VA Form 10 7959C


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Get your VA Form 10 7959C in 3 easy steps

  • 01 Fill and edit template
  • 02 Sign it online
  • 03 Export or print immediately

What Is VA Form 10-7959C PDF

Also known as CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10-7959C is a document used to certify and report health insurance coverage for beneficiaries of the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Its purpose is to collect information about other insurance plans that may provide healthcare coverage to CHAMPVA beneficiaries, allowing the VA to coordinate benefits effectively and provide comprehensive healthcare support.

va form 10 7959c screenshot

Who Should Use 10-7959C VA Form

The document should be utilized by:

  • beneficiaries of the CHAMPVA;
  • individuals with other health insurance coverage;
  • those seeking to report and certify their existing health insurance plans to the VA for coordination of benefits;
  • people looking to ensure comprehensive healthcare coverage while being eligible for CHAMPVA benefits.

How to Fill Out 10-7959C VA Form

The VA Form 10-7959C CHAMPVA features two pages. The first page is fillable, while the second one contains notes, definition, and instructions. Gentle reminder: Don’t forget to study these instructions prior to filling out the file. It’s very important. 

These 6 crucial steps will help you throughout the completion process:

  1. Find and open the VA Form 10-7959C fillable template via PDFLiner.
  2. Start filling it out section by section.
  3. In Section I (Beneficiary Information), type your personal details, including your full name, date of birth, and Social Security Number.
  4. In Section II (Medicare Beneficiaries) and Section III, provide comprehensive information about the other health insurance coverage you have, including the insurance company's name, policy number, group number, and effective dates.
  5. Sign and date the document, certifying the accuracy of the info you’ve entered.
  6. Submit the completed file, along with any required documents, to the appropriate VA office. 

va form 10 7959c 2 screenshot

For some extra convenience, consider using online platforms like PDFLiner to easily find, complete, electronically sign, and share documents. It's a time-saving and efficient way to ensure your files are handled promptly and accurately, allowing you to access the benefits you need without unnecessary delays.

Where to Submit VA Form 10-7959C

Now that you’ve completed the form via PDFLiner, it’s time to switch to its submission. To do it, reach out to the US Department of Veterans Affairs office or contact the CHAMPVA program coordinator. They will provide specific instructions on where to send the finished document, ensuring that it is directed to the appropriate department for processing. This step guarantees that your other health insurance coverage is coordinated effectively with CHAMPVA benefits.

Fillable online VA Form 10 7959C
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