CHAMPVA VA Form 10-7959a CHAMPVA Claim Form

In the vast majority of cases, CHAMPVA beneficiaries won’t need to file their own claims.  If a provider agrees to charge VA and accept payment from it directly, the provider will file the claim.  However if the provider will not do this, you must do it yourself if you want CHAMPVA to pay for the service or supply you have received.  You may find it a hassle to gather all the information needed, so save all receipts, diagnosis certificates and billing statements you get from your provider from the start.

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About VA Form 10-7959a

This is a straightforward form with only one fillable page.  (The backside contains additional information.)

In the first section, you enter the patient’s information including name, address, birth date and CHAMPVA member ID number, which is also his or her Social Security Number.

In the next section, provide any other health insurance (OHI) details.  If you have another insurer that pays before CHAMPVA does, including Medicare, you must let the VA know.  If you have only a supplement to CHAMPVA, it pays only after the VA does.

You must also answer if this was a work-related incident or not, among other questions.

In the third section, provide the qualifying veteran sponsor’s information.

In the last section, give the claimant’s info.  The claimant can be either the patient/beneficiary, sponsor or legal guardian.

Form 10-7959a is to be submitted to the VA HAC address shown on the form, along with required documentation.  See also filing CHAMPVA claims for beneficiaries.

As with all applications and petitions you file with the government, you must use the correct VA forms when seeking any kind of CHAMPVA benefit.  Forms for CHAMPVA use are numbered and are formatted similarly to other VA forms.  You can get fillable PDF versions of these from the official VA Health Administration website.  To ensure you always get the latest versions, always check with the official site first.

For the official downloadable version and other CHAMPVA forms, see HAC forms page.

 

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