Form 10-7959a CHAMPVA Claim Form

OMB Number 2900-0219
Estimated Burden: 10 minutes
Expiration Date: 09/20/2016

CHAMPVA Claim Form
Chief Business Office Purchased Care, CHAMPVA, PO Box 469064, Denver CO 80246-9064 | Customer Service Center: 1-800-733-8387
ATTENTION: Refer to the following information for instructions and assistance completing this form in its entirety
(print or type only). Return the form and any additional, requested information to the address shown above.
Claim form usage: This form is to be completed by the patient, sponsor or guardian and is mandatory for all beneficiary claims. This
claim form is NOT to be used for provider submitted claims.
Other Health Insurance (OHI): By law, other coverage must be reported. Except for CHAMPVA supplemental policies, CHAMPVA is
always the secondary payer. If OHI exists, attach an Explanation of Benefits (EOB) from the other health insurance to the provider's
itemized billing statement(s). Dates of service and provider charges on the EOB must match billing statements.
Timely filing requirement: Claims must be received no later than one year after the date of service or, in the case of inpatient care,
within one year of the discharge date.
Itemized billing statements: An itemized statement must be attached and contain:
• patient name, date of birth, and CHAMPVA Identification Card Member Number (same as patient's Social Security number);
• provider name, degree, tax identification number (TIN), address and telephone number; and
• service dates, itemized charges and appropriate procedure/diagnosis codes for each service (i.e., CPT-4, HCPCS, and ICD-9-CM
codes), including narrative descriptions.
Pharmacy claims must include name, quantity, strength, and National Drug Code (NDC) of each drug.

SECTION I – PATIENT INFORMATION
Last Name (required field)

MI

First Name (required field)

Street Address

CHAMPVA Member Number (required field)

Check if new address

City

State

ZIP Code

Date of Birth (mm/dd/yyyy)

Phone Number (include area code)

SECTION II – OTHER HEALTH INSURANCE (OHI) INFORMATION

If more space is needed, please continue in the same format on a separate sheet.
Was treatment for a work-related injury/condition?

Yes

No Was treatment for an injury or accident outside of work?

Yes

No

Is patient covered by OHI, to include coverage through a family member? (Supplemental or secondary insurance excluded)
Yes (check type and provide coverage information below)
employer sponsored (group)

private (non group)

No (proceed to Section III)
Medicare (Part A or B)

other: (specify)

Name of Other Health Insurance (OHI)

Name of Other Health Insurance (OHI)

Policy Number

Policy Number

Phone Number (include area code)

Phone Number (include area code)

SECTION III – SPONSOR INFORMATION
Last Name

First Name

MI

SECTION III – CLAIMANT CERTIFICATION
I certify that the information on this form and any attachments are correct and represent actual services, dates, and fees charged. I
understand that any materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or
imprisonment pursuant to Title 18, United States Code, Sections 287 and 1001. (Sign and date below.)
Date

If certification is signed by a person other Signature
than the patient, complete the following:
Last Name

First Name

Street Address
VA FORM
AUG 2013

10-7959a

City

MI
State Zip Code

Relationship to Patient
Phone Number (with area code)

NOTICE: Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as
of midnight on the effective date of the dissolution of marriage. Changes in status should be reported immediately
to CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver, CO 80246-9028 or call 1-800-733-8387.
Privacy Act Information: Information on this form is collected in accordance with the System of Records Notice
54VA10NB3, Veterans and Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility,
Inquiry and Payment Files-VA (Published March 3, 2015, FR 80, number 41). Category: Records maintained in the system
include program applications, eligibility information concerning the Veteran, family members, caregivers, other health
insurance information to include information regarding eligibility or entitlement to other federal medical programs.
Authority: 38 USC 501 and 1781. Purpose: Records may be used for purposes of establishing and monitoring eligibility to
receive VA benefits, processing claims for medical care and services, and processing stipends. Routine Use: The Privacy
Act permits VA to disclose information about individuals without their consent under the Privacy Act Routine Use Disclosure
when the information will be used for a purpose that is compatible with the purpose for which VA collected the information.
Disclosure: Voluntary. 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 Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of
Section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed and completing and reviewing the collection of information.
Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the
burden, may be addressed by calling the CHAMPVA Help Line, 1-800-733-8387. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number. The purpose of this data collection is to provide
a mechanism to claim CHAMPVA benefits.

VA FORM
AUG 2013

10-7959a