U.S. Government Forms » Department of Veterans Affairs Forms » Fillable VA Form 10-7959A - CHAMPVA Claim Form

VA Form 10-7959A - CHAMPVA Claim Form

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What is VA Form 10-7959A?

CHAMPVA is a government-sponsored health insurance program that provides coverage to the spouses and dependents of veterans who have been rated by the Veterans Administration (VA) as having a service-connected disability.

VA Form 10-7959A Screenshot 1

What is VA Form 10-7959A used for?

The CHAMPVA program is operated by the Department of Veterans Affairs and is available to eligible beneficiaries. To apply for CHAMPVA benefits, the veteran or their spouse must complete and mail VA Form 10-7959A, the CHAMPVA Application Form, to VA.

How to fill out VA Form 10-7959A?

CHAMPVA is a health insurance program for certain veterans and their dependents. Eligibility for CHAMPVA benefits is determined by the Department of Veterans Affairs (VA). You must complete and submit a CHAMPVA claim form. You will need to provide the following information on the application:

name, address, and phone number
name, address, and phone number of your next of kin or emergency contact
social security number
date of birth
gender
marital status
name, address, and phone number of your spouse or former spouse (if applicable)
name, address, and phone number of your children (if applicable)
veteran's information, including their name, social security number, and date of birth
veteran's service information, including their branch of service, dates of service, and discharge status
veteran's disability information, including their disability rating and date of award
veteran's health insurance information, including any other health insurance coverage they may have

VA Form 10-7959A Screenshot 2

How to submit VA Form 10-7959A?

Once you have completed your application, you will need to submit it to the VA for review. Champva forms 10 7959a must be accompanied by a copy of the veteran's DD-214, Certificate of Release or Discharge from Active Military Service, or other proof of military service.

The veteran or their spouse must also provide a copy of the divorce or divorce decree if the marriage has been dissolved. Once the VA receives the completed champva claim form 10 7959a, it will review the information and determine if the veteran and his or her spouse are eligible for benefits.

Who should sign the VA Form 10-7959A?

The VA form 10-7959a champva claim form is used by the VBA to process claims for reimbursement of medical expenses incurred by Veterans and their dependents. The form must be signed by the Veteran or the Veteran's representative in order to be processed.

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