Blank Va 10 10D Template

The VA Form 10-10D is an application used to request CHAMPVA benefits, which provide healthcare coverage for eligible family members of veterans. Completing this form accurately is essential for determining your eligibility and ensuring timely access to necessary medical services. If you are ready to apply, please fill out the form by clicking the button below.

Article Structure

The VA Form 10-10D, officially known as the Application for CHAMPVA Benefits, serves as a crucial document for individuals seeking healthcare coverage through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). Designed for the spouses and children of veterans with permanent and total service-connected disabilities, this form is essential for determining eligibility for benefits. Applicants must complete the form in its entirety, providing detailed information about both the veteran and the applicant. Key sections include sponsor information, where details about the veteran's service and status are recorded, and applicant information, which collects personal data from those applying for benefits. If the applicant has Medicare or other health insurance, additional documentation, such as the VA Form 10-7959c, must be submitted. The form also includes a certification section, where applicants affirm the accuracy of their information under penalty of perjury. It is important for applicants to be aware that changes in marital status can affect eligibility and should be reported promptly. With an estimated completion time of around 10 minutes, this form is a vital step in accessing necessary healthcare services for eligible family members of veterans.

Form Sample

OMB Number 2900-0219

Estimated Burden: 10 minutes

Expiration Date: 01/31/2017

Application for CHAMPVA Benefits

Chief Business Office	CHAMPVA	PO Box	Denver, CO	Customer Service Center	FAX
Purchased Care	Eligibility	469028	80246-9028	1-800-733-8387	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

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

Yes

If yes →

Date of Death (mm-dd-yyyy)

Did veteran die while

Yes

deceased?

If no go to sect. II

on active military service?

Section II - Applicant

Information (if

necessary, continue on additional 10-10d and complete in its entirety)

Last Name

First Name

Social Security Number

Sex

Male

Female

Email Address

Street Address

City

State

Zip Code

Telephone Number

Date of Birth

Enrolled in

Yes

Other Health

Yes

Relationship to the veteran

Medicare?

Insurance?

(i.e., spouse, child, stepchild)

(include area code)

(mm-dd-yyyy)

If yes, complete VA

Form

If yes, complete VA

Form

10-7959c and attach a copy of

Medicare Card

Insurance card

Last Name

First Name

Social

Security Number

Sex

Male

Female

Email Address

Street Address

City

State

Zip Code

Telephone Number

Date of Birth

Enrolled in

Yes

Other Health

Yes

Relationship to the veteran

Medicare?

Insurance?

(i.e., spouse, child, stepchild)

(include area code)

(mm-dd-yyyy)

If yes, complete VA

Form

10-7959c and attach a copy of

Medicare Card

Insurance card

Last Name

First Name

Social Security Number

Sex

Male

Female

Email Address

Street Address

City

State

Zip Code

Telephone Number

Date of Birth

Enrolled in

Yes

Other Health

Yes

Relationship to the veteran

Medicare?

Insurance?

(i.e., spouse, child, stepchild)

(include area code)

(mm-dd-yyyy)

If yes, complete VA

Form

If yes, complete VA

Form

10-7959c and attach a copy of

Medicare Card

Insurance card

Section III - Certification

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious, or fraudulent statements or claims

I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any

Signature

Date

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:

Last Name

First Name

Telephone Number (include area code)

Relationship to Applicant(s)

Street Address

City

State

Zip Code

VA FORM

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED

JUL 2014 10-10d

Page 2 of 3

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.

Application for CHAMPVA Benefits – Important Notes and Definitions

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.

VA FORM JUL 2014 10-10d

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED

Application for CHAMPVA Benefits – Important Notes and Definitions

Page 3 of 3

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.

VA FORM JUL 2014 10-10d

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED

⇩ PDF

Document Specifications

Fact Name	Description
OMB Number	The OMB Number for the VA Form 10-10D is 2900-0219.
Estimated Burden	It is estimated that completing the form takes approximately 10 minutes.
Expiration Date	The form is set to expire on January 31, 2017.
Submission Address	Completed forms should be sent to the Chief Business Office CHAMPVA, PO Box 469028, Denver, CO 80246-9028.
Eligibility Criteria	Eligible applicants include spouses and children of veterans with a permanent and total service-connected disability.
Medicare Requirement	If eligible for Medicare, individuals must have Part B to qualify for CHAMPVA benefits.
Privacy Act	The collection of information is authorized under 38 USC 501 and 1781, ensuring confidentiality.
Certification	Applicants must certify the accuracy of the information under penalty of perjury, as per federal law.

Steps to Filling Out Va 10 10D

Filling out the VA Form 10-10D is an important step for those seeking CHAMPVA benefits. Once you have completed the form, it will need to be submitted to the appropriate address along with any additional requested documentation. Ensure that all sections are filled out accurately to avoid delays in processing your application.

Begin with Section I - Sponsor Information. Fill in the veteran's last name, first name, and middle initial.
Enter the veteran's Social Security Number and VA File Number (Claim Number).
Provide the veteran's street address, city, state, and zip code.
Include a telephone number with the area code.
Fill in the veteran's date of birth (mm-dd-yyyy) and date of marriage (mm-dd-yyyy).
Indicate if the veteran is deceased. If yes, provide the date of death (mm-dd-yyyy). If no, proceed to Section II.

Move to Section II - Applicant Information. If there are multiple applicants, continue on additional forms as necessary.
For each applicant, enter their last name, first name, and middle initial.
Provide the applicant's Social Security Number and indicate their sex (Male or Female).
Include the applicant's email address and street address, city, state, and zip code.
Fill in the applicant's telephone number with the area code and date of birth (mm-dd-yyyy).
Indicate if the applicant is enrolled in Medicare and if they have other health insurance. If yes to either, complete VA Form 10-7959c and attach the necessary cards.

In Section III - Certification, read the certification statement carefully.
Sign and date the form in the designated area.
If someone other than the applicant is signing, provide their last name, first name, middle initial, telephone number, relationship to the applicant(s), and their address.

After completing the form, review all entries for accuracy. Once confirmed, send the form and any required attachments to the address provided on the form. Be sure to keep a copy for your records.

More About Va 10 10D

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

The VA Form 10-10D is an application for CHAMPVA benefits. This form is used by eligible dependents of veterans to apply for health care coverage under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). It helps determine eligibility for benefits based on the veteran's service-connected conditions.

Who is eligible to apply using the VA Form 10-10D?

Eligibility for CHAMPVA benefits extends to the spouse or child of a veteran who has been rated as having a permanent and total service-connected condition. It also includes the surviving spouse or child of a veteran who died from a service-connected condition or while rated permanently and totally disabled. Additionally, dependents of individuals who died in the line of duty may also qualify.

What information is required to complete the VA Form 10-10D?

Applicants must provide personal information such as their name, Social Security number, date of birth, and relationship to the veteran. The form also requires details about the veteran, including their name, Social Security number, and VA file number. If applicable, information about other health insurance and Medicare enrollment must be included.

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

If you have Medicare or any other health insurance, you must complete VA Form 10-7959c and attach a copy of your Medicare card or insurance card. This is necessary for each applicant listed on the 10-10D form who has additional coverage.

How do I submit the completed VA Form 10-10D?

Once the form is completed, it should be mailed to the Chief Business Office CHAMPVA at the address provided on the form. Alternatively, you can also fax the form to the number listed. Ensure that all sections are filled out completely to avoid delays in processing.

What happens if my marital status changes after applying?

If your marriage ends due to divorce or annulment, your CHAMPVA eligibility will terminate as of the effective date of the dissolution. It is important to report any changes in marital status immediately to CHAMPVA to ensure your benefits are accurately managed.

Common mistakes

Incomplete Information: One of the most common mistakes is failing to fill out all required sections of the VA Form 10-10D. Each section must be completed in its entirety. Missing information can delay processing or lead to denial of benefits.
Incorrect Social Security Numbers: Applicants often make errors when entering Social Security numbers. Double-checking this information is crucial, as an incorrect number can cause significant delays in the application process.
Not Submitting Required Attachments: If the applicant or veteran has Medicare or other health insurance, it is essential to submit the VA Form 10-7959c along with the 10-10D form. Failing to include these documents may result in a denial of the application.
Ignoring Certification Requirements: The certification section must be signed and dated. If someone other than the applicant is signing, their relationship to the applicant must be clearly stated. Omitting this information can lead to complications or rejection of the application.

Documents used along the form

When applying for CHAMPVA benefits using the VA Form 10-10D, it's essential to be aware of additional forms and documents that may be required to complete your application. These documents help ensure that your eligibility is accurately assessed and can expedite the process. Here’s a brief overview of six important forms that often accompany the VA 10-10D form.

VA Form 10-7959c: This form is necessary if the applicant has Medicare or other health insurance. It provides details about the applicant's insurance coverage, which is crucial for determining benefits.
VA Form 10-10EZ: This is the application for health benefits that veterans may need to complete. It helps establish eligibility for various VA health care services.
VA Form 21-534: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits for surviving spouses and children of veterans who died from service-related conditions.
VA Form 21-686c: This form is used to report changes in dependency status, such as adding or removing dependents. Keeping this information updated is vital for maintaining eligibility for benefits.
VA Form 21-22: This is the Appointment of Veterans Service Organization as Claimant's Representative form. It allows applicants to designate a representative to assist them in navigating the claims process.
School Certification: If the applicant is a child aged 18 to 23, a school certification is required to verify full-time enrollment in an educational institution. This documentation is essential for extending benefits during their education.

Completing the VA Form 10-10D and submitting the necessary accompanying documents is crucial for a smooth application process. Ensure that all forms are filled out accurately and submitted promptly to avoid delays in receiving your CHAMPVA benefits. Staying organized and proactive can make a significant difference in your experience.

Similar forms

The VA Form 10-10D, which is used to apply for CHAMPVA benefits, shares similarities with the Medicare Application Form (CMS-10106). Both documents require applicants to provide personal information, including Social Security numbers and details about any existing health insurance coverage. The Medicare Application Form also assesses eligibility for benefits based on criteria that include age and disability status. Like the 10-10D, it emphasizes the need for accurate information, as any discrepancies can lead to delays or denials of benefits.

Another document that resembles the VA Form 10-10D is the VA Form 21-526EZ, which is used to apply for disability compensation. Both forms collect personal information from the applicant and require documentation to support claims. The 21-526EZ focuses on the veteran’s service-connected disabilities, while the 10-10D addresses eligibility for healthcare benefits. Both forms aim to ensure that applicants meet specific criteria before benefits are granted, thus streamlining the approval process.

The VA Form 10-10D is also similar to the VA Form 21-534EZ, which is used by surviving spouses and dependents to apply for Dependency and Indemnity Compensation (DIC). Both forms require the applicant to provide information about their relationship to the veteran and any existing insurance coverage. The 21-534EZ specifically addresses eligibility based on the veteran's death, while the 10-10D focuses on healthcare benefits. Each form plays a critical role in determining eligibility for different types of VA benefits.

In addition, the VA Form 10-10D has parallels with the VA Form 10-7959c, which is used to report other health insurance coverage. Both forms require detailed information about health insurance plans, including policy numbers and coverage details. The 10-7959c is often submitted alongside the 10-10D when applicants indicate they have other insurance. This ensures that the VA can coordinate benefits effectively, minimizing out-of-pocket expenses for applicants.

The VA Form 10-10D is akin to the Form 10-10EZ, which is used for applying for VA health care benefits. Both forms collect similar information regarding the applicant’s demographics and health insurance status. However, the 10-10EZ is typically used for first-time applications for health care, while the 10-10D is specifically for CHAMPVA benefits. Each form serves to assess eligibility for different aspects of VA health services.

Lastly, the VA Form 10-10D is comparable to the VA Form 10-10164, which is a request for a copy of medical records. Both forms require personal identification information and aim to facilitate the processing of benefits or claims. While the 10-10D focuses on eligibility for CHAMPVA benefits, the 10-10164 is concerned with obtaining medical documentation necessary for various VA-related purposes. Each form is essential in ensuring that applicants receive the appropriate benefits and services they are entitled to.

Dos and Don'ts

When filling out the VA Form 10-10D for CHAMPVA benefits, there are several important dos and don’ts to keep in mind. Following these guidelines can help ensure a smoother application process.

Do read the instructions carefully before starting the form.
Do fill out the form completely, ensuring all sections are addressed.
Do provide accurate information, especially your Social Security number and veteran details.
Do submit any additional requested documents, such as Medicare cards if applicable.
Don’t leave any sections blank; if a question doesn’t apply, indicate that clearly.
Don’t forget to sign and date the form before submission.
Don’t submit the form without making a copy for your records.

By adhering to these guidelines, you can help facilitate the review process and avoid unnecessary delays in receiving your benefits.

Misconceptions

Understanding the VA Form 10-10D is essential for those seeking CHAMPVA benefits. However, several misconceptions can lead to confusion. Here are six common misunderstandings regarding this form:

Misconception 1: The VA Form 10-10D is only for veterans.

This form is actually for the dependents of veterans, such as spouses and children, who are seeking CHAMPVA benefits. Veterans themselves do not apply using this form.

Misconception 2: Submitting the form guarantees benefits.

While the form is necessary for applying, it does not guarantee approval. Eligibility is determined based on specific criteria outlined by the VA.

Misconception 3: You do not need to provide additional documentation.

If you or your dependents have Medicare or other health insurance, you must submit additional forms, such as VA Form 10-7959c, along with your application.

Misconception 4: The form can be completed in any format.

It is important to fill out the VA Form 10-10D completely and clearly, using either print or type. Incomplete forms may lead to delays or denial of benefits.

Misconception 5: Changes in marital status do not affect eligibility.

Changes such as divorce or annulment can impact CHAMPVA eligibility. It is crucial to report any changes in marital status immediately to avoid complications.

Misconception 6: The application process is quick and straightforward.

While the estimated burden for completing the form is around 10 minutes, the overall process may take longer due to verification and eligibility checks. Patience is important during this time.

Being aware of these misconceptions can help applicants navigate the process more effectively and ensure they are taking the right steps to secure the benefits they may be entitled to.

Key takeaways

Key Takeaways for Filling Out and Using the VA Form 10-10D

Ensure you complete the form in its entirety, using either print or type. Missing information can lead to delays or denial of benefits.
If you have Medicare or other health insurance, you must submit VA Form 10-7959c along with your application.
Changes in marital status, such as divorce or annulment, affect CHAMPVA eligibility. Report these changes immediately to avoid complications.
For students aged 18 to 23, a school certification is required to maintain benefits. This certification must confirm full-time enrollment and be submitted regularly.