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

CHAMP VA Benefits - Application, Claim, Other Health Insurance & Potential Liability

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0219 can be found here:

Documents and Forms

Document Name Document Type
Form VA Form 10-7959a CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form
VA Form 10-7959a CHAMPVA Claim Form vha-10-7959a-fill 2010.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-7959c CHAMPVA Other Health Insurance (OHI) Certification vha-10-7959c-fill 2010.pdf www.gov/vaforms/Search_action.asp Form and Instruction
VA Form 10-7959d Potential Liability Claim Form vha-10-7959d-fill 2010.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-7959e Claim for Miscellaneous Expenses vha-10-7959e-fill_012010.pdf www.gov/vaforms/Search_action.asp Form
VA Form 10-10d Application for Benefits vha-10-10d-fill 2010.pdf www.gov/vaforms/Search_action.asp Form

Information Collection (IC) Details

IC Title:	CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability	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 17.900 through 17.905 38 CFR 1.900

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	VA Form 10-7959a	CHAMPVA Claim Form	vha-10-7959a-fill 2010.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form and Instruction	VA Form 10-7959c	CHAMPVA Other Health Insurance (OHI) Certification	vha-10-7959c-fill 2010.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959d	Potential Liability Claim Form	vha-10-7959d-fill 2010.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959e	Claim for Miscellaneous Expenses	vha-10-7959e-fill_012010.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-10d	Application for Benefits	vha-10-10d-fill 2010.pdf	http://www.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 339,619	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	339,619	4,400	216,019	119,200
Annual IC Time Burden (Hours)	56,570	900	36,002	19,668
Annual IC Cost Burden (Dollars)	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.