-7959d