VA Form 10-7959c Champva Other Health Insurance (Ohi) Certification

VA Form 10-7959C, CHAMPVA - Other Health Insurance (OHI) Certificate

The VA Form 10-7959C, CHAMPVA - Other Health Insurance (OHI) Certificate is a Department of Veterans Affairs (VA) document used to collect data required to determine payer status when there are other health insurances present. You may also use this form to provide information about changes in your health insurances.

The latest version of the form was released by the VA in May 2010. An up-to-date fillable version of the VA Form 10-7959C is available for download and digital filing below or can be found on the VA official website.

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health care program administered by the Veterans Health Administration Office of Community Care in Denver, Colorado. This program is very similar to TRICARE. The CHAMPVA does not have its own network of health-care providers, but it shares the costs of necessary medical procedures and supplies with eligible beneficiaries.


Download VA Form 10-7959c Champva Other Health Insurance (Ohi) Certification

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Form 10-7959C Instructions

The VA CHAMPVA Form 10-7959C instructions are provided on the second page of the document. They should be read carefully before completing the paper. The general instructions are as follows:

  • The requested information must be provided in full, since failure to furnish necessary details may result in a delay or complete rejection of benefits;
  • The indicated data must be true and correct. If you knowingly make false statements in this document, you may be subject to criminal penalties;
  • The new beneficiaries must provide the Other Health Insurance (OHI) information from the date the CHAMPVA eligibility became effective;
  • The current beneficiaries are obliged to update OHI information every time it changes;
  • The Medicare supplement plan details can be found on the policy cover sheet or insurance membership card;
  • The information about additional policies can be typed or legibly printed on the plain bond paper and attached to this certificate;
  • The completed document should be submitted to the Health Administration Center in Denver via mail or fax. The address and fax number can be found on the top of the paper.

When submitting the completed VA 10-7959C Form it is necessary to also attach:

  • a copy of front and back of the OHI member ID card;
  • a copy of the Medicare card.

If the OHI does not provide its customers with the Explanation of Benefits paper, the copy of the schedule of benefits may be attached to this document.

How to Fill out VA Form 10-7959C?

It usually takes about 10 minutes to complete the document. Most of its fields are self-explanatory. The CHAMPVA - Other Health Insurance Certificate consists of three sections:

  1. Section I should contain personal data of the beneficiary including name, sex, address, phone number, and SSN. It is necessary to complete a separate form for each member of the veteran's family;
  2. Section II requires details about Medicare supplement plan;
  3. Section III is designed for all other types of medical insurance if any. In case the policy is currently inactive, it is necessary to indicate the termination date only;
  4. The last Section is designed for certification and requires the signature of the beneficiary, sponsor, or legal guardian and the date of completing.

VA 10-7959C Related Forms

The VA 10-7959C has several related documents:

  • The VA Form 10-7959A, CHAMPVA Claim Form is a paper completed by the patient, sponsor or guardian. The information provided in it is necessary to process claims for CHAMPVA benefits;
  • The VA Form 10-7959D, CHAMPVA Potential Liability Claim is used to collect information required to assess potential liability;
  • The VA Form 10-7959E, Claim for Miscellaneous Expenses is necessary to fill out when claiming reimbursement of miscellaneous expenses of health care benefits for veteran's children;
  • The VA Form 10-7959F-1, Foreign Medical Program (FMP) Registration Form is used to provide information necessary for the determination of veteran's eligibility to participate in the VA Foreign Medical Program;
  • The VA Form 10-7959F-2, Claim Cover Sheet - Foreign Medical Program (FMP) is filled out in order to receive reimbursement for medical services outside the United States.
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