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CHAMPVA Other Health Insurance (OHI) Certification

ZIP CODEFIRST NAMESEXLAST NAMEMIMaleFemaleCITYSTATEPHONE # (INCLUDE AREA CODE)SOCIAL SECURITY NUMBERCHECK IF NEW ADDRESSPart A: YesNoPart B:YesNoPart D: YesNoPART A CARRIER NAMEPART B CARRIER NAMEPART D CARRIER NAMEDid you choose a Medicare Advantage Plan for your Medicare coverage?Does your Medicare provide Pharmacy benefits?YesNoYesNoNoYesDo you have Health Insurance Other than MEDICARE?IF NO, go to Section IVOnly put in the termination date if the policy is this Insurance through employment?YesNoDoes the Insurance cover prescriptions?YesNoDoes the Insurance provide an explanation of benefits for prescriptions?YesNoWhat type of Insurance ?

This form is also used to report any changes in your other health insurance status. Updates can be sent by FAX or call by phone. PLEASE READ INSTRUCTIONS AND INFORMATION ON THE REVERSE SIDE BEFORE COMPLETING THIS FORM SECTION II: MEDICARE BENEFICIARIES: ATTACH A COPY OF YOUR MEDICARE CARD. CHAMPVA Other Health

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  Health, Other, Insurance, Other health, Other health insurance

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