Section I: Patient information
Last name, first name, middle initial, Social Security number, street address, date of birth, city, state, ZIP code and telephone number.
10-7959e
Claim for Miscellaneous Expenses
- Agency
- VA
- Revision
- June 2025
- Fillable fields
- 58
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-7959e: Claim for Miscellaneous Expenses
VA Form 10-7959e is the U.S. Department of Veterans Affairs Claim for Miscellaneous Expenses, issued by the VHA Office of Integrated Veteran Care. The form says it is required for all claims for reimbursement of miscellaneous expenses related to the treatment of spina bifida and other covered birth defects and associated covered conditions. Page 2 lists two programs: the Spina Bifida Health Care Program and Children of Women Vietnam Veterans.
The form has four sections. It says Sections I, II and IV are mandatory regardless of the type of expense being claimed, and Section III is required only for claims involving travel. Receipts go with the form, and the form says reimbursement for approved expenses, including attendant travel and miscellaneous expenses, is made payable to the beneficiary.
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What's on VA Form 10-7959e
Section II: Sponsor information
The sponsor's last name, first name, middle initial and Social Security number.
Section III: Travel and medical service
Whether the provider will be billing for services, then the Certification of Medical Service with date of service, provider tax ID number and provider signature.
Section III: Trip and expenses
Mode of travel (airline, taxi, POV round trip mileage, bus, train or other), two travel dates with departure and arrival city, state and time, attendant details, lodging, other costs such as parking and tolls, and meals.
Section IV: Certification
A release of medical information that authorizes the patient's providers to release medical record documentation for the claim, and a certification that the information and attachments represent actual services, dates and fees charged.
Page 2: Notices and addresses
The Privacy Act notice, the burden statement with an average of 10 minutes per respondent, and the addresses of the two programs.
How to file VA Form 10-7959e
- 1
Gather your receipts
The form says receipts must be provided with it to ensure proper payment. Section III says receipts for privately owned vehicle (POV) mileage are excluded.
- 2
Fill in Sections I and II
The form says to print or type only and, if more space is needed, to continue in the same format on a separate sheet.
- 3
Complete Section III for travel
For a travel claim, list the trip and expenses, and have the provider complete the Certification of Medical Service.
- 4
Sign and date Section IV
Sign and date the certification. The form says the signature may be typed if electronic.
- 5
Send it to the program
Page 2 lists the mailing address, phone and fax number for the Spina Bifida Health Care Program and for Children of Women Vietnam Veterans.
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Where to send it
Spina Bifida Health Care Program
VHA Office of Integrated Veteran Care, Spina Bifida Health Care Benefits Program, P.O. Box 400, Spring City, PA 19475.
Children of Women Vietnam Veterans
VHA Office of Integrated Veteran Care, Children of Women Vietnam Veterans, P.O. Box 400, Spring City, PA 19475.
Phone and fax
Both programs list Phone: 1-833-930-0816 and Fax: 1-303-331-7807.
Edition
The current edition is dated JUN 2025. Its OMB control number is 2900-0219, which expires 12/31/2027.
Related forms
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fields, 2 pages
10-7959D
CHAMPVA Potential Liability Claim
57 fields, 2 pages
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)
15 fields, 2 pages
Who uses VA Form 10-7959e?
The form names the people who fill in or sign each part.
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Questions about Form 10-7959e
What is VA Form 10-7959e used for?
The form says it is required for all claims for reimbursement of miscellaneous expenses related to the treatment of spina bifida and other covered birth defects and associated covered conditions.
Which sections do I fill in?
The form says Sections I, II and IV are mandatory regardless of the type of expense being claimed. Section III is required only for claims involving travel.
Do I need to send receipts?
The form says receipts must be provided with it to ensure proper payment, and that failure to provide the requested information will result in a delay or denial of reimbursement. Receipts for POV mileage are excluded.
Who is the reimbursement paid to?
The form says reimbursement for approved expenses, including attendant travel and miscellaneous expenses, will be made payable to the beneficiary.
Does the provider need to sign?
For travel claims, yes. The form says the Certification of Medical Service, with the provider's signature certifying service on the service date, is required for all travel claims.
What does signing Section IV authorize?
The form says the signature authorizes the patient's providers to release medical record documentation related to the services associated with the claim.
Where do I send VA Form 10-7959e?
Page 2 lists P.O. Box 400, Spring City, PA 19475 for both the Spina Bifida Health Care Benefits Program and Children of Women Vietnam Veterans, with fax 1-303-331-7807.