• Was treatment for an injury or accident
outside of work?
CHAMPVA Claim Form
VA Health Administration Center CHAMPVA PO Box 469064 Denver CO 80246-9064 1-800-733-8387
Attention: After reviewing the following information, complete the form in its entirety (print or type only) and return with the
required documentation.
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): If OHI exists, attach OHI’s Explanation of Benefits (EOB) to the provider’s itemized billing statement(s).
Dates of service and provider charges on 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 (ID-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 are to include name, quantity, strength, and NDC of each drug.
Section I - Patient Information
OMB Number: 2900-0219 Est. Burden: 10 minutes
Last Name (this is a mandatory field)
First Name (this is a mandatory field)
CHAMPVA Member Number (this is a mandatory field)
Street Address
Check if new
Date of Birth (mm/dd/yyyy)
City State
ZIP Code
Telephone Number (include area code)
Section II - Other Health Insurance (OHI) Information
By law, other coverage must be reported. Except for CHAMPVA supplemental policies, CHAMPVA is always the secondary payer.
If more space is needed, please continue in the same format on a separate sheet.
• Is patient covered by other primary health
insurance to include coverage through a
family member (supplemental or
secondary insurance excluded)?
Yes No
Yes (check type below and provide
coverage information on the right)
no (proceed to Section III)
employer sponsored (group)
private (non group)
Medicare (Part A or B)
Name of Other Health Insurance (OHI)
OHI Policy Number
OHI Telephone Number (include area code)
Name of Other Health Insurance (OHI)
OHI Policy Number OHI Telephone Number (include area code)
Section III - Sponsor Information
Last Name First Name MI CHAMPVA Member Number (this is a mandatory field)
Section IV - Claimant Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false, fictitious, or fraudulent statements or claims.
I certify that the above information and attachments are correct
and represent actual services, dates, and fees charged. (Sign and
date on right.) If certification is signed by a person other than the
patient, complete the information the signature and date.
Signature (type if electronic)
Last Name
First Name
MI Relationship to Patient
Street Address
City State ZIP Code Telephone Number (include area code)
MAY 2010
• Was treatment for a work-related injury or
Yes No
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: The authority for collection of the requested information on this form is 38 U.S.C. 501 and
1781. The purpose of collecting this information is to adjudicate and process claims for CHAMPVA benefits. You do not
have to provide the requested information 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 responses you submit are considered confidential and may be
disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA
system of records 54VA16, titled "Health Administration Center Civilian Health and Medical Program Records -VA", as set
forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess/privacyact/index.html.For
example, information on this form may be disclosed to contractors, trading partners, health care providers and other
suppliers of health care services to determine your eligibility for medical benefits and payment for services. Disclosure of
Social Security number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is
voluntary. Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or
persons claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title
38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
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
MAY 2010
CHAMPVA Claim Form