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19 wrz 2023 · Get VA Form 10-7959C, CHAMPVA Other Health Insurance (OHI) Certification. Use this VA form as part of your CHAMPVA 10-10d benefit application if you have other health insurance, or to report changes in your other health insurance, such as new beneficiaries or coverage changes.
- VHA 10-7959c
VA FORM . 10-7959c. AUG 2013. CHAMPVA OTHER HEALTH INSURANCE...
- CHAMPVA Benefits
To apply, submit these required documents: Application for...
- VHA 10-7959c
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).
To apply, submit these required documents: Application for CHAMPVA Benefits (VA Form 10-10d), and. Other Health Insurance Certification (VA Form 10-7959c), and. Documents related to your Medicare status: If you qualify for Medicare for any reason, you’ll need to submit a copy of your Medicare card.
SECTION III: Provide all periods of other health insurance coverage since you became CHAMPVA eligible. Required: Attach a copy of any active health insurance cards (front & back). VA Health Administration Center, PO BOX 469063, Denver, CO 80246-9063 1-800-733-8387 www.va.gov/hac FAX: 1-303-331-7808
Use this form to report any changes in your other health insurance. -- New beneficiaries - we need OHI information from the date your CHAMPVA eligibility became effective. -- Re-certification - update OHI information every time a change is made to your OHI coverage.
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.
31 sty 2024 · Application for CHAMPVA Benefits (VA Form 10-10d) (PDF), and Other Health Insurance Certification ( VA Form 10-7959c ) However, you only need to submit the second form if the CHAMPVA applicant currently has another type of health insurance coverage (e.g. an employer-sponsored plan).
