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Content Overview

The VA Form 10-10D serves as a crucial application for individuals seeking CHAMPVA benefits, a program designed to provide health care coverage for eligible family members of veterans. This form requires applicants to furnish essential information about both the veteran and the applicant, including names, social security numbers, and addresses. It is imperative that the form is completed in its entirety, as any missing details could delay the processing of benefits. The application also includes sections that address the veteran's status, including whether they are deceased or currently on active military service. Additionally, if the applicant has Medicare or other health insurance, they must submit a supplementary form, VA Form 10-7959c, to ensure comprehensive coverage. The certification section emphasizes the importance of accuracy, as submitting false information can lead to serious legal consequences. Understanding the eligibility criteria is vital; applicants must meet specific conditions related to the veteran’s service-connected disabilities or death. Moreover, the form outlines the impact of Medicare on CHAMPVA eligibility, particularly for individuals aged 65 and older. By navigating the requirements of the VA Form 10-10D, applicants can take significant steps toward securing the health care benefits they need.

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Application for CHAMPVA Benefits
Chief Business Office
Purchased Care
CHAMPVA
Eligibility
PO Box
469028
Denver, CO
80246-9028
Customer Service Center
1-800-733-8387
FAX
303-331-7809
Attention: Please review the instructions on the reverse side and then complete this form in its entirety (print or type only). Return the form and any additional requested information to the address shown
above. If applicants indicate in Section II that they have Medicare or Other Health Insurance, each applicant must submit a VA Form 10-7959c. If additional space is needed complete another 10-10d
Application for CHAMPVA Benefits, submit and sign.
Section I - Sponsor Information
Veteran's Last Name First Name
MI
Social Security Number
VA File Number (Claim Number)
Street Address
City State Zip Code
Telephone Number (include area code)
Date of Birth (mm-dd-yyyy)
Date of Marriage (mm-dd-yyyy)
Is veteran
deceased?
No
Yes
If yes →
If no go to sect. II
Date of Death (mm-dd-yyyy)
Did veteran die while
on active military service?
No
Yes
Section II - Applicant Information (if necessary, continue on additional 10-10d and complete in its entirety)
Last Name
First Name
MI Social Security Number
Sex
Female
Male
Email Address
Street Address
City
State
Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Last Name
First Name
MI Social Security Number
Sex
Female
Male
Email Address
Street Address
City State Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Last Name
First Name
MI Social Security Number
Sex
Female
Male
Email Address
Street Address
City State Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Section III - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious, or fraudulent statements or claims
Signature
X
Date
Last Name
First Name
MI
Telephone Number (include area code)
Relationship to Applicant(s)
Street Address City State Zip Code
VA FORM
JUL 2014
10-10d
OMB Number 2900-0219
Estimated Burden: 10 minutes
Expiration Date: 01/31/2017
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED
I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any
materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or
imprisonment pursuant to title 18, United States Code, Sections 287 and 1001 (Sign and date on right). If certification is signed
by a person other than an applicant, complete the following:
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: Eligibility Unit, PO Box 469028, Denver, CO
80246-9028 or call 1-800-733-8387.
Privacy Act Information: The authority for collection of the requested information on this form is 38
USC 501 and 1781. The purpose of collecting this information is to determine your eligibility for
CHAMPVA benefits. The information you provide may be verified by a computer matching program at
any time. You are requested to provide your social security number as your VA record is filed and
retrieved by this number. You do not have to provide the requested information on this form but if any or
all of the requested information is not provided, it may delay or result in denial of your request for
CHAMPVA benefits. Failure to furnish the requested information will have no adverse impact on any
other VA benefit to which you may be entitled. The responses you submit are considered confidential
and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the
routine uses identified in the VA system of records number 54VA16, titled "Health Administration Center
Civilian Health and Medical Program Records -VA", as set forth in the Compilation of Privacy Act
Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html
. For example,
information including your Social Security number may be disclosed to contractors, trading partners,
health care providers and other suppliers of health care services to determine your eligibility for medical
benefits and payment for services.
The Paperwork Reduction Act: This information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this
collection of information is estimated to average 10 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Comments regarding this burden estimate or any
other aspect of this collection, including suggestions for reducing the burden, may be addressed by
calling the CHAMPVA Help Line, 800-733-8387. Respondents should be aware that nothwithstanding
any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number. The purpose of this
data collection is to determine eligibility for CHAMPVA benefits.
CHAMPVA Eligibility Criteria
The following persons are eligible for CHAMPVA benefits, providing they are NOT eligible for
DoD's TRICARE benefits:
• the spouse or child of a veteran who has been rated by a VA regional office as having a
permanent and total service-connected condition/disability;
• the surviving spouse or child of a veteran who died as a result of a VA-rated service-
connected condition; or who, at the time of death, was rated permanently and totally
disabled from a service-connected condition; and
• the surviving spouse or child of a person who died in the line of duty and not due to
misconduct.
Medicare Impact. If you are eligible or become eligible for Medicare Part A and you are under age 65,
you MUST have Part B to be covered by CHAMPVA. Effective October 1, 2001, CHAMPVA benefits
were extended to beneficiaries age 65 or older. If you are eligible for Medicare Part A and you are age
65 or older, you are required to have Part B to be covered by CHAMPVA if your 65th birthday was on or
after June 5, 2001, or if you were already enrolled in Part B prior to June 5, 2001.
Page 2 of 3
Application for CHAMPVA Benefits – Important Notes and Definitions
VA FORM JUL 2014 10-10d
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED
Eligibility Definitions
Service-connected condition/disability – Refers to a VA determination that a veteran's illness or
injury was incurred or aggravated while on active duty in military service and resulted in some degree of
disability.
Sponsor – Refers to the veteran upon whom CHAMPVA eligibility for the applicant is based.
Spouse –
Refers to a person who is married to or is a widow(er) of an eligible CHAMPVA sponsor. If you are
certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the
place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse reside
when you file your claim (or at a later date when you become eligible for benefits) (38 U.S.C. 103(c)). Additional
guidance on when VA recognizes marriages is available at
http://www.va.gov/opa/marriage/. If the spouse
remarries prior to age 55, CHAMPVA benefits end on the date of the remarriage. Effective February 4, 2003, if
the spouse remarries on or after age 55, CHAMPVA benefits continue. Additionally, in some instances, a
remarried surviving spouse whose remarriage is either terminated by death, divorce or annulment is CHAMPVA
eligible when supported by a copy of the appropriate documentation (death certificate/divorce decree/annulment
certification).
Child – Includes legitimate, adopted, illegitimate, and stepchildren. To be eligible, the child must be
unmarried and: 1) under the age of 18; or 2) who, before reaching age 18, became permanently
incapable of self-support as rated by a VA regional office; or 3) who, after reaching age 18 and
continuing up to age 23, is enrolled in a full-time course of instruction at an approved educational
institution---school certification required (see below).
NOTE: Except for stepchildren, the eligibility of children is not affected by divorce or remarriage of
the spouse or surviving spouse.
School Certification
In order to extend CHAMPVA benefits to students age 18 to 23, school certification of full-time
enrollment must be submitted by the college, vocational or high school, etc. Student status for
CHAMPVA purposes is established up to a full school term based on the initial enrollment letter from the
accredited education institution, that is, four years (4) for traditional schooling programs, two years (2) for
technical schooling programs. School certification for each term or a full year is required for
recertification of full time attendance until graduation or age 23. For high schools, this period is the
normal beginning and ending school year.
School certification letters should be on school letterhead and include:
• Student's full name
• Student's Social Security number (SSN)
• Exact beginning date and projected graduation date
• Number of semester hours or equivalent (high schools excluded)
• Certification of full-time status
School generated forms are acceptable as long as they provide the above information. While
certifications submitted in a foreign language are acceptable, additional time will be required for
translation. Certifications may be submitted by mail to the address on the front or by FAX
to 1-303-331-7809.
NOTE: It is important to notify the Chief Business Office Purchased Care of any change in student
status such as withdrawal or change from full-time to part-time status. School vacation periods,
holidays, and summer breaks (providing the student attends school on a full-time basis both before and
after the summer break) are not considered an interruption in full-time attendance and will not create a
break in CHAMPVA eligibility.
Application for CHAMPVA Benefits – Important Notes and Definitions
Page 3 of 3
VA FORM JUL 2014 10-10d
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The VA Form 10-10D is used to apply for CHAMPVA benefits.
OMB Number The OMB Number for this form is 2900-0219.
Estimated Time Completing the form typically takes about 10 minutes.
Expiration Date The form expired on January 31, 2017.
Eligibility Criteria Eligible applicants include spouses and children of veterans with service-connected disabilities.
Additional Requirements If applicants have Medicare or other health insurance, they must submit VA Form 10-7959c.
Submission Address Forms should be sent to CHAMPVA, PO Box 469028, Denver, CO 80246-9028.
Governing Law The collection of information is governed by 38 USC 501 and 1781.
Privacy Act Information provided is confidential and may be disclosed only under the Privacy Act.
Impact of Divorce Divorce from the qualifying sponsor ends CHAMPVA eligibility immediately.

Va 10 10D: Usage Guidelines

Completing the VA Form 10-10D is an essential step in applying for CHAMPVA benefits. Once the form is filled out accurately, it should be returned to the designated address for processing. Ensure all required information is provided to avoid delays in your application.

  1. Begin with Section I, Sponsor Information. Fill in the veteran's last name, first name, and middle initial.
  2. Enter the veteran's Social Security Number and VA File Number (Claim Number).
  3. Provide the veteran's street address, city, state, and zip code.
  4. Include a telephone number with area code and the veteran's date of birth in mm-dd-yyyy format.
  5. Fill in the date of marriage in mm-dd-yyyy format.
  6. Indicate if the veteran is deceased by selecting "Yes" or "No." If yes, provide the date of death in mm-dd-yyyy format.
  7. Answer whether the veteran died while on active military service by selecting "Yes" or "No." If no, proceed to Section II.
  1. In Section II, Applicant Information, fill in the last name, first name, and middle initial of the applicant.
  2. Provide the applicant's Social Security Number and select the gender (Male or Female).
  3. Enter the applicant's email address and street address, including city, state, and zip code.
  4. Include a telephone number with area code and the applicant's date of birth in mm-dd-yyyy format.
  5. Indicate if the applicant is enrolled in Medicare by selecting "Yes" or "No."
  6. State whether the applicant has other health insurance by selecting "Yes" or "No." If yes, complete VA Form 10-7959c and attach a copy of the insurance card.
  7. Repeat this process for additional applicants as necessary, using a new 10-10D form if needed.
  1. In Section III, Certification, read the statement carefully.
  2. Sign and date the form. If someone else is signing on behalf of the applicant, provide their last name, first name, middle initial, telephone number, relationship to the applicant, and their address.

Once completed, send the form along with any additional requested documents to the address provided. Keep a copy for your records. Following these steps ensures a smoother application process for CHAMPVA benefits.

Your Questions, Answered

What is the VA Form 10-10D?

The VA Form 10-10D is an application for CHAMPVA benefits. CHAMPVA, or the Civilian Health and Medical Program of the Department of Veterans Affairs, provides health care benefits to eligible dependents of veterans. This form is essential for those seeking to apply for these benefits.

Who is eligible to apply for CHAMPVA benefits?

Eligibility for CHAMPVA benefits extends to the spouse or child of a veteran who has a permanent and total service-connected condition. It also includes the surviving spouse or child of a veteran who died due to a service-connected condition. Additionally, children of a person who died in the line of duty may also qualify, provided they meet specific criteria.

How do I complete the VA Form 10-10D?

To complete the VA Form 10-10D, follow the instructions carefully. Fill out all sections accurately, using either printed or typed text. If you need more space, you can submit additional forms. Ensure that you provide all requested information to avoid delays in processing your application.

What should I do if I have Medicare or other health insurance?

If you have Medicare or other health insurance, you must submit a VA Form 10-7959c along with your 10-10D application. This form provides necessary details about your other health coverage, which is crucial for determining your eligibility for CHAMPVA benefits.

What happens if my marital status changes?

Changes in marital status, such as divorce or annulment, can affect your CHAMPVA eligibility. If you terminate your marriage to the qualifying sponsor, your eligibility ends at midnight on the effective date of the dissolution. It is important to report such changes immediately to CHAMPVA.

How long does it take to process the VA Form 10-10D?

The estimated burden for completing the VA Form 10-10D is about 10 minutes. However, processing times can vary based on the volume of applications and the completeness of the submitted information. Ensure that all required documents are included to help expedite the process.

What information is required on the form?

The form requires personal information such as the veteran's name, Social Security number, and details about the applicant, including their relationship to the veteran. You must also provide contact information and, if applicable, details regarding other health insurance coverage.

Where do I send the completed VA Form 10-10D?

Once you have completed the VA Form 10-10D, send it to the Chief Business Office CHAMPVA at the address provided on the form: PO Box 469028, Denver, CO 80246-9028. You can also contact their customer service center at 1-800-733-8387 for assistance.

Common mistakes

  1. Incomplete Information: Failing to fill out all required fields can lead to delays. Ensure that every section is completed, especially personal details like Social Security numbers and dates of birth.

  2. Incorrect Sponsor Details: Entering inaccurate information about the veteran can cause complications. Double-check the veteran's name, Social Security number, and VA file number.

  3. Missing Required Attachments: If applicable, do not forget to include the VA Form 10-7959c for those with Medicare or other health insurance. Missing this form can result in denial of benefits.

  4. Not Signing the Form: A signature is mandatory. Failing to sign the certification section will render the application invalid.

  5. Incorrect Relationship Designation: Misidentifying your relationship to the veteran can lead to ineligibility. Clearly indicate whether you are a spouse, child, or stepchild.

  6. Outdated Information: Using outdated forms or not updating personal information, such as a change in marital status, can affect eligibility. Always ensure the most current version of the form is used.

  7. Ignoring Instructions: Overlooking the instructions on the reverse side can lead to mistakes. Review them carefully to avoid common pitfalls.

  8. Submitting Without a Copy: Not keeping a copy of the submitted form can create issues later. Always retain a copy for your records.

Documents used along the form

The VA Form 10-10D is essential for applying for CHAMPVA benefits. However, several other forms and documents may be required to support the application process. Understanding these documents can help streamline the submission and ensure all necessary information is provided.

  • VA Form 10-7959c: This form is required for applicants who have Medicare or other health insurance. It collects information about the applicant's additional coverage, which is crucial for determining eligibility for CHAMPVA benefits.
  • VA Form 21-534: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits. Surviving spouses and children of veterans who died due to service-related conditions may need this form to claim benefits.
  • VA Form 21-686c: This document is necessary for reporting changes in dependency status. Applicants must use it to update the VA about any changes, such as the birth of a child or changes in marital status.
  • VA Form 21-4142: This form allows applicants to authorize the release of medical records and other information from healthcare providers. It is often needed to support claims for benefits.
  • VA Form 21-22: This form is used to appoint a representative to assist with VA claims. It is important for applicants who wish to have someone help navigate the benefits process.
  • VA Form 21-527EZ: This form is for veterans applying for pension benefits. It may be relevant for applicants seeking additional financial support alongside CHAMPVA benefits.
  • School Certification: For dependents aged 18 to 23, a school certification is required to confirm full-time enrollment in an educational institution. This document ensures continued eligibility for CHAMPVA benefits.

Each of these documents plays a significant role in the application process for CHAMPVA benefits. Ensuring that all necessary forms are completed accurately can help prevent delays and facilitate a smoother experience for applicants.

Similar forms

  • VA Form 10-7959c: This form is required for applicants who have Medicare or other health insurance. It collects similar information regarding health coverage to ensure proper coordination of benefits.
  • VA Form 10-10EZ: This form is used for enrolling in the VA health care system. It shares the purpose of determining eligibility but is focused on general health care benefits rather than CHAMPVA specifically.
  • VA Form 21-526EZ: This application is for disability compensation and pension benefits. Like the 10-10D, it requires personal information about the applicant and their relationship to the veteran.
  • VA Form 21-534EZ: This form is for survivors seeking dependency and indemnity compensation (DIC). It also collects information about the deceased veteran and the survivor's relationship, similar to the CHAMPVA application.
  • VA Form 10-10SH: This form is used for applying for CHAMPVA benefits for surviving spouses and children of veterans. It gathers similar demographic and eligibility information.
  • VA Form 21-686c: This is used for reporting the status of dependents. It complements the 10-10D by ensuring that all dependents are accurately reported for benefits eligibility.
  • VA Form 10-10B: This form is for veterans applying for a VA health care benefits package. It serves a similar purpose in determining eligibility but is not specifically for CHAMPVA.

Dos and Don'ts

When filling out the VA Form 10-10D for CHAMPVA benefits, it is essential to follow specific guidelines to ensure the application is processed smoothly. Below is a list of six things you should and shouldn't do during this process.

  • Do complete the form in its entirety, using either print or type.
  • Do ensure all personal information, including names and Social Security numbers, is accurate.
  • Do submit the form along with any additional requested documentation, such as Medicare cards.
  • Do keep a copy of the completed form for your records.
  • Don't leave any sections blank; if more space is needed, attach additional sheets.
  • Don't forget to sign and date the form before submission.

Following these guidelines will help facilitate the processing of your application and avoid potential delays.

Misconceptions

Understanding the VA Form 10-10D is crucial for those seeking CHAMPVA benefits. However, several misconceptions can lead to confusion. Here are five common misunderstandings:

  • Misconception 1: The form is only for veterans.

    • This is incorrect. The VA Form 10-10D is intended for the spouses and children of veterans who meet specific eligibility criteria, not just the veterans themselves.

  • Misconception 2: You do not need to submit additional forms.

    • In fact, if applicants have Medicare or other health insurance, they must also complete and submit VA Form 10-7959c. This is essential for processing the application.

  • Misconception 3: CHAMPVA benefits are automatically granted.

    • Eligibility must be established through the application process. Simply filling out the form does not guarantee benefits; applicants must meet specific criteria.

  • Misconception 4: There is no deadline for submitting the form.

    • While there is no strict deadline, delays in submission can result in a delay or denial of benefits. It is advisable to submit the form promptly.

  • Misconception 5: You can skip sections if they do not apply.

    • Every section of the form must be completed in its entirety, even if some parts do not apply to the applicant. Incomplete forms can lead to processing delays.

Key takeaways

When filling out and using the VA Form 10-10D for CHAMPVA benefits, it is essential to understand the following key points:

  • Eligibility Criteria: Ensure that the applicant meets the eligibility requirements for CHAMPVA benefits, which include being a spouse or child of a veteran rated with a permanent and total service-connected disability.
  • Correct Completion: Complete the form in its entirety, using either print or type. Incomplete forms may delay processing.
  • Medicare Requirements: If the applicant has Medicare, they must also submit VA Form 10-7959c, along with a copy of their Medicare card.
  • Certification: The form requires a signature certifying that the information provided is accurate. False statements can lead to penalties.
  • Submission Address: Send the completed form and any additional requested information to the specified address in Denver, CO.
  • Change in Status: Report any changes in marital status immediately, as divorce or annulment can affect CHAMPVA eligibility.
  • Privacy Concerns: Understand that the information provided is confidential and may be shared only under specific conditions as outlined in the Privacy Act.
  • Time Commitment: Filling out the form typically takes about 10 minutes, so plan accordingly.
  • School Certification: For children aged 18 to 23, submit school certification to confirm full-time enrollment to maintain eligibility.
  • Communication: If there are questions or concerns, contact the CHAMPVA Help Line at 1-800-733-8387 for assistance.

These takeaways should help guide applicants through the process of applying for CHAMPVA benefits using the VA Form 10-10D. Proper understanding and completion of the form can significantly impact eligibility and access to necessary health care services.