Va Form 10-7959c - Champva Other Health Insurance (Ohi) Certification
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2OMB Number 2900-0219
Estimated burden: 10 minutes
CHAMPVA Other Health Insurance (OHI) Certification
Department of Veterans Affairs
VA Health Administration Center, PO BOX 469063, Denver, CO 80246-9063 1-800-733-8387 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
MI
SEX
ADDRESS (NUMBER, STREET, PO BOX, APT #)
Male
Female
CITY
STATE
ZIP CODE
SOCIAL SECURITY NUMBER
PHONE # (INCLUDE AREA CODE)
CHECK IF NEW ADDRESS
SECTION II: MEDICARE BENEFICIARIES: ATTACH A COPY OF YOUR MEDICARE CARD
Yes
No
Yes
No
Yes
No
Part A:
Part B:
Part D:
EFFECTIVE DATE
EFFECTIVE DATE
EFFECTIVE DATE
(MMDDYYYY)
(MMDDYYYY)
(MMDDYYYY)
PART A CARRIER NAME
PART B CARRIER NAME
PART D CARRIER NAME
Did you choose a Medicare Advantage
No
Does your Medicare provide
Yes
NO
Yes
Plan for your Medicare coverage?
Pharmacy benefits?
Do you have health insurance other than MEDICARE?
Yes
No
IF NO, go to Section IV
Provide all periods of other health insurance coverage since you became CHAMPVA eligible.
SECTION III:
Required: Attach a copy of any active health insurance cards (front & back).
Name of insurance # 1
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
Yes
No
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
Comments
Name of insurance # 2
Only put in the termination date if
EFFECTIVE DATE
TERMINATION DATE
the policy is inactive.
(MMDDYYYY)
(MMDDYYYY)
No
Yes
Yes
No
Is this insurance through employment?
Does the insurance cover prescriptions?
Yes
No
Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?
HMO
PPO
Medicaid/State Assistance
Prescription Discount
Medigap
Other
[if Medigap, specify
(specialty, limited coverage, or exclusively CHAMPVA supplemental)
(A-J)]
Comments
SECTION IV: CERTIFICATION BY BENEFICIARY, SPONSOR OR LEGAL GUARDIAN
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious or
fraudulent statements of claims.
I certify that the above information is correct to the best of my knowledge and belief. If there is any change in insurance status for the
above person, I agree to promptly notify VA's Health Administration Center. Sign, date below and return to the address at the top of the form.
DATE
SIGNATURE (type if electronic):
VA FORM 10-7959c
MAY 2010
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