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CHAMPVA Potential Liability Claim Form
CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses
OMB: 2900-0219
IC ID: 246408
OMB.report
VA
OMB 2900-0219
ICR 202407-2900-007
IC 246408
( )
Documents and Forms
Document Name
Document Type
Form 10-7959d
CHAMPVA Potential Liability Claim Form
Form
10-7959d CHAMPVA Potential Liability Claim Form
VA Form 10-7959d_updated 2024.pdf
www.gov/vaforms/Search_action.asp
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
CHAMPVA Potential Liability 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
10-7959d
CHAMPVA Potential Liability Claim Form
VA Form 10-7959d_updated 2024.pdf
http://www.gov/vaforms/Search_action.asp
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
2,045
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
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
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.