VA Form 10-7959d Potential Liability Claim Form

OMB Number: 2900-0219

CHAMPVA Potential Liability Claim

Department of Veterans Affairs
VA Health Administration Center

Est. Burden: 7 minutes

CHAMPVA

PO Box 469063

Denver CO 80246-9063

1-800-733-8387

Attention: After reviewing the following information, complete this form (print or type only) in its entirety and return.
Purpose: Based on recent claim information, medical services have been received for the treatment of an injury or potential work-related illness.
Because the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such services when the
injury/illness was caused or is covered by a third party, the following information is required.

Section I - Patient Information

1. Last Name (this is a mandatory field)

2. First Name (this is a mandatory field)

MI

4. Street Address

3. Social Security Number (this is a mandatory field)

5. Date of Birth (mm/dd/yyyy)

6. City

7. State

Section II - Injury/Illness Information

If more space is needed, continue in the same format on separate sheet
10. Diagnosis

8. ZIP Code

9. Telephone Number (include area code)

Section III - Third Party Claim Information

If more space is needed, continue in the same format on separate sheet
20. Based on location of incident in Section II, provide insurance information for:

11. Circumstances
b. Where

a. When

12. Describe What Happened

Work
Home

Auto Insurance
Other (specify)

Employer

Home Owner Insurance

21. Name of Insurance Company/Employer

Auto Accident
Other (specify below)

22. Street Address

23. City

24. State

13. Last Name of Witness

14. First Name of Witness

MI

25. ZIP Code

26. Insurance Co. / Employer Phone (include area code)

27. Insurance Policy Number

15. Witness Telephone Number (include area code)

28. Is patient represented by an attorney or contemplating representation?

16. Last Name of Investigator (i.e. police)

29. Last Name of Attorney

Yes (complete attorney information below)
No (proceed to Section IV)

17. First Name of Investigator

MI

30. First Name of Attorney

31. Street Address

18. Title

32. City

19. Investigator Telephone Number (include area code)

33. State

34. ZIP Code

35. Attorney Telephone Number (include area code)

Section IV - Certification

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any fictitious, or fraudulent statements or claims.

36. I certify that the above information and attachments are correct
to the best of my knowledge and belief. (Sign and date on right.) If
signed by a person other than patient, complete the following.
37. Last Name

Signature

Date

38. First Name

MI

39. Relationship to Patient

40. Street Address

41. City

VA FORM
MAY 2010

42. State

10-7959d

43. ZIP Code

44. Telephone Number (include area code)

CHAMPVA Potential Liability Claim Form
PRIVACY ACT: The authority for collection of the requested information 38 U.S.C. 501, 38 C.F.R. 1.900 et. seq; 42 U.S.C.
2651-2653; and E.O. 9397. The purpose of collecting this information is to provide basic information from which potential
liability can be assessed. You do not have to provide the requested information but if any or all of the requested information
is not provided, it may delay or result in denial of your request for CHAMPVA benefits. Failure to furnish the requested
information will have no adverse impact on any other VA benefit to which you may be entitled. The responses you submit
are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act,
including the routine uses identified in the VA system of records 54VA16, titled "Health Administration Center Civilian
Health and Medical Program records -VA". For example, information on this form may be disclosed to contractors, trading
partners, health care providers and other suppliers of health care services to determine your eligibility for medical benefits
and payment for services. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested
under the authority of Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of
veterans benefits, in the identification of veterans or persons claiming or receiving VA benefits and their records and may
be used for other purposes where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where
required by other statute.
Paperwork Reduction Act: This information is in accordance with the clearance requirements of Section 3507 of the
Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 7
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed and completing and reviewing the collection of information. Comments regarding this burden
estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by calling
the CHAMPVA Help Line, 1-800-733-8387. Respondents should be aware that notwithstanding any other provision of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number. Based on recent claim information, medical services have been received for the treatment of an
injury or potential work-related illness. Because of the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the
recovery of VA costs associated with such services when the injury/illness was caused or is covered by a third party, this
information is required.
VA FORM
MAY 2010

10-7959d