Forms
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Form | |
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SF-3881 Form * | Fillable (pdf) |
* Providers, if you want to apply for payment via Electronic Funds Transfer, complete the "Payee/Company Information" and "Financial Institution" sections of the SF-3881 form, and mail the signed form to: Department of Veterans Affairs Financial Services Center PO Box 149971 Austin, TX 78714-8971 Or, fax the signed form to: (512) 460-5221 |
Form | |
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CHAMPVA Application for Benefits 10-10d | Fillable (pdf) |
CHAMPVA Claim Form (not for providers) 10-7959a | Fillable (pdf) |
Meds by Mail - Prescription Order Form 10-0426 | Fillable (pdf) |
CHAMPVA Other Health Insurance Certification 10-7959c | Fillable (pdf) |
Form | |
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Spina Bifida Miscellaneous Claim Form 10-7959e (not for providers) | Fillable (pdf) |
Form | |
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FMP Registration Form - VA Form 10-7959f-1 | Fillable (pdf) |
FMP Claim Cover Sheet - VA Form 10-7959f-2 | Fillable (pdf) |
Form | |
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Recurring Authorization VA Form10-5345 + Fact Sheet 06-01. Note: Use this form for continuous release of your information to a spouse, relative, or other designee. |
Print-Only (pdf) |
Authorization Form VA Form10-5345 Note: Only use this form for one time release of information. |
Fillable (pdf) |
Form | |
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Forma S10-10d AplicaciĆ³n a los Beneficios CHAMPVA | Fillable (pdf) |
Forma S10-7959a Formulario de Reclamo CHAMPVA | Fillable (pdf) |
Forma S10-0426 Medicinas por Correo | Fillable (pdf) |
Forma S10-7959c Certificacion CHAMPVA de Otros Seguros de Salud | Fillable (pdf) |
Form | |
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Forma S10-7959e Reclamo de Gastos Miscelaneos | Fillable (pdf) |