• 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)
MI
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)
other
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.
4
Signature (type if electronic)
Last Name
First Name
MI Relationship to Patient
Street Address
Date
City State ZIP Code Telephone Number (include area code)
VA FORM
MAY 2010
10-7959a
(specify)
• Was treatment for a work-related injury or
condition?
Yes No
