CHAMPVA Claim Form

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

OMB: 2900-0219

IC ID: 246404

Information Collection (IC) Details

View Information Collection (IC)

CHAMPVA Claim Form 2900-0219
 
No Modified
 
Required to Obtain or Retain Benefits
 
38 CFR 1.900 38 CFR 17.900 through 17.905

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

Health Health Care Services

 

55,000 0
   
Individuals or Households
 
   0 %

  Approved 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 55,000 0 55,000 0 0 0
Annual IC Time Burden (Hours) 9,167 0 9,167 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy