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About VA Form 10-7959C

Form name: CHAMPVA—Other Health Insurance (OHI) Certification
Form revision date: August 2013
Related to: Family member benefits, Health care

When to use this form

Only use VA Form 10-7959C or Formulario VA 10-7959c (español) if one of these descriptions is true for you:

  • You’re applying for CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), and have other health insurance to declare as part of your VA Form 10-10d application, or
  • You’re already enrolled in CHAMPVA and need to report changes in your other non-VA health insurance, such as new beneficiaries or coverage changes. In this case, be sure to wait until you receive your enrollment packet in the mail before you submit this form.

If you applied for CHAMPVA benefits by mail, download the PDF version of this form and send it to us by mail.

If you applied for CHAMPVA benefits online, use our online tool to submit this form online.

Downloadable PDF

Online tool

VA Form 10-10d

Form name: Application for CHAMPVA Benefits

If you’re the spouse or child of a Veteran with disabilities, or the surviving spouse or child of a Veteran who has died, use VA Form 10-10d to apply for health insurance through CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs).

Helpful links related to VA Form 10-7959C

  • Learn how eligible spouses and children of Veterans can get health insurance through CHAMPVA.

  • Find out about VA benefits for spouses, dependents, survivors, and family caregivers.

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