Fillable Vha Form 10-7959a - Champva Claim Form (Page 2 of 2) in pdf

CHAMPVA Claim Form

Notice: Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of

midnight on the effective date of the dissolution of marriage. Changes in status should be reported immediately to

CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver, CO 80246-9028 or call 1-800-733-8387.

PRIVACY ACT INFORMATION: The authority for collection of the requested information on this form is 38 U.S.C. 501 and

1781. The purpose of collecting this information is to adjudicate and process claims for CHAMPVA benefits. You do not

have to provide the requested information but if any or all of the requested information is not provided, it may delay or result

in denial of your request for CHAMPVA benefits. Failure to furnish the requested information will have no adverse impact on

any other VA benefit to which you may be entitled. The responses you submit are considered confidential and may be

disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA

system of records 54VA16, titled "Health Administration Center Civilian Health and Medical Program Records -VA", as set

forth in the Compilation of Privacy Act Issuances via online GPO access at

example, information on this form may be disclosed to contractors, trading partners, health care providers and other

suppliers of health care services to determine your eligibility for medical benefits and payment for services. Disclosure of

Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is

voluntary. Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or

persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title

38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.

PAPERWORK REDUCTION ACT: This information collection is in accordance with the clearance requirements of

Section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated

to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed and completing and reviewing the collection of information.

Comments regarding this

burden estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by

calling the CHAMPVA Help Line, 1-800-733-8387.

Respondents should be aware that notwithstanding any other provision

of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a

currently valid OMB control number. The purpose of this data collection is to provide a mechanism to claim CHAMPVA

benefits.

VA FORM

10-7959a

MAY 2010

Vha Form 10-7959a - Champva Claim Form Page 2