Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CHAMPVA Appeal Process New 12510 6255 0
CHAMPVA Application for Benefits New 53775 8963 0 Form 10-10d
CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability Removed 0 0 0 Form VA Form 10-7959a
Form and Instruction VA Form 10-7959c
Form VA Form 10-7959d
Form VA Form 10-7959e
Form VA Form 10-10d
CHAMPVA Claim Form New 55000 9167 0 Form 10-7959a
CHAMPVA Claim for Miscellaneous Expenses New 800 200 0 Form 10-7959e
CHAMPVA Clinical Review New 2332 777 0
CHAMPVA Other Health Insurance (OTI) Certification New 53680 8947 0 Form and Instruction 10-7959c
CHAMPVA Potential Liability Claim Form New 2045 239 0 Form 10-7959d
Total burden requested under this ICR: 180142 34548 0  
To view an IC, click on IC Title