United States Department of Veterans Affairs


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Forms for Providers

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

Forms for CHAMPVA Beneficiaries

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)
CHAMPVA School Certificate Form Print-Only (pdf)

Forms for Spina Bifida Beneficiaries

Spina Bifida Miscellaneous Claim Form 10-7959e (not for providers) Fillable (pdf)

Forms for Foreign Medical Program (FMP)

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

Authorization Form VA Form10-5345
Note: Only use this form for one time release of information.
Fillable (pdf)

Solicitudes para beneficios de CHAMPVA en Espanol

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)

Solicitudes para beneficios de Espina Bifida

Forma S10-7959e Reclamo de Gastos Miscelaneos Fillable (pdf)