Web Content View
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
Forms in English
Forms for CHAMPVA Beneficiaries
- 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
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
- Recurring Authorization VA Form 10-5345 + Fact Sheet 06-01
Note: Use this form for continuous release of your information to a spouse, relative, or other designee. - Authorization Form VA Form 10-5345
Note: Only use this form for one time 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.