Web Content View

Content starts here.

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.


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

Forms in English


Forms for Spina Bifida Beneficiaries


Forms in Spanish

Solicitudes para beneficios de Espina Bifida



Forms in English


Forms for Foreign Medical Program (FMP)

Forms in English


Authorization for Release of Medical Records and Release of Information




Customer Service

We are always working to improve our service to you. We are committed to getting you accurate and timely information about your benefits and giving you a variety of ways to obtain the needed information. If this site doesn't provide you with the answers to your questions or the information you need, the following sources may be of use to you.


Interactive Voice Response System


Phone Toll Free: 1-800-733-8387
Hours of Availability: 24 Hours a Day, 7 Days a Week

You can obtain information and request forms through our interactive voice response system, without waiting to speak to a customer service representative.

Services available through this system are:

  • Ordering CHAMPVA forms and applications. The prompts will instruct you to leave a voice mail request by leaving your CHAMPVA Member Number (Social Security number), full name and address.
  • You can check on your eligibility, claims status, annual deductible and annual catastrophic cap.
  • Your providers can check on your eligibility or the status of a payment.

Talk to a Customer Service Representative

Phone Toll Free: 1-800-733-8387 Monday through Friday (excluding holidays)
Hours of operation: 8:05 a.m. to 7:30 p.m. Eastern Time

We have recently implemented a Virtual Hold system to allow us to call you back when our estimated wait time exceeds three minutes.

Content ends here.