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Agency Information Collection (Application for CHAMPVA Benefits) Activities Under OMB Review

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Information about this document as published in the Federal Register.

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Veterans Health Administration, Department of Veterans Affairs.




In compliance with the Paperwork Reduction Act (PRA) of 1995 (44 U.S.C. 3501-21), this notice announces that the Veterans Health Administration (VHA), Department of Veterans Affairs, has submitted the collection of information abstracted below to the Office of Management and Budget (OMB) for review and comment. The PRA submission describes the nature of the information collection and its expected cost and burden and includes the actual data collection instrument.


Comments must be submitted on or before June 7, 2010.


Submit written comments on the collection of information through;​ or to VA's OMB Desk Officer, OMB Human Resources and Housing Branch, New Executive Office Building, Room 10235, Washington, DC 20503, (202) 395-7316. Please refer to “OMB Control No. 2900-0219” in any correspondence.

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Denise McLamb, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 461-7485, fax (202) 273-0443 or e-mail Please refer to “OMB Control No. 2900-0219.”

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a. Application for CHAMPVA Benefits, VA Form 10-10d.

b. CHAMPVA Claim Form, VA Form 10-7959a.

c. CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10-7959c.

d. CHAMPVA Potential Liability Claim, VA Form 10-7959d.

e. Claim for Miscellaneous Expenses, VA Form 10-7959e.

OMB Control Number: 2900-0219.

Type of Review: Revision of a currently approved collection.


a. VA Form 10-10d is used to determine eligibility of persons applying for healthcare benefits under the CHAMPVA program.

b. VA Form 10-7959a is used to accurately adjudicate and process beneficiaries claims for payment/reimbursement of related healthcare expenses.

c. VA Form 10-7959c is used to systematically obtain other health insurance information and to correctly coordinate benefits among all liable parties.

d. VA Form 10-7959d is used to gather additional information relative to the injury or illness as well as third party claim information.

e. Beneficiaries complete VA Form 10-7959e to claim payment/reimbursement of expenses related to spina bifida and certain covered birth defects.

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 Federal Register Notice with a 60-day comment period soliciting comments on this collection of information was published on March 1, 2010, at pages 9276-9277.

Affected Public: Individuals or households, business or other for-profit, and not-for-profit institutions.

Estimated Annual Burden:

 a. VA Form 10-10d—4,411 hours.

 b. VA Form 10-7959a—37,336 hours.

 c. VA Form 10-7959c—13,456 hours.

 d. VA Form 10-7959d—467 hours.

 e. VA Form 10-7959e—725 hours.

Estimated Average Burden Per Respondent:

 a. VA Form 10-10d—10 minutes.

 b. VA Form 10-7959a—10 minutes.

 c. VA Form 10-7959c—10 minutes.

 d. VA Form 10-7959d—7 minutes.

 e. VA Form 10-7959e—10 minutes.

Frequency of Response: On occasion.

Estimated Number of Respondents:

 a. VA Form 10-10d—26,468.

 b. VA Form 10-7959a—224,018.

 c. VA Form 10-7959c—80,733.

 d. VA Form 10-7959d—4,000.

 e. VA Form 10-7959e—4,400.

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Dated: May 4, 2010.

By direction of the Secretary.

Denise McLamb,

Program Analyst, Enterprise Records Service.

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[FR Doc. 2010-10796 Filed 5-6-10; 8:45 am]