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10-7959a NOTICE: Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the dissolution of marriage. Changes in status should be reported immediately to CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver, CO 80246-9028 or call 1-800-733-8387.
1 maj 2024 · CHAMPVA Claim Form, VA Form 10-7959a | Forma S10-7959a en Español. If you fail to complete VA Form 10-7959a, CHAMPVA Claim Form, your health care provider will be paid directly. Your name must be listed on the claim form exactly as it is on your CHAMPVA Identification Card.
21 paź 2022 · Form name: CHAMPVA Claim Form. Related to: Health care. Form revision date: August 2013. Downloadable PDF. Download VA Form 10-7959A (PDF) Helpful links. Find out how to update your direct deposit information online for disability compensation, pension, or education benefits.
Claim form usage: This form is to be completed by the patient, sponsor or guardian and is mandatory for all beneficiary claims. This claim form is NOT to be used for provider submitted claims. Other Health Insurance (OHI): By law, other coverage must be reported.
CHAMPVA beneficiary claim form. This form is to be completed by the patient, sponsor, or guardian and is mandatory for all beneficiary claims. This claim\r\nform is NOT to be used for provider submitted claims.
Fillable PDF forms include Application for CHAMPVA Benefits, Meds by Mail, Spina Bifida Claim, Foreign Medical Program Registration, and more. Forms. Please follow the instructions on each form and mail or fax your completed form to the address provided.
10-7959a. CHAMPVA Claim Form. Notice: Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the dissolution of marriage.
