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

OMB 2900-0219

Used by CHAMP VA claimants to claim reimbursement for medical care and by VA to determine eligibility, process claims, detect fraud and recover costs from third parties.

The latest form for CHAMPVA Benefits - Application, Claim, Other Health Insurance, Potential Liability & Misc Expenses expires 2021-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form
Form 10-10d CHAMPVA Application for Benefits Form
Form 10-7959e CHAMPVA Claim for Miscellaneous Expenses Form
Form 10-7959d CHAMPVA Potential Liability Claim Form Form
Form 10-7959c CHAMPVA Other Health Insurance (OTI) Certification Form and Instruction
Form 10-7959a CHAMPVA Claim Form Form
30-day FRN_CHAMPVA Benefits_2900-0219_pub 09022021.pdf Supplementary Document
60-day FRN_CHAMPVA Benefits_2900-0219_pub 06032021.pdf Supplementary Document
Supporting Statement A_2900-0219_CHAMPVA Benefits Forms_updated Sep 2021.docx Supporting Statement A
Memorandum_Request for Emergency PRA Clearance_CHAMPVA Benefits_Mar 2021.pdf Supplementary Document
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form
CHAMPVA Clinical Review
CHAMPVA Appeal Process
CHAMPVA Application for Benefits Form
CHAMPVA Claim for Miscellaneous Expenses Form
CHAMPVA Potential Liability Claim Form Form
CHAMPVA Other Health Insurance (OTI) Certification Form and Instruction
CHAMPVA Claim Form Form

All Historical Document Collections

202104-2900-006 Approved without change	Reinstatement with change of a previously approved collection	2021-09-09
202102-2900-011 Improperly submitted	Extension without change of a currently approved collection	2021-03-25
201708-2900-036 Approved without change	Revision of a currently approved collection	2018-01-10
201602-2900-032 Approved with change	Extension without change of a currently approved collection	2016-03-01
201211-2900-001 Approved without change	Revision of a currently approved collection	2013-08-23
201001-2900-009 Approved without change	Revision of a currently approved collection	2010-06-02
200703-2900-003 Approved with change	Extension without change of a currently approved collection	2007-03-12
200402-2900-001 Approved without change	Extension without change of a currently approved collection	2004-02-20
200107-2900-018 Approved without change	Revision of a currently approved collection	2001-07-25
200011-2900-005 Approved without change	Reinstatement with change of a previously approved collection	2000-11-30
199508-2900-005 Withdrawn and continue	Revision of a currently approved collection	1995-08-15
199308-2900-007 Approved without change	Reinstatement with change of a previously approved collection	1993-08-12
198811-2900-003 Approved without change	Revision of a currently approved collection	1988-11-10
198704-2900-012 Approved without change	Revision of a currently approved collection	1987-04-08
198610-2900-012 Approved with change	No material or nonsubstantive change to a currently approved collection	1986-10-01
198407-2900-008 Approved without change	Reinstatement with change of a previously approved collection	1984-07-30
198210-2900-028 Approved with change	No material or nonsubstantive change to a currently approved collection	1982-10-01
198011-2900-064 Approved with change	No material or nonsubstantive change to a currently approved collection	1980-11-14
197904-2900-002 Approved without change	Revision of a currently approved collection	1979-04-27
197705-2900-010 Approved without change	Revision of a currently approved collection	1977-05-09