Va 10 10D PDF Template

Va 10 10D PDF Template

The VA Form 10-10D is the application used to request CHAMPVA benefits, which provide healthcare coverage for eligible family members of veterans. This form is essential for individuals such as spouses and children of veterans who have been rated as having a permanent and total service-connected disability. To begin the application process, please fill out the form by clicking the button below.

Article Guide

The VA Form 10-10D, also known as the Application for CHAMPVA Benefits, plays a crucial role in providing healthcare benefits to eligible veterans' dependents. This form is essential for those who are seeking coverage under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). It is designed for spouses and children of veterans who have been rated as having a permanent and total service-connected disability, or for those who have died as a result of such a condition. To complete the form, applicants must provide detailed personal information, including their relationship to the veteran, social security numbers, and relevant health insurance details. Additionally, if applicants have Medicare or other health insurance, they must submit a separate form (VA Form 10-7959c) to ensure proper processing. The form also includes a certification section, where applicants affirm the accuracy of the information provided, highlighting the importance of honesty in the application process. Understanding the eligibility criteria and the necessary documentation is vital for a successful application, as it can significantly impact access to medical benefits. Overall, the VA Form 10-10D serves as a gateway for eligible individuals to receive essential healthcare services, ensuring that the sacrifices made by veterans are honored through support for their families.

Va 10 10D Preview

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
↓ Va 10 10D

File Properties

Fact Name Details
OMB Number 2900-0219
Estimated Burden 10 minutes
Expiration Date 01/31/2017
Governing Law 38 USC 501 and 1781
Purpose To determine eligibility for CHAMPVA benefits.
Eligibility Criteria Spouses and children of veterans rated permanently and totally disabled or who died from service-connected conditions.
Medicare Requirement If eligible for Medicare Part A, must also have Part B to be covered by CHAMPVA.
Certification Requirement Applicants must declare the truth of their statements under penalty of perjury.
Privacy Act Information Information collected is confidential and may be disclosed only under specific circumstances.

Instructions on Utilizing Va 10 10D

Completing the VA Form 10-10D is an important step in applying for CHAMPVA benefits. This form requires personal information about both the veteran and the applicant. Make sure to gather all necessary documents and information before starting the process to ensure accuracy and completeness.

  1. Obtain the VA Form 10-10D. You can find it online or request a paper form.
  2. Begin with Section I, which requires information about the veteran. Fill in the following details:
    • Last Name
    • First Name
    • Middle Initial
    • Social Security Number
    • VA File Number (Claim Number)
    • Street Address
    • City
    • State
    • Zip Code
    • Telephone Number (including area code)
    • Date of Birth (mm-dd-yyyy)
    • Date of Marriage (mm-dd-yyyy)
    • Indicate if the veteran is deceased and, if yes, provide the date of death.
  3. Proceed to Section II, which gathers information about the applicant. Complete the following for each applicant:
    • Last Name
    • First Name
    • Middle Initial
    • Social Security Number
    • Sex (Male/Female)
    • Email Address
    • Street Address
    • City
    • State
    • Zip Code
    • Telephone Number (including area code)
    • Date of Birth (mm-dd-yyyy)
    • Indicate if enrolled in Medicare and/or Other Health Insurance.
    • Specify the relationship to the veteran (e.g., spouse, child, stepchild).
  4. If additional applicants are included, repeat the information gathering for each one.
  5. In Section III, provide your signature and date to certify the information is accurate. If someone else is signing, include their details as well.
  6. Review the completed form for accuracy and completeness.
  7. Mail the form and any additional requested documents to the address provided on the form.

Important Facts about Va 10 10D

What is the VA Form 10-10D used for?

The VA Form 10-10D, also known as the Application for CHAMPVA Benefits, is utilized by eligible individuals to apply for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This program provides health care benefits to the spouses and children of veterans who are permanently and totally disabled due to a service-connected condition or who have died as a result of such a condition. Completing this form is the first step toward accessing these important health care benefits.

Who is eligible to apply for CHAMPVA benefits using this form?

Eligibility for CHAMPVA benefits is primarily focused on the relationship to the veteran. The following individuals can apply: the spouse or child of a veteran rated as having a permanent and total service-connected disability, the surviving spouse or child of a veteran who died from a service-connected condition, and the surviving spouse or child of a person who died in the line of duty. It's important to note that applicants must not be eligible for Department of Defense's TRICARE benefits to qualify for CHAMPVA.

What information is required on the VA Form 10-10D?

When filling out the VA Form 10-10D, applicants must provide comprehensive information. This includes details about the veteran, such as their name, Social Security number, VA file number, and address. Additionally, applicants must include their own personal information, including their relationship to the veteran, contact details, and date of birth. If the applicant has Medicare or other health insurance, they must also complete VA Form 10-7959c and attach the relevant insurance cards.

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

The estimated time to complete the VA Form 10-10D is about 10 minutes. This includes reviewing the instructions, gathering necessary information, and filling out the form. While this estimate provides a general guideline, the actual time may vary depending on the individual’s familiarity with the required information and their specific circumstances.

What should I do if my marital status changes after applying?

It's crucial to report any changes in marital status immediately to the CHAMPVA office. If a marriage is terminated by divorce or annulment, CHAMPVA eligibility ends as of midnight on the effective date of the dissolution. Keeping the CHAMPVA office informed helps ensure that benefits are accurately maintained and avoids potential issues with eligibility.

How can I submit the VA Form 10-10D?

The completed VA Form 10-10D can be submitted by mailing it to the Chief Business Office CHAMPVA at the specified address in Denver, Colorado. Alternatively, applicants can also fax the form to the provided fax number. It is important to ensure that all required sections are filled out completely to avoid delays in processing the application.

Common mistakes

Filling out the VA Form 10-10D can be a straightforward process, but many applicants make common mistakes that can lead to delays or denials of benefits. One frequent error is failing to complete the form in its entirety. Each section is important, and missing information can slow down the processing of your application.

Another mistake is not providing accurate personal information. This includes the veteran's name, Social Security number, and other identifying details. Ensure that all names are spelled correctly and that dates are entered in the correct format. Inaccuracies can lead to confusion and may require additional verification.

Many applicants overlook the requirement to submit additional forms when applicable. For instance, if you indicate that you have Medicare or other health insurance in Section II, you must also complete and attach VA Form 10-7959c. Failure to do so can result in a denial of your application.

In Section III, the certification must be signed and dated correctly. Some individuals forget to sign or date the form, which can cause delays. If someone other than the applicant is signing, that person's information must also be provided. This step is crucial to validate the application.

Another common issue is not providing supporting documents. If you are applying as a spouse or child, you may need to include proof of your relationship to the veteran. This could be a marriage certificate or birth certificate. Missing documentation can lead to complications in processing your application.

It is also important to check the expiration date of the form. Some applicants may use an outdated version, which can lead to unnecessary delays. Always ensure you are using the most current form available.

Additionally, applicants often forget to include contact information, such as a phone number or email address. This information is vital for the VA to reach you if they have questions or need further information.

Finally, many people do not keep a copy of the completed form for their records. Retaining a copy is essential in case you need to reference it later or if any issues arise with your application.

By being mindful of these common mistakes, applicants can improve their chances of a smooth application process and timely receipt of CHAMPVA benefits.

Documents used along the form

The VA Form 10-10D is an important document for individuals seeking CHAMPVA benefits. However, it is often accompanied by several other forms and documents that help establish eligibility and provide necessary information. Below is a list of these commonly used forms and documents.

  • VA Form 10-7959c: This form is required if the applicant has Medicare or other health insurance. It collects information about the applicant's health insurance coverage and must be submitted alongside the 10-10D form.
  • VA Form 21-534: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits. Surviving spouses and children of veterans may need to complete this form to establish eligibility for benefits related to the veteran's service-connected death.
  • VA Form 21-686c: This form is for reporting a change in dependency status. It is essential for applicants who have experienced changes in their marital status or number of dependents, as it affects eligibility for benefits.
  • VA Form 22-1990: This application is used for veterans seeking education benefits under the GI Bill. If the applicant is a dependent of a veteran, they may need to provide this form to access educational assistance.
  • School Certification Letter: This document is necessary for students aged 18 to 23 who wish to maintain their CHAMPVA benefits. It must confirm full-time enrollment in an accredited educational institution and include specific details about the student.

These forms and documents work together to ensure that applicants provide comprehensive information needed for the evaluation of their eligibility for CHAMPVA benefits. Proper submission of all required documentation can help streamline the process and avoid delays in receiving benefits.

Similar forms

  • VA Form 10-7959c: This form is used to report health insurance information when applicants have Medicare or other health insurance. Like the 10-10D form, it collects essential details to determine eligibility for benefits.
  • VA Form 21-526EZ: This is an application for disability compensation and related benefits. Similar to the 10-10D, it requires personal information and details about the applicant's relationship to the veteran.
  • VA Form 21-534EZ: This form is for survivors applying for dependency and indemnity compensation. It shares similarities with the 10-10D in that it focuses on eligibility based on the veteran's service-connected conditions.
  • VA Form 21-686c: This document is used to add dependents to a veteran’s benefits. Both forms require detailed information about the applicant's relationship to the veteran.
  • VA Form 22-1990: This is an application for education benefits. Like the 10-10D, it assesses eligibility and requires personal information from the applicant.
  • VA Form 21-8940: This form is for applying for a total disability based on individual unemployability. It collects information about the veteran’s service and disability status, similar to the 10-10D.
  • VA Form 21-526: This is a standard application for veterans seeking compensation for service-related injuries. It parallels the 10-10D in gathering personal and service-related information.
  • VA Form 10-10EZ: This is the application for health benefits for veterans. It is akin to the 10-10D in that it aims to determine eligibility for health care services.
  • VA Form 10-10SH: This form is used for applying for CHAMPVA benefits for certain survivors. It shares the goal of determining eligibility based on the veteran's service.
  • VA Form 10-10B: This application is for veterans seeking enrollment in the VA health care system. Like the 10-10D, it requires comprehensive information to assess eligibility for services.

Dos and Don'ts

When filling out the VA Form 10-10D for CHAMPVA benefits, it is crucial to follow specific guidelines to ensure a smooth application process. Below are seven important dos and don'ts to consider:

  • Do complete the form in its entirety. Ensure all sections are filled out accurately.
  • Don't leave any required fields blank. Incomplete forms may lead to delays in processing your application.
  • Do provide a valid Social Security number. This number is essential for processing your application.
  • Don't submit false or misleading information. Doing so can result in serious legal consequences.
  • Do attach any required documents, such as a copy of your Medicare card if applicable.
  • Don't forget to sign and date the application. Your signature is necessary to validate the form.
  • Do keep a copy of the completed form for your records. This can be helpful for future reference.

Following these guidelines will help facilitate the review of your application and ensure that you receive the benefits for which you may be eligible.

Misconceptions

Here are five common misconceptions about the VA Form 10-10D, which is used to apply for CHAMPVA benefits:

  • Only Veterans Can Apply: Many people believe that only veterans are eligible for CHAMPVA benefits. In reality, the spouse or child of a veteran with a permanent and total service-connected disability can also apply.
  • CHAMPVA Benefits Are Automatic: Some assume that if they meet the eligibility criteria, benefits will be granted without any further action. However, applicants must complete the VA Form 10-10D and submit it along with any required documentation.
  • Medicare Coverage Is Not Required: There is a misconception that having Medicare is not necessary for CHAMPVA eligibility. In fact, if you are under 65 and eligible for Medicare Part A, you must also have Part B to receive CHAMPVA benefits.
  • Divorce Has No Impact on Benefits: Some individuals think that divorce does not affect CHAMPVA eligibility. This is incorrect; if a qualifying spouse divorces the veteran, their eligibility ends on the date of the divorce.
  • Application Processing Is Quick and Easy: Many believe that submitting the form will lead to a quick approval. However, processing times can vary, and any missing information may delay the review of the application.

Key takeaways

Filling out the VA Form 10-10D, which is the application for CHAMPVA benefits, is an important step for eligible applicants. Here are some key takeaways to consider when completing and using this form:

  • Eligibility Criteria: Only certain individuals can apply for CHAMPVA benefits. This includes spouses and children of veterans who have been rated as having a permanent and total service-connected condition or disability.
  • Medicare Requirements: If you are eligible for Medicare, it is essential to have both Part A and Part B to maintain CHAMPVA coverage. This is particularly important for individuals under 65 years of age.
  • Completing the Form: It is crucial to fill out the VA Form 10-10D completely and accurately. Missing information can lead to delays or denial of benefits. If additional space is needed, another form can be submitted.
  • Certification of Information: When signing the form, applicants must certify that the information provided is true and accurate. Misrepresentation can lead to serious legal consequences.
  • Notification of Changes: If there are any changes in marital status or eligibility, such as divorce or annulment, it is necessary to report these changes immediately to CHAMPVA to maintain eligibility for benefits.

Understanding these key points can help ensure a smoother application process and better access to the benefits available through CHAMPVA.