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VA FORM . 10-7959c. AUG 2013. CHAMPVA OTHER HEALTH INSURANCE (OHI) CERTIFICATION NOTES, DEFINITIONS, AND INSTRUCTIONS. ITEMS TO RETURN WITH THIS COMPLETED OTHER HEALTH INSURANCE (OHI) CERTIFICATION -- A . COPY . of your Medicare card (do NOT send the original). -- A . COPY. of your other health insurance (OHI) member ID card (front and back).
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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.
person, I agree to promptly notify VA's Health Administration Center. Sign, date below and return to the address at the top of the form. SECTION I: BENEFICIARY INFORMATION - PLEASE USE A SEPARATE FORM FOR EACH FAMILY MEMBER Name of insurance # 2 SECTION IV: CERTIFICATION BY BENEFICIARY, SPONSOR OR LEGAL GUARDIAN DATE (MMDDYYYY) VA FORM SEP 2020
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.
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View, download and print fillable Va 10-7959c - Champva Other Health Insurance (ohi) Certification in PDF format online. Browse 2 Va Form 10-7959c Templates collected for any of your needs.
