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

OMB Control Number: 2900-0822
Estimated Burden: 15 minutes
Expiration Date: XX/XX/20XX

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
Last Name

First Name
Is this a change of address?

Email Address

Yes

Street Address
Permanent address?
Yes

Social Security Number

MI

City

Is this a phone number change?
Yes

No

No
State

Zip Code

Temporary address?
No

Yes

No

Please indicate if you would like to receive correspondence via

to

regular mail

email
Alt Phone Number

Phone Number (include area code)

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
MAY 2025

10-10068c

(MMDDYYYY)

HMO

PPO

HMO

PPO

No
IVC (16)

Page 1 of 2

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.
VA Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. The OMB control number for this project is
2900-0822, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average
15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing
the burden, to VA Reports Clearance Officer at vapra@va.gov. Please refer to OMB Control No. 2900-0822 in any
correspondence. Do not send your completed VA Form 10-10068c to this email address.
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
MAY 2025

10-10068c

Page 2 of 2