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Keywords:formc;c;c;VAformc;CHAMPVAForms;CHAMPVAOtherHealthInsuranceForms;CHAMPVAOtherHealthInsurance;VeteranOther HealthInsurance;DepartmentofveteranAffairsOtherHealthInsurance;VAOtherHealthInsurances;VAbenefit;VeteranOtherHealthToapply,submitthese requireddocuments:ApplicationforCHAMPVABenefits(VAFormd),andNoICStatus:ModifiedObligationtoRespond:VoluntaryCFRCitationCFR InformationCollectionInstruments:FormNoFormNameInstrumentFileURLAvailableElectronically?Contactinformationfortheorganizationisavailableat theendIsthisaCommonForm?Schoolcertificationoffull-timeenrollmentforchildrenages–PleaserefertoYoudonotneedtodownloadanydocumentsto completeandToapplyforbenefits,sendthefollowingtotheVHAOficeofCommunityCare(VHACC):ApplicationforCHAMPVABenefits(VAFormd) CHAMPVAOtherHealthInsuranceCertification(VAFormc)AcopyofyourMedicarecard,ifyouarealsoeligibleforMedicarehealthinsurance,asignedand datedVAFormc,CHAMPVAOtherHealthInsurance(OHI)Certification,isrequired.DocumentsrelatedtoyourMedicarestatus:IfyouqualifyforMedicare foranyreason,you’llneedtosubmitacopyofyourMedicarecardVAFormd.Getreadyyourdocumentsontheinternetusingaprintabletemplateofthepaper. ReturntheformandanyadditionalrequestedinformationtotheaddressOtherHealthInsurance\(OHI\)CertificationFormChampVAProgramOffice,Officeof IntegratedVeteranCare,CHAMPVAEligibility,POBox,DenverCOCustomerServiceCenter|FAX:DownloadFillableVaFormcInPdfTheLatestVersion ApplicableForFillOutTheChampvaOtherHealthInsurance(ohi)CertificationOnlineAndPrintItOutForFreefordetailsSECTIONI:BENEFICIARY LookattheVAcOtherHealthInsuranceCertification(VAFormc),andFactSheetSchoolEnrollmentCertificationRequirementsforCHAMPVABenefitsOr youneedtoreportchangesinyourothernon-VAhealthinsurance,suchasnewbeneficiariesorcoveragechangeshealthinsurance,asignedanddatedVAForm c,CHAMPVAOtherHealthInsurance(OHI)Certification,isrequired.CanBeFormVAFormaCHAMPVABenefitsApplication,Claim,OtherHealth Insurance&PotentialLiabilityFormdayFRNCHAMPVABenefits pubpdfVAHealthCHAMPVAPOBoxDenver,COFAXAdministrationCenter EligibilityAttention:Pleasereviewtheinstructionsonthereversesideandthencompletethisforminitsentirety(printortypewrittenonly)VAHealthCHAMPVA POBoxDenver,COCustomerServiceCenterFAXAdministrationCenterEligibiltyAttention:Pleasereviewtheinstructionsonthereversesideandthen completethisforminitsentirety(printortypeonly)Schoolcertificationoffull-timeenrollmentforaboveperson,IagreetopromptlynotifyVA'sHealth AdministrationCenterVaFormcIsOftenUsedInVaForms,OtherHealthInsurance,ChampvaForms,PatientForms,HealthInsuranceForm,Us DepartmentOfVeteransAffairs,MedicalForms,Life,UnitedStatesFederalLegalVAFormCYou’reapplyingforCHAMPVA(CivilianHealthandMedical ProgramoftheDepartmentofVeteransAffairs),andhaveotherhealthinsurancetolareaspartofyourVAFormdapplication.Sendyourcompletepackageto OMBControlNoRespondentBurdenMinutesExpirationDate/31/APPLICATIONFORCHAMPVABENEFITSSign,datebelowandreturntotheaddressat thetopoftheform