Your information as the CHAMPVA beneficiary. Each covered person files their own 10-7959c. The veteran sponsor does not file this - it is for covered dependents.

(your name, SSN, CHAMPVA eligibility number)

• ×Filing one form for all family members instead of one per beneficiary.

List every insurance plan you are covered under: Medicare Part A, Medicare Part B, employer group health plan, TRICARE (if applicable for certain family members), private individual insurance, state Medicaid. For each: insurance company name, ID/policy number, group number, effective dates, and type of coverage. CHAMPVA will coordinate with each plan listed.

e.g., Medicare Part A (No.1EG4-TE5-MK72): effective 01/2020
Medicare Part B (same): effective 01/2020
No other insurance

• ×Not listing Medicare - CHAMPVA requires disclosure of Medicare coverage.
• ×Forgetting a secondary insurance - CHAMPVA asks for ALL coverage.
• ×Not updating when insurance changes - failure to update means CHAMPVA cannot coordinate correctly and you may owe more out-of-pocket.

If you have NO other health insurance, check this box and sign. This is the most common situation for many CHAMPVA beneficiaries who rely on CHAMPVA as their sole coverage.

Check if no other health insurance

• ×Not disclosing employer insurance - even if not enrolled, if you are eligible for employer insurance, CHAMPVA may require you to enroll.

Sign and date. File annually or whenever insurance changes.

(your signature/date)

• ×Not re-filing when insurance changes - CHAMPVA will continue coordinating with old insurance.