Application for CHAMPVA Benefits

Eligible for Medicare? If yes, complete VA Form 10- 7959c and attach a copy of Medicare CardOther Health Insurance? If yes, complete VA Form 10- 7959c and attach a copy of Insurance card Telephone Number (include area code)Date of Birth (mm-dd-yyyy)Relationship to the veteran ( , spouse, child, stepchild)Eligible for Medicare? If yes, complete VA Form 10- 7959c and attach a copy of Medicare CardOther Health Insurance? If yes, complete VA Form 10- 7959c and attach a copy of Insurance card Telephone Number (include area code)Date of Birth (mm-dd-yyyy)Relationship to the veteran ( , spouse, child, stepchild) Street Address City State Zip CodeYesNoYesNo Email Address Last Name First NameMI Social Security NumberSexMaleFemaleIs veteran deceased? Application for CHAMPVA BenefitsVA Health Administration CenterAttention: Please review the instructions on the reverse side and then complete this form in its entirety (print or type only).

Dec 21, 2012 · continuing up to age 23, is enrolled in a full-time course of instruction at an approved educational institution---school certification required (see below). NOTE: Except for stepchildren, the eligibility of children is not affected by divorce or remarriage of the spouse or surviving spouse.

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