Form 10-10068c Camp Lejeune Family Member Program Information Update Fo

OMB Number 2900-XXXX
Burden Hours: 30 minutes
OMB EXP Date: XX/XX/XXXX

Department of Veterans Affairs

Camp Lejeune Family Member Program Information Update Form
Department of Veterans Affairs, Financial Services Center
PO Box 149200, Austin TX 78714-9200
Customer Service Center: 1-866-372-1144 FAX: 512-460-5536

Family Member
First Name

Last Name

Is this a change of address?

Email Address

Yes

Street Address

Is this a phone number change?
Yes

No

No
State

City

Permanent address?
Yes

Social Security Number

MI

Zip Code

Temporary address?
No

Yes

No

Alt Phone Number

Phone Number (include area code)

to

regular mail

email

Please indicate if you would like to receive correspondence via

from
(include area code)

Health Care Coverage Update
Is this an update to your previous health care coverage?
Has your previous health care coverage ended?
Yes

Yes

No

No

If Yes, please complete the following. If No, Please continue with next section.

Name of prior health care coverage:

Effective Date

(MMDDYYYY)

End Date

Other health care coverage:

Effective Date

(MMDDYYYY)

End Date (MMDDYYYY)

Do you have health care coverage?

Yes, please complete the following

(MMDDYYYY)

No, continue with next section

Note: This includes coverage you may have through an employer, spouse, significant other or federal/state health care benefit plan.

Please complete the following (check all that apply and provide the effective date(s).)
Medicare Part A

Effective Date

(MMDDYYYY)

Medicare Part B

Effective Date

(MMDDYYYY)

Effective Date

Medicare Advantage
Medicare Part D

Effective Date

CHAMPVA

Effective Date

(MMDDYYYY)

Effective Date

Medicaid/State Assistance
TRICARE

(MMDDYYYY)

(MMDDYYYY)

(MMDDYYYY)

Effective Date

(MMDDYYYY)

Please complete the following if you have other health care coverage not identified above.
Name of Primary Insurance:

Effective Date

Name of Secondary Insurance:

Effective Date (MMDDYYYY)

Does your health care coverage provide Pharmacy benefits? Yes
VA FORM
Jul 2013

10-10068c

(MMDDYYYY)

HMO

PPO

HMO

PPO

No

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Certification
I give permission for my personal information to be used by appropriate Federal Government agencies and Federal
Government contractors.
By my signature I attest that I have answered the questions truthfully and that I understand the following: Any person who
knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to gain enrollment
in the Camp Lejeune Family Member Program to which that person is not entitled is subject to civil and/or administrative
remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or
imprisonment or both.
I certify that the above information is correct and true to the best of my knowledge and belief. (Sign and date on below.)
Signature
If certification is signed by a person other than an applicant, complete the following:

Date

First Name

Last Name
Mailing Address
City

State

Zip Code

Telephone Number (include area code)

This form may be faxed to 512-460-5536 or mailed to:
Department of Veterans Affairs
Financial Services Center
PO Box 149200
Austin, TX 78714-9200
NOTE: This form is to be used for updating your address, phone and/or health care coverage.
Directions for Camp Lejeune Family Member, representative or POA: please complete all fields that require updating.
The Paperwork Reduction Act: This information collection 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 10 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. 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. The purpose of this data collection is
to determine eligibility for benefits.
Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 1787. The
purpose of collecting this information is to determine your eligibility for reimbursement of health care related to conditions
determined to result from contaminated water while you resided at Camp Lejeune, North Carolina, for a period of at least
30 days. The information you provide may be verified by computer matching programs with authoritative sources such as
the Civilian Health and Medical Program of the Department of Veteran Affairs ( CHAMPVA), Department of Defense
(DoD), Defense Enrollment Eligibility Reporting System (DEERS), Centers for Medicare & Medicaid Services (CMS) or any
other applicable authoritative source at any time. You are requested to provide your social security number as your VA
record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or
all of the requested information is not provided, it may delay or result in denial of your request for Camp Lejeune Family
Member Program 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 private 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
number 23VA16. For example, information including your social security number may be disclosed to the Department of
Defense, contractors, trading partners, health care providers and other suppliers of health care services to determine your
eligibility for medical benefits and payment for services
VA FORM
jul 2013

10-10068c

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