Section I: beneficiary information
Name, Social Security number, street address, city, state, zip code, country code, email address, phone number, sex and a box for a new address.
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
- Agency
- VA
- Revision
- March 2025
- Fillable fields
- 51
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-7959c: CHAMPVA Other Health Insurance (OHI) Certification
VA Form 10-7959c is the CHAMPVA Other Health Insurance (OHI) Certification from the U.S. Department of Veterans Affairs. CHAMPVA is the Civilian Health and Medical Program of the Department of Veterans Affairs. VA's form page says to use it if you recently applied for CHAMPVA and VA asked for your other non-VA health insurance information, or if you're enrolled in CHAMPVA and need to report updates to that insurance, like Medicare.
Page 1 has four sections: beneficiary information, Medicare beneficiaries, other health insurance and the certification. Page 2 holds instructions, the items to return with the form, definitions such as OHI, EOB and Medicare supplemental policies, the Privacy Act information and the burden statement. VA's page also links a Spanish version, Formulario VA 10-7959c.
VA's page says to mail the PDF if you applied for CHAMPVA by mail, or use the online tool if you applied online. 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 10-7959c
Section II: Medicare beneficiaries
Yes or no for Medicare Parts A, B, C and D with effective dates, a Medicare Advantage or replacement plan carrier name, the MBI, and whether there is health insurance other than Medicare. If no, the form says to go to Section IV.
Section III: other health insurance
All periods of OHI coverage since becoming CHAMPVA eligible, with room for two insurers: name, effective and termination dates, whether it is through employment or covers prescriptions, the type of insurance and comments.
Section IV: certification
A certification that the information is correct to the best of the signer's knowledge and belief and an agreement to promptly notify the Chief Business Office Purchased Care of any change, with signature (type if electronic) and date.
Page 2: instructions and definitions
Instructions for new beneficiaries and re-certification, the items to return, and definitions of OHI, EOB, carrier, OHI primary to CHAMPVA, supplemental CHAMPVA policies, Medicare supplemental policies, indemnity and termination date.
How to fill out VA Form 10-7959c
- 1
Read page 2 first
The form says to read the instructions on the reverse side before completing it.
- 2
Fill in one form per person
Complete Section I for one family member. The instructions say new beneficiaries give OHI information from the date CHAMPVA eligibility became effective.
- 3
Answer the Medicare questions
Mark Parts A to D and their dates in Section II. If there is no health insurance other than Medicare, the form says to go to Section IV.
- 4
List other insurance
Give each period of coverage in Section III and enter a termination date only if the policy is inactive. The form says more policies go on plain bond paper with your name and SSN, attached to the form.
- 5
Attach card copies
The form lists a copy of your Medicare card, not the original, and a copy of your OHI member ID card, front and back.
- 6
Sign and send it
Sign and date Section IV, then mail or fax the form to CHAMPVA Eligibility, or submit it online if you applied for CHAMPVA online.
Why fill Form 10-7959C on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and getting help
Mailing address
VHA Office of Integrated Veteran Care CHAMPVA Eligibility PO Box 137 Spring City, PA 19475.
Fax and phone updates
The form lists FAX: 303-331-7808 and says updates can be sent by FAX or call by phone.
Online
VA's page says you can submit your form online instead of filling out and sending the paper form, and to use the online tool if you applied for CHAMPVA online.
Questions
The form lists the Customer Service Center at 1-800-733-8387 and the CHAMPVA Help Line at 800-733-8387.
Edition
The PDF is dated MAR 2025 and carries OMB Control Number 2900-0219, which expires 12/31/2027.
Related forms
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fields, 3 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-7959D
CHAMPVA Potential Liability Claim
57 fields, 2 pages
10-7959e
Claim for Miscellaneous Expenses
58 fields, 2 pages
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)
15 fields, 2 pages
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Questions about Form 10-7959C
When is VA Form 10-7959c used?
VA's page says to use it if you recently applied for CHAMPVA and VA asked for your other non-VA health insurance information, or if you're enrolled and need to report updates, like Medicare.
Can I submit VA Form 10-7959c online?
VA's page says you can submit the form online instead of sending the paper form, and to use the online tool if you applied for CHAMPVA online. If you applied by mail, it says to send the PDF by mail.
Does each family member need a separate form?
Yes. Section I says to use a separate form for each family member.
What goes with the completed form?
The form lists a copy of your Medicare card, not the original, and a copy of your other health insurance member ID card, front and back.
Is CHAMPVA primary or secondary to other insurance?
The form says CHAMPVA by law is always supplemental or the secondary payer of health care benefits, except for Medicaid, State Victims of Crimes Compensation Programs and policies purchased exclusively to supplement CHAMPVA benefits.
Is there a Spanish version?
Yes. VA's page links to Formulario VA 10-7959c (español, PDF).
What if I haven't applied for CHAMPVA yet?
VA's page says to submit the Application for CHAMPVA Benefits, VA Form 10-10d, first, and that you'll be able to submit other health insurance information when you apply for CHAMPVA online.