Va Form 10-7959e - Claim For Miscellaneous Expenses Page 2
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2Claim for Miscellaneous Expenses
PRIVACY ACT: The authority for collection of the requested information on this form is 38 U.S.C. 501 and 1805
and 38 CFR 17.900 et seq. This information is required for all claims for reimbursement of miscellaneous
expenses related to the health care benefits for children of qualifying veterans. 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 payment. 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". 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 collection is in accordance with the clearance requirements of Title
44 U.S.C. 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. Respondents should be aware that 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.
Spina Bifida Health Care Program
Children of Women Vietnam Veterans
VA Health Administration Center
VA Health Administration Center
Spina Bifida Health Care Benefits
Children of Women Vietnam Veterans
PO Box 469065
PO Box 469065
Denver CO 80246-9065
Denver CO 80246-9065
Phone:
1-888-820-1756
Phone:
1-888-820-1756
Fax:
1-303-331-7807
Fax:
1-303-331-7807
VA FORM
10-7959e
MAY 2010
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