Sign date below and return to the address at the top of the form. SIGNATURE type if electronic VA FORM 10-7959c FEB 2017 DATE CHAMPVA OTHER HEALTH INSURANCE OHI CERTIFICATION NOTES DEFINITIONS AND INSTRUCTIONS INSTRUCTIONS Failure to complete all applicable sections on the front can result in a delay or denial of benefits. OMB Number 2900-0219 Estimated burden 10 minutes Department of Veterans Affairs CHAMPVA Other Health Insurance OHI Certification VA Health Administration Center PO BOX 469063 Denver CO 80246-9063 1-800-733-8387 www. Va.gov/hac FAX 1-303-331-7808 Failure to provide the requested information will result in a delay or denial of reimbursement until OHI information is received. This form is also used to report any changes in your other health insurance status. Updates can be sent by FAX or call by phone. PLEASE READ INSTRUCTIONS AND INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM SECTION I BENEFICIARY INFORMATION - PLEASE USE A SEPARATE FORM FOR EACH FAMILY ME....
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How to fill out the VA 10-7959c online
Filling out the VA 10-7959c, the CHAMPVA Other Health Insurance Certification form, online can streamline the process of updating your health insurance information. This guide provides a detailed overview and step-by-step instructions to ensure you complete the form accurately and efficiently.
Follow the steps to successfully complete the VA 10-7959c online.
- Click the ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin by entering the beneficiary information in Section I, which includes the last name, first name, middle initial, address, city, state, ZIP code, phone number, sex, and Social Security number. Ensure this information is accurate as it is essential for processing your certification.
- If applicable, fill out Section II regarding Medicare beneficiaries. Indicate whether you have Part A, Part B, and Part D coverage by selecting 'Yes' or 'No' and provide the effective dates and carrier names.
- In Section III, provide details of all other health insurance coverage since becoming CHAMPVA eligible. Input the effective date, termination date (if applicable), and whether the insurance is through employment. Specify the type of insurance and whether it covers prescriptions.
- Complete Section IV by certifying that the information provided is correct. If submitting electronically, sign the form digitally and enter the date.
- After finishing all sections, review your entries for accuracy. Once confirmed, save your changes, download the completed form, and prepare to print or share it if necessary.
Complete your VA 10-7959c form online today to ensure proper maintenance of your health benefits.
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