Get U.s. Dod Form Dod-va-10-7959d

This guide will assist you in completing the U.S. DOD Form Dod-va-10-7959d, which is necessary for filing a CHAMPVA potential liability claim. The process outlined here will ensure that you fill out the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling out Section I - Patient Information. Provide your last name, first name, middle initial, social security number, street address, date of birth, city, state, and zip code. Ensure that you enter one character per block and adhere to the designated space.
3. Proceed to Section II - Injury/Illness Information. Fill in your telephone number including the area code. Enter the diagnosis and circumstances of the incident, such as the date and what happened. Make sure to clearly describe the event.
4. In Section III - Third Party Claim Information, if applicable, include details of the incident location, insurance information, and witness information. If additional space is needed, continue the same format on a separate sheet.
5. Complete Section IV - Certification by signing and dating the form. If you are not the patient, provide your last name, first name, relationship to the patient, and your address.
6. Once you have filled out the entire form, review all information for accuracy. Save your changes, and then you have options to download, print, or share the form as necessary.

Complete the U.S. DOD Form Dod-va-10-7959d online today to ensure your claim is processed efficiently.