Submit claims within 1 year of the date of service (or 1 year from the date of the other insurer's EOB)

Use CHAMPVA-authorized providers when possible to avoid balance billing

Keep copies of all claims and EOBs for your records

Veterans Affairsmoderate

CHAMPVA Claim Form

VA 10-7959a · VA

CHAMPVA claim form for reimbursement of medical expenses not filed directly by a provider. Requires itemized bills.

Form Details

Total fields: 30
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Filled by: patient
Frequency: per incident

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Where to Submit This Form

📬

Mail to CHAMPVA

VHA Office of Community Care CHAMPVA PO Box 469028 Denver, CO 80246-9028

📠

Fax to CHAMPVA

Fax: 303-331-7809

Required Attachments

📎 Itemized billing statements from providers
📎 Explanation of Benefits (EOB) from other health insurance (if applicable)
📎 Proof of payment (receipts) if seeking reimbursement

Processing Time

30-45 days for claims processing. Reimbursement mailed or direct-deposited after approval.

What Happens Next

CHAMPVA will process the claim and send an Explanation of Benefits. If there is a balance, reimbursement will be issued to the provider or beneficiary.

Tips for This Form

✓ Submit claims within 1 year of the date of service (or 1 year from the date of the other insurer's EOB)
✓ Use CHAMPVA-authorized providers when possible to avoid balance billing
✓ Keep copies of all claims and EOBs for your records

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