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pdfOMB Control Number: 2900-0219
Expiration Date: 10/31/2024
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 2024
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.
VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for this
project is 2900-0219, and it expires 10/31/2024. Public reporting burden for this collection of information is estimated to
average 7 minutes per respondent, per year, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control
No. 2900-0219 in any correspondence. Do not send your completed VA Form 10-7959d to this email address. Questions
regarding completion of this form may be addressed by calling the CHAMPVA Help Line at 1-800-733-8387. The Federal
Medical Care Recovery Act, 42 USC 2651-2653, requires VA to recover costs associated with medical services received for
treatment of an injury or potential work-related illness when the injury/illness was caused or is covered by a third party.
VA FORM
AUG 2024
10-7959d
File Type | application/pdf |
File Modified | 2024-10-21 |
File Created | 2024-10-21 |