Identification
The Veteran's last and first name, the last 4 of the SSN, street address, city, state and zip code.
10-493b
CHAMPVA Benefits Election Affirmation
- Agency
- VA
- Revision
- January 2016
- Fillable fields
- 10
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-493b: CHAMPVA Benefits Election Affirmation
VA Form 10-493b is the U.S. Department of Veterans Affairs CHAMPVA Benefits Election Affirmation. It is filled in to elect to use CHAMPVA benefits for a visit or appointment at a VA medical facility. The form says the election applies only to that episode of care, and that the VA medical facility where treatment is performed submits claims to CHAMPVA on the patient's behalf.
The form is one page: identification details, the election statement with the appointment date and facility, the billing terms and the patient's signature in ink. It is not the CHAMPVA application: VA's page lists VA Form 10-10d for applying. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-493b
Election statement
The Veteran or beneficiary's full name, the appointment date and the name of the appropriate medical treatment facility.
Billing terms
Related ancillary services such as x-rays and laboratory are part of the visit and also billed to CHAMPVA, and the VA medical facility submits the claims.
Other health insurance
The form says CHAMPVA by law is always supplemental or the secondary payer, except for Medicaid, State Victims of Crimes Compensation Programs and policies purchased exclusively to supplement CHAMPVA benefits.
Scope and signature
A statement that the election applies only to this episode of care, the dual-eligible rule, and the patient's signature in ink with the date.
How to fill in VA Form 10-493b
- 1
Enter the identification details
Fill in the Veteran's name, last 4 of the SSN and the address at the top of the form.
- 2
Complete the election statement
Insert the Veteran or beneficiary's full name, the appointment date and the name of the medical treatment facility.
- 3
Read the billing terms
The form covers ancillary services, other health insurance and care for a service-connected condition.
- 4
Sign in ink and date it
The signature line says Patient's Signature (Sign in ink), next to the date.
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Filing and edition details
No address on the form
The form and VA's form page print no mailing address, fax number or email. The form says the VA medical facility where treatment is performed submits claims to CHAMPVA.
One episode of care
The form says the election applies only to this episode of care.
Related forms
VA's page lists VA Form 10-10d, Application for CHAMPVA Benefits, VA Form 10-493, TRICARE Affirmation, and VA Form 10-493a, TRICARE For Life Affirmation-Spanish.
Edition
The form is dated JAN 2016, which matches the revision date on VA's form page. No OMB control number is printed on it.
Related forms
Who uses VA Form 10-493b?
The form is filled in by the Veteran or beneficiary receiving care and names the VA medical facility that bills CHAMPVA.
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Questions about Form 10-493b
What is VA Form 10-493b used for?
It records the election to use CHAMPVA benefits for an appointment at a VA medical facility.
Is VA Form 10-493b the CHAMPVA application?
No. VA's page lists VA Form 10-10d, Application for CHAMPVA Benefits, for applying for health care benefits through CHAMPVA.
Does one form cover future visits?
The form says the election applies only to this episode of care, and that CHAMPVA benefits are elected at each episode of care.
What if I have other health insurance?
The form says VA bills the Other Health Insurance (OHI) as the primary carrier and then CHAMPVA as the secondary payer, with exceptions for Medicaid, State Victims of Crimes Compensation Programs and policies bought only to supplement CHAMPVA.
Is CHAMPVA billed for service-connected care?
The form says a dual-eligible (CHAMPVA/Veteran Status) patient seeking care for a service-connected condition in a VA medical facility receives it using Veteran's benefits, and CHAMPVA will not be billed.
Are x-rays and lab work included?
The form says associated ancillary services related to the visit, such as x-rays and laboratory, are part of the visit and will also be billed to CHAMPVA.