Va Form 10-7959d - Champva Potential Liability Claim
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2OMB 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
Section III - Third Party Claim Information
If more space needed, continue in the same format on separate sheet.
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:
10. Diagnosis
Auto Insurance
Employer
Home Owner Insurance
Other (specify)
11. Circumstances
21. Name of Insurance Company/Employer
a. When
b. Where
Work
(mm/dd/yyyy)
Home
22. Street Address
Auto Accident
Other (specify)
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)
16. Last Name of Investigator (i.e. police)
30. First
29. Last Name of Attorney
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.
Signature
Date
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
39. Relationship to Patient
Ml
40. Street Address
41. City
42. State
43. Zip Code
44. Phone Number (include area code)
VA FORM
EXISTING STOCK OF VA FORM 10-7959d, JUL 1999, WILL BE USED.
10-7959d
MAR 2004 (R)
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