CHAMPVA 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⚠️ Notice: This information collection may be referencing outdated material.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 10-7959a CHAMPVA Claim Form Form
10-7959a CHAMPVA Claim Form 10-7959a-fill_CHAMPVA_Claim Form.pdf www.gov/vaforms/Search_action.asp Form
10-7959a CHAMPVA Claim Form 10-7959a-fill_CHAMPVA_Claim Form.pdf www.gov/vaforms/Search_action.asp Form

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

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	10-7959a	CHAMPVA Claim Form	10-7959a-fill_CHAMPVA_Claim Form.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: 55,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	55,000	55,000
Annual IC Time Burden (Hours)	9,167	9,167
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.