Forms

You will need to submit the right form to the VA Health Administration Center depending on what you wish to do with CHAMPVA:

  • 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

Get PDF versions of the forms above at the VA HAC site.

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*** IMPORTANT!***


CHAMPVA and government programs and policies are subject to change. For the most CURRENT information, please visit the OFFICIAL website for CHAMPVA at http://www.va.gov/PURCHASEDCARE/programs/dependents/champva/index.asp . We are an unofficial, privately owned website, so we cannot guarantee that the information here is 100% and up-to-date. Please always check with official sources for the latest information before you do anything relating to CHAMPVA health coverage. See also the CHAMPVA Program Guide, the CHAMPVA Policy Manual and the VA Chief Business Office Purchase Care page.

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