Free vha-10-7959d-form.xft - Federal

OMB Number: 2900-0219 Estimated Burden: 7 minutes Expiration Date: 3/31/2007

CHAMPVA Potential Liability Claim
VA Health Administration Center CHAMPVA PO Box 65023 Denver CO 80206-9023 1.303.331.7519
Attention: After reviewing the following, complete form in its entirety (print or typewritten only) and return. Limit entries to one character per block and do NOT exceed the designated space (i.e. do NOT extend last name into First Name area). Purpose: Based on recent claim information, medical services have been received for the treatment of an injury or potential work-related illness. Because the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such services when the injury/illness was caused or is covered by a third party, the following information is required. Section I - Patient Information
1. Last Name 2. First Name Ml 3. Social Security Number

4. Street Address

5. Date of Birth (mm/dd/yyyy)

6. City

7. State

8. Zip Code

9. Telephone Number (include area code)

Section II - Injury/Illness Information
If more space needed, continue in the same format on separate sheet.
10. Diagnosis

Section III - Third Party Claim Information
If more space needed, continue in the same format on separate sheet.
20. Based on location of incident identified in Section II, provide insurance information for:

Auto Insurance 11. Circumstances a. When
(mm/dd/yyyy)

Employer

Home Owner Insurance

Other (specify)
21. Name of Insurance Company/Employer

b. Where Work Home Auto Accident Other (specify)

22. Street Address

12. Describe What Happened

23. City

13. Last Name of Witness

24. State 25. Zip Code

26. Insurance Co/Employer Phone No. (include area code)

14. First Name

Ml

27. Insurance Policy Number

15. Witness Phone Number (include area code)

28. Is patient represented by an attorney or contemplating representation? Yes (complete attorney information below) No (proceed to Section IV) 29. Last Name of Attorney 30. First

16. Last Name of Investigator (i.e. police)

17. First Name

Ml

31. Street Address

18. Title

32. City

19. Investigator Phone Number (include area code)

33. State

34. Zip Code

35. Attorney Phone Number (include area code)

Section IV - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, ficticious, or fraudulent statements or claims.

36. I certify that the above information and attachments are correct to the best of my knowledge and belief. (Sign and date on right.) If signed by a person other than patient, complete the following.
37. Last Name 38. First Name

Signature

Date

Ml

39. Relationship to Patient

40. Street Address

41. City

42. State

43. Zip Code

44. Phone Number (include area code)

VA FORM MAR 2004 (R)

10-7959d

EXISTING STOCK OF VA FORM 10-7959d, JUL 1999, WILL BE USED.

(retain this portion for your records)

CHAMPVA Potential Liability Claim

Appendix

PRIVACY ACT: The authority for collection of the requested information 38 U.S.C. 501, 38 C.F.R. 1.900 et. seq; 42 U.S.C. 2651-2653; and E.O 9397. The purpose of collecting this information is to provide basic information from which potential liability can be assessed. 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 54VA17, titled "Health Administration Center Civilian Health and Medical Program records - VA". For 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 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 7 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. 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. Based on recent claim information, medical services have been received for the treatment of an injury or potential work-related illness. Because of the Federal Medical Care Recovery Act, 42 USC 2651-2653, requires the recovery of VA costs associated with such services when the injury/illness was caused or is covered by a third party, the following information is required.
VA FORM MAR 2004 (R)

10-7959d