CHAMPVA Potential Liability Claim Form

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

OMB: 2900-0219

IC ID: 246408

Information Collection (IC) Details

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CHAMPVA Potential Liability 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 10-7959d CHAMPVA Potential Liability Claim Form VA Form 10-7959d_updated 2024.pdf http://www.gov/vaforms/Search_action.asp Yes No Fillable Printable

Health Health Care Services

 

2,045 0
   
Individuals or Households
 
   0 %

  Requested 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 2,045 0 0 0 0 2,045
Annual IC Time Burden (Hours) 239 0 0 0 0 239
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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