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* 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 Download VA Form 10-7959C (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). Download VA Form 10-10d (PDF) * 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.