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19 wrz 2023 · Use VA Form 10-7959C or Formulario VA 10-7959c (español) when: You’re applying for CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), and have other health insurance to declare as part of your VA Form 10-10d application.
- VHA 10-7959c
INSTRUCTIONS. Failure to complete all applicable sections on...
- VHA 10-7959c
INSTRUCTIONS. Failure to complete all applicable sections on the front can result in a delay or denial of benefits. Use this form to report any changes in your other health insurance. ITEMS TO RETURN WITH THIS COMPLETED OTHER HEALTH INSURANCE (OHI) CERTIFICATION. -- A COPY of your Medicare card (do NOT send the original).
To apply for benefits, send the following to the VHA Ofice of Community Care (VHA CC): • Application for CHAMPVA Benefits (VA Form 10-10d) • CHAMPVA Other Health Insurance Certification (VA Form 10-7959c) • A copy of your Medicare card, if you are also eligible for Medicare.
Download Fillable Va Form 10-7959c In Pdf - The Latest Version Applicable For 2024. Fill Out The Champva Other Health Insurance (ohi) Certification Online And Print It Out For Free.
To apply, the following documents are required: Application for CHAMPVA Benefits, VA Form 10-10d. The application is required to be signed/dated. Medicare information: − A copy of your Medicare card, if you are eligible for Medicare. (Please do not send originals.)
You need to submit both an Application for CHAMPVA Benefits (VA Form 10-10d), and VA Form 10-7959c, and your Medicare card. For those who don’t qualify for Medicare, you have to prove that you don’t qualify under anyone’s SSN by providing the appropriate documents from the SSA.
This form is also used to report any changes in your other health insurance status. Updates can be sent by FAX or call by phone. PLEASE READ INSTRUCTIONS AND INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM
