Skip to Content


Proposed Information Collection (Application for CHAMPVA Benefits); Comment Request

Document Details

Information about this document as published in the Federal Register.

Enhanced Content

Relevant information about this document from provides additional context. This information is not part of the official Federal Register document.

Published Document

This document has been published in the Federal Register. Use the PDF linked in the document sidebar for the official electronic format.

Start Preamble


Veterans Health Administration, Department of Veterans Affairs.




The Veterans Health Administration (VHA), Department of Veterans Affairs (VA), is announcing an opportunity for public comment on the proposed collection of certain information by the agency. Under the Paperwork Reduction Act (PRA) of 1995, Federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed revision of a currently approved collection, and allow 60 days for public comment in response to the notice. This notice solicits comments for information needed for Health Administration Center staff to adjudicate/pay healthcare benefit claims.


Written comments and recommendations on the proposed collection of information should be received on or before August 9, 2013.


Submit written comments on the collection of information through the Federal Docket Management System (FDMS) at;​ or to Cynthia Harvey-Pryor, Veterans Health Administration (10B4), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420 or email: Please refer to “OMB Control No. 2900-0219” in any correspondence. During the comment period, comments may be viewed online through FDMS.

Start Further Info


Cynthia Harvey-Pryor at (202) 461-5870 or Fax (202) 495-5397.

End Further Info End Preamble Start Supplemental Information


Under the PRA of 1995 (Pub. L. 104-13; 44 U.S.C. 3501-21), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. This request for comment is being made pursuant to Section 3506(c)(2)(A) of the PRA.

With respect to the following collection of information, VHA invites comments on: (1) Whether the proposed collection of information is necessary for the proper performance of VHA's functions, including whether the information will have practical utility; (2) the accuracy of VHA's estimate of the burden of the proposed collection of information; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or the use of other forms of information technology.


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 adjudicate claims for CHAMPVA benefits in accordance with 30 U.S.C. Sections 501 and 1781, and 10 U.S.C. Sections 1079 and 1086.

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 form provides basic information from which potential liability can be assessed.

e. Beneficiaries complete VA Form 10-7959e to carry out health care programs for certain children of Korea and/or Vietnam Veterans authorized under 38, U.S.C., chapter 18, as amended by section 401, Public Law 106-419 and section 102, Public Law 108-183.

Affected Public: Individuals or households.

Estimated Annual Burden:

a. VA Form 10-10d—5,294 hours.

b. VA Form 10-7959a—22,402 hours.

c. VA Form 10-7959c—6,728 hours.

d. VA Form 10-7959d—467 hours.

e. VA Form 10-7959e—1500 hours.Start Printed Page 34710

Estimated Average Burden per Respondent:

a. VA Form 10-10d—12 minutes.

b. VA Form 10-7959a—6 minutes.

c. VA Form 10-7959c—5 minutes.

d. VA Form 10-7959d—7 minutes.

e. VA Form 10-7959e—30 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—3,000.

Start Signature

Dated: June 5, 2013.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, Enterprise Records Service, Office of Information Security, Office of Information and Technology, U.S. Department of Veterans Affairs.

End Signature End Supplemental Information

[FR Doc. 2013-13693 Filed 6-7-13; 8:45 am]