VA Form 10-7959c tells CHAMPVA what other health insurance covers a beneficiary and when that coverage started or ended. VA uses that information to coordinate payments. An insurance card's renewal date is not necessarily the date the policy ended.

Download the current VA Form 10-7959c PDF

Use the official March 2025 PDF, linked from VA's form page. I checked the two-page form on October 2, 2026. Page 1 contains Sections I through IV; page 2 explains insurance terms and supporting documents.

The fields are not individually numbered. Follow the printed section names below. Use a separate form for each family member, even when everyone has the same employer policy.

OHI means other health insurance. If you need the broader program explanation first, Claim Raven's CHAMPVA glossary guide covers eligibility, costs and how CHAMPVA works with other coverage.

When to submit this certification

VA's form page identifies two uses: reporting other insurance as part of a new 10-10d application, and reporting changes after CHAMPVA enrollment. For the second use, VA says to wait until you have received your enrollment packet before submitting this form.

The PDF asks new beneficiaries for insurance history from the date CHAMPVA eligibility became effective. After enrollment, update the information whenever other coverage changes. Examples include a new employer plan, loss of a policy, or a change in Medicare coverage.

This is not the form that applies for CHAMPVA itself. 10-10d is the enrollment application. 10-7959a requests reimbursement for an eligible beneficiary's health care expenses. Updating insurance information does not, by itself, file a claim for a particular medical bill.

The timing matters because VA's CHAMPVA care page says missing or newly reported insurance information can stop claim payments until VA has what it needs. If other insurance is reported after VA has already paid, VA may reprocess the claim and recover an overpayment.

Section I: beneficiary information

Identify the person whose coverage this form reports. That may be a spouse or child rather than the veteran sponsor.

  • Last name, first name and middle initial: Enter the beneficiary's name.
  • Social Security number: Enter that beneficiary's number, not the sponsor's.
  • Street address: Include the street or PO box and apartment number where applicable.
  • City, state and ZIP code: Complete the mailing details.
  • Country code: Complete the applicable field.
  • Email and telephone: Enter the requested contact information, including the area code.
  • New-address box: Check it when this is a new address.
  • Sex: Select the applicable box printed on the form.

Check this section before attaching an insurance card. The card may name the employee who holds the policy, while the CHAMPVA beneficiary is a dependent covered by it. The form still needs the beneficiary's identity.

Do not combine two children on one certification to save a page. Their coverage dates or later Medicare eligibility could differ, and VA expressly asks for separate forms.

Section II: Medicare beneficiaries

Attach a copy of the Medicare card. Report each Medicare part separately rather than treating “Medicare” as one undifferentiated policy.

  • Part A: Answer Yes or No and enter the effective date when applicable.
  • Part B: Answer Yes or No and enter its effective date.
  • Part C: Answer Yes or No. If applicable, identify the Medicare Advantage or replacement-plan carrier and its effective date.
  • Part D: Answer Yes or No and complete the printed MBI, effective-date and termination-date fields as applicable. MBI means Medicare Beneficiary Identifier; copy it from the Medicare record rather than substituting a Social Security number.
  • Other insurance besides Medicare: Answer the question below the Medicare fields. If No, the form directs you to Section IV. If Yes, complete Section III.

Read dates from the coverage records. Part A and Part B do not always begin on the same date, and enrolling in a drug plan does not mean Part B is active.

VA's Medicare explanation says Medicare-eligible beneficiaries generally need Parts A and B to get or keep CHAMPVA; Medicare Advantage also meets the requirement. Part D is not required for CHAMPVA. If you have Part D, VA asks for a copy of both sides of that card when reporting insurance.

The enrollment form describes limited older Medicare exceptions. If you have an unusual Medicare history or were told you are ineligible for Medicare, ask CHAMPVA what proof it requires. Do not cancel coverage based on a general form example.

Section III: other health insurance

This section has two insurance blocks. Report all periods of other coverage since CHAMPVA eligibility began, and attach the front and back of active insurance cards. Use the same approach for each policy.

Name of insurance: Identify the insurance company or plan. Use the card and policy documents so VA can connect the form with the attachments.

Effective date: Enter the date the policy began covering this beneficiary. A sponsor's employment start date is not necessarily the dependent's insurance effective date.

Termination date: Enter a date only if the policy is inactive. Page 2 specifically distinguishes actual termination from the end of a card period that will be renewed. If the policy remains active, do not put an annual card-expiration date in this field.

Insurance through employment: Answer Yes or No. This includes the applicable employer coverage, even when another family member is the employee.

Prescription coverage: Answer Yes or No separately. A medical plan and a prescription benefit are not always the same coverage. Confirm what the plan actually provides if the card is unclear.

Type of insurance: Select HMO, PPO, Medicaid or state assistance, Medigap, or Other. If it is Medigap, specify the plan letter requested on the form. The Other option covers categories such as limited coverage and insurance purchased exclusively to supplement CHAMPVA.

Comments: Use this space to clarify relevant coverage information. Keep the explanation factual, such as which policy ended and which replaced it. It is not a place to estimate what CHAMPVA will pay.

For more than two policies, the instructions permit an attached sheet containing the beneficiary's name, Social Security number and the same requested information for each additional policy. An electronic submission can include an attachment. Keep those sensitive identifiers inside the material submitted securely to VA, not in a public example or email discussion.

Section IV: certification

The beneficiary, sponsor or legal guardian certifies the information. Sign and date the form; the PDF says to type the signature when completing it electronically.

The certification also commits the signer to promptly report a change in the beneficiary's insurance status. Review the coverage history before signing, especially when a plan ended months ago but VA's records may still show it as active.

Send copies of the cards, not your originals. Check that the back is readable and that each attachment belongs to the beneficiary named in Section I.

Fictional example: one employer plan replaces another

This is a fictional worksheet exercise, not a real beneficiary or payment result. Identifying details are deliberately omitted.

Assume an enrolled CHAMPVA spouse has no Medicare. An employer policy ended on June 30, 2026, and a replacement policy began July 1, 2026. The beneficiary has received the CHAMPVA enrollment packet and needs to report the change.

  • Section I identifies the spouse and uses the new-address box only if the address also changed.
  • Section II accurately reflects that the beneficiary has no Medicare; the non-Medicare coverage belongs in Section III.
  • Insurance block 1 identifies the former plan, its actual effective date and the 06/30/2026 termination date.
  • Insurance block 2 identifies the replacement plan and its 07/01/2026 effective date. Its termination field remains empty because the policy is active.
  • Employment, prescription coverage and plan-type answers come from each policy's records.
  • The beneficiary attaches both sides of the active card and signs Section IV.

The dates explain which plan applied on a particular treatment date. They do not establish that a service is covered or calculate a reimbursement amount.

Where to submit it

For a new CHAMPVA application, include the required insurance information with 10-10d. For later updates, VA's form page says applicants who applied by mail should send the PDF by mail, while online applicants should use the online tool. VA's broader CHAMPVA page also lists online and mail updates after enrollment.

  • Online: Use VA's other-insurance submission tool and upload the card copies.
  • Mail: VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, PO Box 137, Spring City, PA 19475.
  • Fax for insurance updates: The March 2025 10-7959c prints 303-331-7808. Its introductory instructions expressly allow updates by fax or telephone.

The insurance-certification fax number ends in 7808. The 10-10d enrollment application prints 7809. Follow the instructions for the document and transaction you are sending. If you are unsure which route applies, call CHAMPVA at 800-733-8387.

Keep a copy of the signed form, card images and submission confirmation. Do not send an application to the paperwork-burden comment email printed on the reverse side.

How the insurance information affects later claims

CHAMPVA generally pays after other health insurance. VA's current care page identifies exceptions for Medicaid, state crime-victim compensation programs, Indian Health Services and CHAMPVA supplemental policies. Report the policy accurately so VA can determine the order of payment.

A later reimbursement claim ordinarily needs the primary insurer's explanation of benefits, or EOB. An EOB describes how that insurer processed a particular claim. The insurance card and this certification describe coverage; they do not replace that claim-specific record.

Page 2 of 10-7959c explains what to submit when an insurer does not issue EOBs, including documentation of applicable copayments. Ask CHAMPVA about the documentation for your plan rather than sending an unrelated policy summary.

After an update, review any CHAMPVA request or EOB for missing insurance information. The sources reviewed do not promise a specific processing time for this certification.

Check for a sponsor's number entered as the beneficiary's, one form covering several people, missing card backs, an active plan marked terminated, and prescription coverage left unanswered. An insurance update and a medical-expense claim should be prepared for their separate purposes.

If you are also reviewing the veteran's compensation and dependent payments, Claim Raven's public calculator lets you compare the ratings and household assumptions you enter without an account. That is a separate household planning step; CHAMPVA reimbursement depends on the health program's rules and the actual claim.

The 21-686c form guide explains dependency changes. Use 10-10d for CHAMPVA enrollment and 10-7959a for beneficiary reimbursement. Keeping those three CHAMPVA forms distinct makes it easier to answer a VA request with the document it actually needs.

Sources and scope

Verified October 2, 2026: both pages of the March 2025 PDF, VA's form page, online submission entry point and CHAMPVA care guidance. The PDF supplies the fax number; the webpage supplies the application-channel instructions. No guaranteed insurance-update processing time was verified. The example is fictional.

Where to go next

Claim Raven is data analysis, not legal, medical, or VA-accredited advice. Contact CHAMPVA for a determination about your insurance coordination or payment.

-Landon Founder, Claim Raven | U.S. Army Veteran