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

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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 September 16, 2013.


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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Crystal Rennie, Enterprise Records Service (005R1B), Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, (202) 632-7492 or email 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.Start Printed Page 50144


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. 501 and 1781, and 10 U.S.C. 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.

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.

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Dated: August 13, 2013.

By direction of the Secretary.

Crystal Rennie,

VA Clearance Officer, U.S. Department of Veterans Affairs.

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[FR Doc. 2013-19914 Filed 8-15-13; 8:45 am]