VA Form 10-10d, Application for CHAMPVA Benefits, is the U.S. Department of Veterans Affairs form used to apply for health care coverage through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). It serves the spouse, child or survivor of a veteran who meets the program's requirements. On this page you can fill out the 10-10d online on FillingPDF and download or print the completed PDF; the form and its online alternative are published by the VA.
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What is 10-10d?
VA Form 10-10d, Application for CHAMPVA Benefits, is the Department of Veterans Affairs form that spouses, children and survivors of eligible veterans use to apply for health care coverage under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
The form is issued by the Veterans Health Administration (VHA) Office of Integrated Veteran Care under OMB No. 2900-0219. It has three sections: Section I for the sponsor (the veteran on whom the applicant's eligibility is based), Section II for up to three applicants, and Section III for the certification and signature. It records the sponsor's and each applicant's identity details, whether the veteran is deceased or died on active military service, and whether an applicant is enrolled in Medicare or has other health insurance.
The pages that follow the form explain CHAMPVA eligibility, the Medicare Part B rule, the definitions of sponsor, spouse and child, and the school certification required for students age 18 to 23. The form notes that people eligible for the Department of Defense's TRICARE benefits are not eligible for CHAMPVA. The VA also offers an online application as an alternative to the paper form.
Who needs to file 10-10d?
According to the VA, the spouse, dependent or survivor of a veteran who meets certain requirements uses Form 10-10d to apply for CHAMPVA. The form lists these eligible persons, provided they are not eligible for TRICARE:
- the spouse or child of a veteran rated by a VA regional office as having a permanent and total service-connected condition or disability;
- the surviving spouse or child of a veteran who died from a VA-rated service-connected condition, or who was rated permanently and totally disabled from one at the time of death;
- the surviving spouse or child of a person who died in the line of duty and not due to misconduct.
A child must be unmarried and under 18; or have become permanently incapable of self-support before 18, as rated by a VA regional office; or be 18 to 23 and enrolled full time at an approved educational institution. Stepchildren, adopted and other children are included. A spouse who remarries before age 55 loses CHAMPVA benefits on the date of remarriage.
If someone other than an applicant signs the certification, that person completes the extra block in Section III with their name, address, phone number and relationship to the applicant(s).
When to file 10-10d
Submit Form 10-10d when you are the spouse, child or survivor of a veteran and want to apply for CHAMPVA. The form prints no filing deadline.
Later events matter too. Report changes in status right away to CHAMPVA at 1-800-733-8387 or by mail to the address printed on the form; a divorce or annulment from the qualifying sponsor ends eligibility at midnight on the effective date of the dissolution. Students age 18 to 23 need a school certification for each term or full year to recertify attendance until graduation or age 23, and the CHAMPVA Program Office must be told of any change in student status, such as withdrawal. If you need more room for applicants, complete another 10-10d in its entirety, sign it and submit it.
Documents you need
- VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification: each applicant must submit one if Section II shows Medicare or other health insurance.
- A copy of the Medicare card, for each applicant who checks Enrolled in Medicare.
- A copy of the insurance card, for each applicant who checks Has other health insurance.
- School certification for a child age 18 to 23 in full-time study: on school letterhead, with the student's full name, Social Security number, exact beginning date and projected graduation date. School-generated forms are accepted if they include this.
- For a remarried surviving spouse whose remarriage ended by death, divorce or annulment: the appropriate documentation, such as a death certificate, divorce decree or annulment certification.
How to fill out 10-10d
Check the eligibility notes
Read the pages after the form: the eligibility criteria, the Medicare Part B rule and the definitions of sponsor, spouse and child. Complete the form by typing or printing.
Enter the sponsor's identity (Section I)
Provide the veteran's last and first name, middle initial, Social Security number (999-99-9999), address, country code, phone number, email address and date of birth (MM/DD/YYYY). Add the date of marriage (MM/DD/YYYY).
Answer the deceased questions
Check Yes or No for Is the veteran deceased. If Yes, enter the date of death and check whether the veteran died while on active military service; if No, go to Section II.
Enter each applicant's details (Section II)
For each applicant, give name, Social Security number, date of birth (MM/DD/YYYY), address, email, phone number with area code and sex. Section II has room for three applicants.
Mark Medicare or other insurance
Check Enrolled in Medicare and/or Has other health insurance where they apply. Each checked box requires VA Form 10-7959c and a copy of the Medicare or insurance card.
State the relationship to the veteran
In Relationship to Veteran, write how each applicant is related to the sponsor, such as spouse or child.
Sign and date the certification (Section III)
Enter your typed or digital signature, the date (MM/DD/YYYY) and your email address. The certification is made under penalty of perjury.
Complete the other-signer block if needed
If someone other than an applicant signs, enter that person's name, relationship to the applicant(s), address and phone number in the block below the signature.
Review, download and assemble
Check names, Social Security numbers and dates, then download or print the completed PDF from FillingPDF. Add any 10-7959c, card copies or school certification and send the package as described under How to submit.
How to submit 10-10d
You can apply online with the VA or return the paper Form 10-10d by mail.
- Online: the VA offers an online application instead of the paper form at https://www.va.gov/family-and-caregiver-benefits/health-and-disability/champva/apply-form-10-10d/.
- By mail: send the completed form and any requested additional information to VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475.
- School certifications: these may be mailed to the same address or faxed to 1-303-331-7809.
If any applicant has Medicare or other health insurance, include VA Form 10-7959c for each applicant plus the card copies described under required documents. Print or type the form; a typed or digital signature is accepted in Section III. Questions about eligibility or completing the form go to the CHAMPVA Help Line at 800-733-8387. Do not send the completed form to the VA Reports Clearance Officer email address printed in the burden statement. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Checking Medicare or other health insurance in Section II without completing VA Form 10-7959c and attaching a copy of the Medicare or insurance card.
- Handwriting the form illegibly; the form asks that it be completed in print or typed only.
- Adding a fourth applicant on the same page instead of completing another VA Form 10-10d in its entirety, signing it and submitting it.
- Entering dates or numbers in the wrong format: use MM/DD/YYYY for dates, 999-99-9999 for Social Security numbers and (999) 999-9999 for phone numbers.
- Leaving out the school certification for a child age 18 to 23, or submitting one without the student's SSN or exact beginning and projected graduation dates.
- Skipping Section III signature and date; the certification is made under penalty of perjury.
- Not reporting a divorce, annulment or other change in status to CHAMPVA; a divorce or annulment from the sponsor ends eligibility on the effective date.
- Sending the completed form to the VA Reports Clearance Officer email address, which is only for comments on the burden estimate.
Frequently asked questions
What is VA Form 10-10d used for?
VA Form 10-10d is the Application for CHAMPVA Benefits. The spouse, dependent or survivor of a veteran who meets certain requirements uses it to apply for health care benefits through the Civilian Health and Medical Program of the Department of Veterans Affairs.
Who is eligible for CHAMPVA?
Eligible persons are the spouse or child of a veteran rated permanently and totally disabled from a service-connected condition, and the surviving spouse or child of a veteran who died from such a condition or in the line of duty not due to misconduct. They must not be eligible for TRICARE.
Can I apply for CHAMPVA online instead of using the 10-10d PDF?
Yes. The VA says you can apply online instead of filling out and sending the paper form, at the VA's CHAMPVA application page. On FillingPDF you can fill out the PDF and download or print it, but you then submit it to the VA yourself.
Where do I mail Form 10-10d?
Mail it to VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475, with any additional information requested. For help completing the form, call the CHAMPVA Help Line at 800-733-8387.
What do I attach if an applicant has Medicare or other insurance?
Each such applicant must submit VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification, plus a copy of the Medicare card if enrolled in Medicare or a copy of the insurance card if there is other health insurance.
Can my adult child in college be covered by CHAMPVA?
Yes, an unmarried child age 18 up to 23 who is in a full-time course at an approved institution can qualify. School certification on letterhead is required, with the student's name, SSN and exact beginning and projected graduation dates, renewed each term or year.
Can I sign Form 10-10d with a typed signature?
Yes. Section III labels the signature as typed or digital. If someone other than an applicant signs, that person also fills in their name, address, phone number and relationship to the applicant(s) in the block below.
What happens to CHAMPVA if the spouse remarries or divorces?
A divorce or annulment from the sponsor ends eligibility at midnight on its effective date. A surviving spouse who remarries before age 55 loses benefits on the remarriage date; remarriage at 55 or later does not end them. Report changes to CHAMPVA at 1-800-733-8387.
Does FillingPDF submit my 10-10d to the VA?
No. FillingPDF lets you fill out the form online and download or print the completed PDF, but it is an independent service and does not file anything with the VA. You submit the form through the VA's online application or by mail.
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