Information Collection

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

IC 28467 under ICR 200703-2900-003 · OMB 2900-0219.

⚠️ Notice: This information collection may be referencing outdated material.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 10-10d CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Form
VA Form 10-10d Application for CHAMPVA Benefits 10-10d.pdf www.va.gov/vaforms/Search_action.asp Form
VA Form 10-7959a CHAMPVA Claim Form 10-7959a.pdf www.va.gov/vaforms/Search_action.asp Form
VA 10-7959c CHAMPVA Other Health Insurance (OHI) Certification 10-7959c.pdf www.va.gov/vaforms/Search_action.asp Form and Instruction
VA Form 10-7959d CHAMPVA Potential Liability Claim 10-7959d.pdf www.va.gov/vaforms/Search_action.asp Form

Information Collection (IC) Details

View Information Collection (IC)

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: Voluntary

CFR Citation: 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 10-10d	Application for CHAMPVA Benefits	10-10d.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959d	CHAMPVA Potential Liability Claim	10-7959d.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form and Instruction	VA 10-7959c	CHAMPVA Other Health Insurance (OHI) Certification	10-7959c.pdf	http://www.va.gov/vaforms/Search_action.asp	Yes	No	Fillable Printable
Form	VA Form 10-7959a	CHAMPVA Claim Form	10-7959a.pdf	http://www.va.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: 119,200	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	119,200	-2,256,300	0	2,375,500
Annual IC Time Burden (Hours)	19,668	0	-374,999	394,667
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.