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- Click ‘Get Form’ to open it in the editor.
- Begin with Section I: Beneficiary Information. Fill in your last name, first name, middle initial, sex, address, social security number, and phone number. If you have a new address, check the corresponding box.
- Proceed to Section II: Medicare Beneficiaries. Indicate whether you have Medicare Part A, B, or D by checking 'Yes' or 'No'. Attach a copy of your Medicare card if applicable.
- In Section III, provide details about any other health insurance coverage since becoming CHAMPVA eligible. Include effective and termination dates where necessary and attach copies of your insurance cards.
- Finally, complete Section IV: Certification by signing and dating the form. Ensure all information is accurate before submission.
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