Forms
IMPORTANT: You must have at least Adobe Reader version 6.0 on your computer to fully utilize all the forms on this site. You can download software at: Free Adobe Reader Download. Forms on this site are available in several formats. Fillable pdf can be filled on-line, printed, saved and edited. XFT forms can be filled on-line, printed, and saved to your pc but cannot be edited later (TURN OFF YOUR POP-UP BLOCKER TO USE XFT). Some PDF are printable blank forms.
Forms for Providers
| Form | |
|---|---|
| SF-3881 Form * | Fillable (pdf) |
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* 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 |
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Forms for CHAMPVA Beneficiaries
| Form | |
|---|---|
| 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) |
Solicitudas para beneficios de CHAMPVA en Espanol
| Form | |
|---|---|
| Forma S10-10d Aplicación 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) |
Forms for Spina Bifida Beneficiaries
| Form | |
|---|---|
| Spina Bifida Miscellaneous Claim Form 10-7959e (not for providers) | Fillable (pdf) |
Forms for Foreign Medical Program (FMP)
| Form | |
|---|---|
| FMP Registration Form - VA Form 10-7959f-1 | Fillable (pdf) |
| FMP Claim Cover Sheet - VA Form 10-7959f-2 | Fillable (pdf) |
Authorization for Release of Medical Records and Release of Information
| Form | ||
|---|---|---|
| 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) |
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