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A Service of the Department of Veterans Affairs and the Department of Defense

Purchased Care Health Benefits Forms

Eligible Veterans and their dependents can get a range of health care services external to VA facilities through Purchased Care @ Health Administration Center. Fillable PDF forms include Application for CHAMPVA Benefits, Meds by Mail, Spina Bifida Claim, Foreign Medical Program Registration, and more.

Forms

Please follow the instructions on each form and mail or fax your completed form to the address provided. IMPORTANT: You must have at least Adobe Reader version 6.0 on your computer to fully utilize all the forms on this site which can be filled on-line, printed, saved and edited. Some PDF are printable blank forms. You can download software at: Free Adobe Reader Download NOTE: If you are eligible for Medicare Part A you must enroll in Medicare Part B to keep your CHAMPVA coverage. For more information visit: Chief Business Office Purchased Care page

• CHAMPVA Application for Benefits 10-10d
• CHAMPVA Claim Form (not for providers) 10-7959a
• Meds by Mail - Prescription Order Form 10-0426
• CHAMPVA Other Health Insurance Certification 10-7959c

Forms in Spanish

Solicitudes para beneficios de CHAMPVA

• Forma S10-10d Aplicacion a los Beneficios CHAMPVA
• Forma S10-7959a Formulario de Reclamo CHAMPVA
• Forma S10-0426 Medicinas por Correo
• Forma S10-7959c Certificacion CHAMPVA de Otros Seguros de Salud