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Purchased Care Health Benefits Forms

Eligible Veterans and their dependents can get a range of health care services external to VA facilities through Purchased Care @ Health Administration Center. Fillable PDF forms include Application for CHAMPVA Benefits, Meds by Mail, Spina Bifida Claim, Foreign Medical Program Registration, and more.

Forms

Please follow the instructions on each form and mail or fax your completed form to the address provided.


IMPORTANT: You must have at least Adobe Reader version 6.0 on your computer to fully utilize all the forms on this site which can be filled on-line, printed, saved and edited. Some PDF are printable blank forms. You can download software at: Free Adobe Reader Download

NOTE: If you are eligible for Medicare Part A you must enroll in Medicare Part B to keep your CHAMPVA coverage. Follow this link for further information. http://www.va.gov/hac/forbeneficiaries/champva/champva.asp

Forms in English Forms in Spanish

Forms for CHAMPVA Beneficiaries

CHAMPVA Application for Benefits 10-10d

CHAMPVA Claim Form (not for providers) 10-7959a

Meds by Mail - Prescription Order Form 10-0426

CHAMPVA Other Health Insurance Certification 10-7959c

Solicitudes para beneficios de CHAMPVA

Forma S10-10d Aplicacion a los Beneficios CHAMPVA

Forma S10-7959a Formulario de Reclamo CHAMPVA

Forma S10-0426 Medicinas por Correo

Forma S10-7959c Certificacion CHAMPVA de Otros Seguros de Salud

Forms for Spina Bifida Beneficiaries

Spina Bifida Miscellaneous Claim Form 10-7959e (not for providers)

Solicitudes para beneficios de Espina Bifida

Forma S10-7959e Reclamo de Gastos Miscelaneos

Forms for Foreign Medical Program (FMP)

FMP Registration Form - VA Form 10-7959f-1

FMP Claim Cover Sheet- VA Form 10-7959f-2

  

Authorization for Release of Medical Records and Release of Information

Recurring Authorization VA Form 10-5345 + Fact Sheet 06-01
Note: Use this form for continuous release of your information to a spouse, relative, or other designee

Authorization Form VA Form 10-5345
Note: Only use this form for one time release of information

  

Customer Service

We are always working to improve our service to you. We are committed to getting you accurate and timely information about your benefits and giving you a variety of ways to obtain the needed information. If this site doesn't provide you with the answers to your questions or the information you need, the following sources may be of use to you.

Interactive Voice Response System

Phone Toll Free: 1-800-733-8387

Hours of Availability: 24 Hours a Day, 7 Days a Week

You can obtain information and request forms through our interactive voice response system, without waiting to speak to a customer service representative.

Services available through this system are:

  • Ordering CHAMPVA forms and applications. The prompts will instruct you to leave a voice mail request by leaving your CHAMPVA Member Number (Social Security number), full name and address.
  • You can check on your eligibility, claims status, annual deductible and annual catastrophic cap.
  • Your providers can check on your eligibility or the status of a payment.

Talk to a Customer Service Representative

Phone Toll Free: 1-800-733-8387 Monday through Friday (excluding holidays)

Hours of operation: 8:05 a.m. to 7:30 p.m. Eastern Time

We have recently implemented a Virtual Hold system to allow us to call you back when our estimated wait time exceeds three minutes.