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This claim form is NOT to be used for provider submitted claims. Other health insurance OHI If OHI exists attach OHI s Explanation of Benefits EOB to the provider s itemized billing statement s. Relationship to Patient VA FORM NOV 2006 10-7959a Appendix Notice Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the dissolution of marriage. Changes in status should be reported immediately to CHAMPVA ATTN...
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The OMB number 2900-0219 is assigned to a specific form or information collection approved by the Office of Management and Budget.
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