Instructions block
Where to return the form, who completes it, how to attach an other health insurance Explanation of Benefits, the timely filing requirement and what an itemized billing statement contains.
10-10068a
Camp Lejeune Family Member Program Claim Form
- Agency
- VA
- Revision
- September 2025
- Fillable fields
- 40
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10068a: Camp Lejeune Family Member Program Claim Form
VA Form 10-10068a is the U.S. Department of Veterans Affairs Camp Lejeune Family Member Program Claim Form. VA's form page says to use it to file a claim through the Camp Lejeune Family Member Program. The form says it is completed by the patient, sponsor or guardian, is mandatory for all beneficiary claims, and is not to be used for provider submitted claims.
The claim goes to VA's Financial Services Center with itemized billing statements attached. The top of page 1 explains other health insurance, the timely filing requirement and what an itemized statement contains. Sections I to IV ask for patient information, other health insurance, Veteran information and a certification. Page 2 holds the burden and Privacy Act notices.
You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10068a
Section I: Patient Information
Patient name, Social Security number, street address with a Check if New box, date of birth, city, state, ZIP code and phone number.
Section II: Other Health Insurance
Whether treatment was for a work-related injury or an accident outside work, whether other primary health insurance covers you, its type, and each insurer's name, policy number and phone.
Section III: Veteran Information
The Veteran's last name, first name, middle initial and Social Security number.
Section IV: Claimant Certification
A certification that the information and attachments are correct and represent actual services, dates and fees charged, a signature (typed if electronic) and date, and details of anyone signing for the patient.
How to file VA Form 10-10068a
- 1
Read the instructions
The form says to review the information at the top, then complete the form in its entirety, print or type only.
- 2
Gather itemized billing statements
Each statement shows patient name, date of birth and Member Number, the provider's name, degree, TIN, address and phone, and service dates, itemized charges and procedure and diagnosis codes with descriptions.
- 3
Attach any Explanation of Benefits
If other health insurance exists, attach its Explanation of Benefits to the provider's itemized billing statements. The form says dates of service and charges on the EOB and the billing statements match.
- 4
Fill in Sections I to III
Enter the patient's details, the other health insurance answers and the Veteran's name and Social Security number. Use a separate sheet in the same format if more space is needed for insurance.
- 5
Sign the certification
Sign and date Section IV. A person other than the patient also enters their name, relationship to the patient, address and phone.
- 6
Mail the claim
Send the form with the itemized billing statements to the Financial Services Center in Austin, Texas, within the timely filing requirement the form prints.
Why fill Form 10-10068a on indox
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Where to send it and the filing window
Mailing address
Department of Veterans Affairs, Financial Services Center, PO Box 149200, Austin TX, 78714-9200.
Timely filing requirement
The form says claims must be received no later than two years after the date of service or, in the case of inpatient care, within two years of the discharge date.
Customer Service Center
The form lists 1-866-372-1144 and fax 512-460-5536.
Pharmacy claims
The form says pharmacy claims include the name, quantity, strength and NDC of each drug.
Edition
The edition is dated SEP 2025. The form carries OMB Control No. 2900-0822, which expires 09/30/2028, and an estimated burden of 15 minutes.
Related forms
10-10068
Camp Lejeune Family Member Program Application
84 fields, 3 pages
10-10068b
Camp Lejeune Family Member Program Treating Physician Report
53 fields, 2 pages
10-10068c
Camp Lejeune Family Member Program Information Update Form (VA Form 10-10068c)
60 fields, 2 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fields, 2 pages
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fields, 3 pages
Who uses VA Form 10-10068a?
The form's claim form usage note says who completes it.
Official sources and the blank
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Questions about Form 10-10068a
What is VA Form 10-10068a used for?
VA's form page says to use it to file a claim through the Camp Lejeune Family Member Program.
Who completes the claim form?
The form says it is completed by the patient, sponsor or guardian and is mandatory for all beneficiary claims.
Can a health care provider use this form?
No. The form says it is NOT to be used for provider submitted claims.
Is there a deadline to file?
The form says claims must be received no later than two years after the date of service or, in the case of inpatient care, within two years of the discharge date.
What goes with the claim form?
Itemized billing statements with the patient, provider and service details the form lists, plus the other health insurance Explanation of Benefits if other coverage exists.
Where do I send VA Form 10-10068a?
The form lists Department of Veterans Affairs, Financial Services Center, PO Box 149200, Austin TX, 78714-9200.