The VA Form 10-10D is an application for CHAMPVA benefits, designed to assist eligible dependents of veterans in accessing healthcare services. This form is crucial for those who are not eligible for DoD's TRICARE benefits and need to provide necessary information about the veteran and the applicant. Completing this form accurately is essential to ensure timely processing of your application; start filling it out by clicking the button below.
The VA Form 10-10D, officially known as the Application for CHAMPVA Benefits, serves as a crucial document for individuals seeking healthcare benefits through the Department of Veterans Affairs. This form is specifically designed for the spouses and children of veterans who have been rated with a permanent and total service-connected disability or who have died as a result of such conditions. The application process requires detailed information about both the veteran and the applicant, including names, Social Security numbers, and relationship to the veteran. Additionally, if the applicant has Medicare or other health insurance, they must complete a separate form, VA Form 10-7959c, to provide further details. The form includes sections for the sponsor's information, the applicant's information, and a certification statement that affirms the accuracy of the provided information. It is important for applicants to be aware that any inaccuracies can lead to penalties under federal law. Moreover, changes in marital status, such as divorce, can impact CHAMPVA eligibility, necessitating timely communication with the VA. The form is estimated to take about ten minutes to complete and must be returned to the designated address for processing. Understanding the requirements and implications of this form is essential for those navigating the benefits available to them through CHAMPVA.
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
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
Yes
If yes →
Date of Death (mm-dd-yyyy)
Did veteran die while
deceased?
No
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
Sex
Male
Female
Email Address
Telephone Number
Date of Birth
Enrolled in
Other Health
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
Social
Security Number
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
X
by a person other than an applicant, complete the following:
Relationship to Applicant(s)
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
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.
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
Completing the VA Form 10-10D is a straightforward process, but it requires careful attention to detail. Once you fill out the form, you'll need to return it to the designated address along with any necessary additional information. This ensures that your application for CHAMPVA benefits can be processed efficiently.
After completing all sections, review the form for accuracy. Make sure all required attachments are included before mailing it to the specified address. This will help prevent any delays in processing your application.
What is the VA Form 10-10D used for?
The VA Form 10-10D is the application for CHAMPVA benefits. CHAMPVA, or the Civilian Health and Medical Program of the Department of Veterans Affairs, provides health care benefits to eligible 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. This form is essential for those seeking to access these benefits.
Who is eligible to apply for CHAMPVA benefits?
Eligibility for CHAMPVA benefits includes:
It is important to note that applicants must not be eligible for DoD's TRICARE benefits.
What information do I need to complete the VA Form 10-10D?
To complete the VA Form 10-10D, you will need to provide various details, including:
Make sure to review the instructions carefully to ensure all required fields are filled out accurately.
What should I do if I have Medicare or other health insurance?
If you or the veteran have Medicare or other health insurance, you must complete an additional form, VA Form 10-7959c. This form is necessary to provide details about your other coverage. Attach a copy of the Medicare card or the insurance card when submitting the VA Form 10-10D. Failing to include this information may delay the processing of your application.
How do I submit the VA Form 10-10D?
Once you have completed the VA Form 10-10D and gathered any necessary documentation, send the application to:
Chief Business Office CHAMPVA PO Box 469028 Denver, CO 80246-9028
You can also contact the Customer Service Center at 1-800-733-8387 if you have questions or need assistance. Additionally, you can fax your application to 303-331-7809.
Filling out the VA Form 10-10D can be straightforward, but many applicants make common mistakes that can delay their application for CHAMPVA benefits. One frequent error is failing to complete the form in its entirety. Each section must be filled out accurately. Incomplete forms can lead to processing delays or even denials.
Another mistake is not providing the correct Social Security numbers. Each applicant must include their own Social Security number as well as the sponsor's. Omitting or miswriting these numbers can cause significant issues in verifying eligibility.
Many applicants also overlook the requirement to submit additional forms when applicable. If an applicant has Medicare or other health insurance, they must complete and attach VA Form 10-7959c. Failing to include this form can result in a delay in processing the application.
Inaccurate information regarding the veteran's status is another common pitfall. For example, if the veteran is deceased, applicants must provide the date of death. If this information is missing or incorrect, it can complicate the eligibility determination.
Some individuals neglect to sign and date the certification section. This step is crucial as it confirms that the information provided is true and accurate. Without a signature, the application cannot be processed.
Lastly, applicants often forget to keep copies of their submitted forms and any supporting documents. This can lead to confusion if there are questions about the application later. Maintaining a record helps ensure that all information is readily available if needed.
When applying for CHAMPVA benefits using the VA Form 10-10D, there are several other forms and documents that may be needed to support your application. Each of these documents serves a specific purpose and helps ensure that your application is processed smoothly. Below is a list of commonly required forms and documents.
Gathering these documents in advance can help streamline the application process for CHAMPVA benefits. Ensuring that all necessary paperwork is complete and accurate will increase the likelihood of a successful application. If you have any questions about these forms, consider reaching out to the appropriate VA office for assistance.
The VA Form 10-10D, which is used to apply for CHAMPVA benefits, shares similarities with several other important documents. Each of these forms serves a specific purpose in the realm of veteran and healthcare benefits. Below is a list of five documents that are similar to the VA Form 10-10D:
Understanding these documents can help streamline the application process and ensure that all necessary information is provided for the best chance of receiving benefits.
When filling out the VA Form 10-10D for CHAMPVA benefits, there are several important dos and don’ts to keep in mind. This guidance can help ensure your application is completed accurately and efficiently.
By following these tips, you can help streamline the application process and avoid unnecessary delays in receiving your benefits.
Understanding the VA Form 10-10D can be challenging, and several misconceptions may lead to confusion. Here are four common misconceptions about this form:
This form is designed for the family members of veterans as well. Spouses and children of eligible veterans can apply for CHAMPVA benefits using this form.
Filing the form does not automatically ensure benefits. Eligibility must be confirmed by the VA, and additional documentation may be required.
You can still apply for CHAMPVA benefits even if you have other health insurance. However, if you have Medicare or other health insurance, you must complete an additional form (VA Form 10-7959c).
While there may not be a strict deadline for submission, it is crucial to file the form promptly to avoid delays in receiving benefits. Changes in eligibility, such as divorce, should also be reported immediately.
Here are key takeaways for filling out and using the VA Form 10-10D for CHAMPVA benefits:
Following these guidelines will help ensure a smoother application process for CHAMPVA benefits.