VA Form 10-7959C Printable, Fillable in PDF

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VA Form 10-7959C Printable, Fillable in PDF – A Certificate of Other Health Insurance (OHI) is a Department of Veterans Affairs (VA) document that is used to gather the information that is necessary to verify payer status when there are several health insurance plans in place. You may also use this form to notify your health insurance provider of any changes in your coverage or coverage amounts.

The most recent version of the form was made available to the public on February 1, 2017. Fillable versions of the VA Form 10-7959C are available for download and digital filing below, and they may also be obtained on the VA’s official website.

It is operated by the Veterans Health Administration Office of Community Care, which is based in Denver, Colorado, and provides health care to civilians and military personnel who serve in the Department of Veterans Affairs (VA). This program is quite similar to the military’s TRICARE program. However, even though the CHAMPVA does not have its network of healthcare providers, it does split the expenses of required medical treatments and supplies with those who qualify.

Instructions for completing VA Form 10-7959C

The directions for completing VA CHAMPVA Form 10-7959C are included on the second page of the publication. They should be thoroughly read before proceeding with the writing of the paper. The following are the general operating instructions:

A comprehensive and accurate response to the request for information is required since failing to submit vital facts may result in a delay or total denial of benefits.
The information provided must be accurate and complete. This document might result in criminal prosecution if you willfully make false representations in it.
The new beneficiaries are required to furnish information about their other health insurance (OHI) coverage beginning on the day their CHAMPVA eligibility became effective.
The present beneficiaries are required to update their OHI information regularly if it changes.
The Medicare supplement plan information may be found on the policy cover sheet or insurance membership card; however, the Medicare supplement plan is not available online.
It is possible to type or print legibly on simple bond paper and attach it to this certificate to provide information about extra insurance.
Submission of the completed paperwork to the Health Administration Center in Denver, either by mail or fax, is recommended. The address, as well as the fax number, are provided at the top of the document.

When submitting the completed VA Form 10-7959C Form, it is important to include the following additional documents:

a photocopy of the front and back of the OHI member identification card; and
a copy of the Medicare identification card
If the OHI does not offer its clients an Explanation of Benefits paper, a copy of the schedule of benefits may be added to this form instead of the explanatory paper.

The VA Form 10-7959C must be completed in its entirety

It normally takes approximately ten minutes to finish the paper in a typical situation. The majority of its fields are self-explanatory. This Certificate of Other Health Insurance (CHAMPVA) is divided into three sections:

Section I should include the beneficiary’s personal information, which should include his or her name, sex, address, phone number, and Social Security number. The veteran’s family must complete a separate application form for each member of the veteran’s household.
In Section II, you must provide specifics about your Medicare supplement plan.
Section III is intended for any other forms of medical insurance, if any, that may be available. If the policy is presently inactive, it is just essential to provide the date on which it will be terminated.
The last section is intended for certification, and it needs the signature of the beneficiary, sponsor, or legal guardian, as well as the date on which the form was completed.

VA Form 10-7959C (Virginia 10-7959C) Forms That Are Related

There are many papers associated with the VA Form 10-7959C:

Patients, sponsors, and guardians must fill out the VA Form 10-7959A, CHAMPVA Claim Form, which is available online. The information included inside it is required to submit claims for CHAMPVA benefits.
It is necessary to gather information to evaluate possible responsibility, and the VA Form 10-7959D, CHAMPVA Potential Liability Claim, is utilized for this purpose.
When seeking reimbursement for various expenditures incurred while receiving health care benefits for a veteran’s children, the VA Form 10-7959E, Claim for Miscellaneous Expenses, is required to be completed.
When completing VA Form 10-7959F-1, Foreign Medical Program (FMP) Registration Form, veterans are required to give information that will be utilized to determine whether or not they are eligible to participate in the VA Foreign Medical Program.
VA Form 10-7959F-2, Claim Cover Sheet – Foreign Medical Program (FMP), must be completed for a veteran to be reimbursed for medical services received while traveling outside the United States.