CHAMPVA Forms for Beneficiaries

There are VA forms a CHAMPVA beneficiary uses for different purposes, such as to add a dependent, file a claim, request authorization, provide health insurance information or get medicine.  Read the instructions in each form you use carefully!  Do not forget to attach required documents (and the optional ones too, if you can and you want to speed up the process) when you submit the form(s). For more forms such as Spanish versions, and the latest forms, see the VA website in the link at the end of this article.  VA provides fillable PDF versions of these forms in almost all cases.

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Form to Add Dependents to VA Disability Compensation

Disabled veterans, including those permanently and totally disabled veterans who qualify as CHAMPVA sponsors to their loved ones, also can receive compensation for their service-connected disabilities.  The compensation rate one receives depends on one’s rating as well as number of dependents.

To add or remove a dependent in the veteran spnosor’s record at the VA (this will adjust the veteran’s disability compensation accordingly), send the form below to your VA regional office or use VONAPP:

  • VA Form 21-686c: Declaration of Status of Dependents

Forms to Apply for CHAMPVA Benefits

If you know you or your loved one is eligible for CHAMPVA, you can enroll in the program by filing an application. To apply for CHAMPVA benefits for a veteran sponsor’s dependent(s), use:

  • VA Form 10-10d: Application for CHAMPVA Benefits
  • VA Form 10-7959c: Other Health Insurance (OHI) Certificate
  • CHAMPVA Marriage Status Application Attachment

Forms for CHAMPVA Claims

After enrolling in CHAMPVA, the beneficiary may sometimes need to file claims on his or her own, when the provider won’t do it.  To file a claim if you are the beneficiary, guardian or sponsor and you need to file a claim yourself (note that this form is NOT for a provider) use:

To submit a prescription order if you are the beneficiary, family member or caregiver with a power of attorney, use:

  • VA Form 10-0426: Meds By Mail Order Form CHAMPVA

Form for Other Health Insurance

To provide CHAMPVA with information about your other health insurance (if you have any); this is used in conjunction with VA Form 10-10d: to apply for benefits:

  • VA Form 10-7959c: CHAMPVA Other Health Insurance (OHI) Certificate

Other VA Forms

For spina bifida beneficiaries claims, send:

  • VA Form 10-7959e: Claim for Miscellaneous Expense

For authorization to release one’s medical information (remember privacy laws), use:

  • VA Form 10-5345: Request for and Authorization to Release Medical Records OR
  • Recurring Authorization VA Form 10-5345 + Fact Sheet 06-01

Where to Download CHAMPVA Forms

Because government forms are often updated and changed, you won’t find direct links to the PDF forms here.  For a more comprehensive list of CHAMPVA and related forms, and for more information, please visit the VA Health Administration Page for downloadable and fillable forms.

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This website, CHAMPVAbenefits.com, is NOT affiliated with the Department of Veterans Affairs or any part of the U.S. government. Please DO NOT send us information about yourself such as your SSN, name, address, etc. for help with CHAMPVA. Further, we cannot guarantee that the information here is accurate and up-to-date. To ensure you have the latest information, please visit the official CHAMPVA home page at http://www.va.gov/hac/forbeneficiaries/champva/champva.asp. Your use of this site means you agree to and understand this disclaimer. Thank you!

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