Fillable Printable VA Form 10-7959D
Fillable Printable VA Form 10-7959D
VA Form 10-7959D
If more space needed, continue in the same format on separate sheet.
A
ttention: 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.
VA FORM
MAR 2004 (R)
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.
OMB Numbe
r
: 2900-0219
Estimated Burden: 7 minutes
Expiration Date: 3/31/2007
CHAMPVA Potential Liability Claim
Denver CO 80206-9023PO Box 65023CHAMPVAVA Health Administration Center
Section IV - Certification
3. Social Security Number1. Last Name 2. First Name Ml
5. Date of Birth (mm/dd/yyyy)4. Street Address
7. State 9. Telephone Number (include area code)6. City 8. Zip Code
10. Diagnosis
Signature
39. Relationship to Patient37. Last Name 38. First Name
Ml
40. Street Address
43. Zip Code 44. Phone Number (include area code)41. City 42. State
10-7959d
Date
EXISTING STOCK OF VA FORM 10-7959d, JUL 1999, WILL BE USED.
Section I - Patient Information
Section II - Injury/Illness Information
11. Circumstances
a. When b. Whe
r
e
(mm/dd/yyyy)
21. Name of Insurance Company/Employer
20. Based on location of incident identified in Section II, provide insurance information for:
22. Street Address
12. Describe What Happened 23. City
24. State 25. Zip Code 26. Insurance Co/Employer Phone No.
(include area code)
13. Last Name of Witness
14. First Name 27. Insurance Policy Number
Ml
15. Witness Phone Number (include area code) 28. Is patient represented by an attorney or contemplating representation?
16. Last Name of Investigator (i.e. police)
29. Last Name of Attorney
30. First
17. First Name Ml 31. Street Address
32. City
34. Zip Code 35. Attorney Phone Number (include area code)
33. State
18. Title
19. Investigator Phone Number (include area code)
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, ficticious, or fraudulent statements or claims.
Work
Home
Auto Accident
Other (specify)
Auto Insurance Employer Home Owner Insurance
Other (specify)
Yes (complete attorney information below)
No (proceed to Section IV)
If more space needed, continue in the same format on separate sheet.
Section III - Third Party Claim Information
1.303.331.7519
Paperwork Reduction Act: Thisinformationisinaccordancewiththeclearance 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 ins tructions, 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.
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.
V
A
FORM
MAR 2004 (R)
(retain this portion for your records)
CHAMPVA Potential Liability Claim
Appendix
10-7959d
