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Get VA 10-7959c 2020-2021

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 MEMBER LAST NAME FIRST NAME SEX ADDRESS NUMBER STREET PO BOX APT Male CITY STATE Female ZIP CODE SOCIAL SECURITY NUMBER PHONE INCLUDE AREA CODE MI CHECK IF NEW ADDRESS SECTION II MEDICARE BENEFICIARIES ATTACH A COPY OF YOUR MEDICARE CARD No Yes Part B Part A Part D EFFECTIVE DATE MMDDYYYY PART B CARRIER NAME Did you choose a Medicare Advantage NO Plan for your Medicare coverage Do you have health insurance other than MEDICARE IF NO go to Section IV Does your Medicare provide Pharmacy benefits 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. Name of insurance 1 Only put in the termination date if the policy is inactive. The information you provide may be verified by a computer matching program at any time. You are requested to provide your Social Security number as your VA record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the requested information is not provided it may delay or result in denial of your request for CHAMPVA benefits. Failure to furnish the requested information will have no adverse impact on any other VA benefit to which you may be entitled. The responses you submit are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act including the routine uses identified in the VA system of records number 54VA16 titled Health Administration Center Civilian Health and Medical Program Records -VA as set forth in the Compilation of Privacy Act Issuances via online GPO access at http //www. The purpose of collecting this information is to determine payer status when other health insurance coverage exists. The information you provide may be verified by a computer matching program at any time. You are requested to provide your Social Security number as your VA record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the requested information is not provided it may delay or result in denial of your request for CHAMPVA benefits. EOB The abbreviation for an explanation of benefits form or letter that must accompany claims submitted to CHAMPVA. An EOB is a statement or Remittance Advice from an insurance carrier or benefit program that summarizes the action taken on a claim. Note If you have OHI primary to CHAMPVA you must submit EOB s for each primary insurance along with health care claims. If on your insurance card or a document showing your co-payments with every health care claim so CHAMPVA can calculate benefit payments. DEFINITIONS OHI OHI refers to insurance or benefits you may have other than CHAMPVA called Other Health Insurance. EOB The abbreviation for an explanation of benefits form or letter that must accompany claims submitted to CHAMPVA. An EOB is a statement or Remittance Advice from an insurance carrier or benefit program that summarizes the action taken on a claim. Note If you have OHI primary to CHAMPVA you must submit EOB s for each primary insurance along with health care claims. A COPY of your other health insurance OHI member ID card front and back. If your OHI does not issue EOBs then attach a copy card or document of your schedule of benefits that lists your co-payments. DEFINITIONS OHI OHI refers to insurance or benefits you may have other than CHAMPVA called Other Health Insurance. EOB The abbreviation for an explanation of benefits form or letter that must accompany claims submitted to CHAMPVA..

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