Forms

The VA requires specific forms to process applications, claims, etc.  Below is a partial list of forms and their uses, according to the official VA Chief Business Office Purchased Care forms page1 (not connected with this site).  That page also provides Spanish versions of at least some of the forms.

Please visit the link above for a much more comprehensive list of forms than what is listed here.  That page also provides links to fillable/printable PDF versions of these forms.  You might also want to look at this list of CHAMPVA related links.

CHAMPVA Forms

  • VA Form 10-10d, Application for CHAMPVA Benefits
  • VA Form 10-0426, Meds by Mail – Prescription Order Form
  • VA Form 10-7959a, Claim Form (for beneficiaries, not providers)
  • VA Form 10-7959c, Other Health Insurance Certification
  • CHAMPVA School Enrollment Certification Letter
  • CHAMPVA Marriage Status Application Attachment

Meds by Mail Forms

  • VA Form 10-0426, Meds by Mail Prescription Order Form
1. Forms for CBOPC Programs. (2014, December 10). Retrieved April 4, 2015, from http://www.va.gov/purchasedcare/pubs/forms.asp
ATTENTION:

ChampvaBenefits.com is an unofficial, privately owned website that is NOT connected with the VA or the government. Please do not use this site as an alternative to official sources such as the official CHAMPVA site. To find a specific page or resource, see a list of CHAMPVA resource links.

We do not guarantee that the information at our website is 100% correct or accurate, nor that changes in government laws, policies and benefits will be reflected immediately on this websitePlease always check with official sources before doing anything with your CHAMPVA coverage!

We will NEVER ask for your personal/sensitive information relating to your VA benefits, medical information, etc. We will NEVER attempt to contact you either promising or soliciting information about your CHAMPVA benefits! Please DO NOT attempt to send messages to this website about CHAMPVA benefits, claims, applications, etc. We are not the VA, and our website has no encryption to protect data!

If you need to contact CHAMPVA, check the official VA contact info here! Read about their warnings and communication safety here.



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