CHAMPVA Claim Form

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

Documents and Forms

Document Name Document Type
Form 10-7959a CHAMPVA Claim Form Form
10-7959a CHAMPVA Claim Form VA Form 10-7959a_updated 2024.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 17.900 through 17.905 38 CFR 1.900

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	VA Form 10-7959a_updated 2024.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: 74,914	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	74,914	19,914	55,000
Annual IC Time Burden (Hours)	12,486	3,319	9,167
Annual IC Cost Burden (Dollars)	0	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.