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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