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:

You are viewing an unofficial, privately owned website. For the most current information about CHAMPVA, please visit the official CHAMPVA site. For details on program policies, see the CHAMPVA Policy Manual. Providers, please refer to the CHAMPVA Information for Providers. Beneficaries, see also the official CHAMPVA Program Guide. For a comprehensive list of links, see a list of CHAMPVA resource links.

We cannot guarantee all information here is 100% correct or accurate. Further, changes in government laws, policies and benefits may not be reported immediately on this website. Please always check with official sources before doing anything with your CHAMPVA coverage!

We will NEVER ask for your personal/sensitive information. We will NEVER attempt to contact you, either promising or soliciting information about your CHAMPVA benefits! Further, the VA itself warns that email is not secure and that they will NOT send you personal or sensitive information through email. Read more about their warnings and communication safety here.

Please DO NOT attempt to send messages to this website about CHAMPVA benefits, claims, applications, etc. If you need to contact CHAMPVA, check the official VA contact info here!



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