The following information about this VA form comes from the VA forms database, and any changes are updated here nightly. Contact the form administration for further information.
Link to form
https://www.va.gov/vaforms/medical/pdf/VA-10-7959c-fill.pdf
Form number
10-7959C
Row ID
3889
Form title
CHAMPVA - Other Health Insurance (OHI) Certificate
Issue date
Revision date
Form administration
VHA
Number of pages
2
Deleted
False
Form name
CHAMPVA—Other Health Insurance (OHI) Certification
Form Language
English
Related to
Benefits
VA benefits for spouses, dependents, survivors, and family caregivers
VA health care
When to use

Use VA Form 10-7959C or Formulario VA 10-7959c (español) when: 

  • 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 need to report changes in your other non-VA health insurance, such as new beneficiaries or coverage changes.
Related forms
About VA Form 10-10d
Helpful links
CHAMPVA benefits
Learn how eligible spouses and children of Veterans can get health insurance through CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs).
Family member benefits
Find out about VA benefits for spouses, dependents, survivors, and family caregivers.