OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 28467 under ICR 202104-2900-006 · OMB 2900-0219.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form VA Form 10-7959a
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form
Form VA Form 10-7959a
CHAMPVA Claim Form CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form
Form VA Form 10-7959c
CHAMPVA Other Health Insurance (OHI) Certification CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form and Instruction
Form VA Form 10-7959d
Potential Liability Claim Form CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form
Form VA Form 10-7959e
Claim for Miscellaneous Expenses CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form
Form VA Form 10-10d
Application for Benefits CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability		 Form
VA Form 10-7959a CHAMPVA Claim Form
10-7959a-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-7959a CHAMPVA Claim Form
10-7959a-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-7959c CHAMPVA Other Health Insurance (OHI) Certification
vha-10-7959c-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form and Instruction
VA Form 10-7959c CHAMPVA Other Health Insurance (OHI) Certification
vha-10-7959c-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form and Instruction
VA Form 10-7959d Potential Liability Claim Form
vha-10-7959d-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-7959d Potential Liability Claim Form
vha-10-7959d-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-7959e Claim for Miscellaneous Expenses
vha-10-7959e-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-7959e Claim for Miscellaneous Expenses
vha-10-7959e-fill AUG 2013 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-10d Application for Benefits
vha-10-10d-fill 2014 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form
VA Form 10-10d Application for Benefits
vha-10-10d-fill 2014 FIX 2015.pdf
www.gov/vaforms/Search_action.asp 		Form

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form VA Form 10-7959a http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable
Form and Instruction VA Form 10-7959c http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable
Form VA Form 10-7959d http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable
Form VA Form 10-7959e http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable
Form VA Form 10-10d http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 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

Documents for IC
table that charts IC Documents
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.
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