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

OMB 2900-0219

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.

All Historical Document Collections
Reinstatement with change of a previously approved collection 2021-09-09
Improperly submitted
Extension without change of a currently approved collection 2021-03-25
Approved without change
Revision of a currently approved collection 2018-01-10
Approved with change
Extension without change of a currently approved collection 2016-03-01
Approved without change
Revision of a currently approved collection 2013-08-23
Approved without change
Revision of a currently approved collection 2010-06-02
Approved with change
Extension without change of a currently approved collection 2007-03-12
Approved without change
Extension without change of a currently approved collection 2004-02-20
Approved without change
Revision of a currently approved collection 2001-07-25
Approved without change
Reinstatement with change of a previously approved collection 2000-11-30
Withdrawn and continue
Revision of a currently approved collection 1995-08-15
Approved without change
Reinstatement with change of a previously approved collection 1993-08-12
Approved without change
Revision of a currently approved collection 1988-11-10
Approved without change
Revision of a currently approved collection 1987-04-08
Approved with change
No material or nonsubstantive change to a currently approved collection 1986-10-01
Approved without change
Reinstatement with change of a previously approved collection 1984-07-30
Approved with change
No material or nonsubstantive change to a currently approved collection 1982-10-01
Approved with change
No material or nonsubstantive change to a currently approved collection 1980-11-14
Approved without change
Revision of a currently approved collection 1979-04-27
Approved without change
Revision of a currently approved collection 1977-05-09

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