View Information Collection (IC)

View Information Collection (IC)

CHAMPVA Benefits - Application, Claim, Other Health Insurance & Potential Liability 2900-0219
No Modified
38 CFR 1.900

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 Yes No Fillable Printable
Form VA Form 10-7959a CHAMPVA Claim Form 10-7959a.pdf Yes No Fillable Printable
Form and Instruction VA 10-7959c CHAMPVA Other Health Insurance (OHI) Certification 10-7959c.pdf Yes No Fillable Printable
Form VA Form 10-7959d CHAMPVA Potential Liability Claim 10-7959d.pdf Yes No Fillable Printable

Health Consumer Health and Safety


119,200 0
Individuals or Households
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 119,200 0 -2,256,300 0 0 2,375,500
Annual IC Time Burden (Hours) 19,668 0 0 -374,999 0 394,667
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.