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Filling out the VA Form 10-10d is a critical step for those seeking CHAMPVA benefits, a program designed to provide health care support for the spouses and children of veterans who meet specific eligibility criteria. This comprehensive document, which requires an estimated 10 minutes to complete, asks for detailed information, ranging from the veteran's service and personal details to the applicant's health insurance status. It's structured to facilitate the application process for CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), ensuring that applicants provide all necessary information to determine eligibility effectively. The form also addresses legal agreements, underlining the importance of honest and accurate reporting by including a certification section to be signed under penalty of perjury. It's revised periodically to stay current with the legal and procedural requirements, highlighted by its expiration date and OMB (Office of Management and Budget) number. Submission instructions are clear, requiring the form to be returned to a specified address, and additional documentation is requested for those with Medicare or other health insurance. This form serves as a gateway to invaluable health benefits for family members of veterans, reinforcing the commitment to supporting those connected to the nation's service members.

Form Preview Example

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

 

 

Yes

 

 

 

 

 

 

 

deceased?

 

No

If no go to sect. II

 

 

 

 

 

 

 

 

 

 

 

 

on active military service?

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

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)

 

No

 

No

 

 

 

 

 

If yes, complete VA

Form

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

10-7959c and attach a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Card

 

Insurance card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

First Name

 

 

 

MI

 

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)

 

No

 

No

 

 

 

 

 

If yes, complete VA

 

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

10-7959c and attach a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Card

 

Insurance card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

First Name

 

 

 

 

MI

 

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)

 

No

 

No

 

 

 

 

 

If yes, complete VA

Form

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

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

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

by a person other than an applicant, complete the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

First Name

 

 

MI

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
Click for PDF Form

File Characteristics

Fact Name Description
Form Purpose The VA Form 10-10d is an application for CHAMPVA benefits, designed to establish eligibility for health care benefits for the family members of veterans.
OMB Number and Expiration The Office of Management and Budget (OMB) has approved the use of this form, identified by the number 2900-0219. It was set to expire on January 31, 2017.
Eligibility Criteria Eligibility for CHAMPVA benefits extends to spouses and children of veterans who have a VA-rated permanent and total service-connected disability, those who died from a service-connected condition, or who were killed in the line of duty.
Medicare Impact If eligible for Medicare Part A, individuals under 65 must also have Part B to be covered by CHAMPVA. Those 65 or older are required to have Part B if their 65th birthday was on or after June 5, 2001, or if they were already enrolled in Part B prior to this date to be covered by CHAMPVA.

Steps to Writing Va 10 10D

Once you're ready to apply for CHAMPVA benefits, using the VA 10-10D form is a necessary step towards securing the support and services needed. This form is your gateway to access a range of healthcare benefits, but it requires careful attention to detail during completion. Keep in mind, providing accurate and complete information ensures a smoother process in evaluating your eligibility and avoids unnecessary delays. Once you have compiled all relevant information, follow these steps to fill out the VA 10-10D form correctly.

  1. Start with Section I - Sponsor Information. Fill in the veteran's last name, first name, and middle initial (MI), followed by their Social Security Number (SSN) and VA File Number (if known).
  2. Enter the veteran's street address, including city, state, and zip code. Provide a contact telephone number, including the area code.
  3. Detail the veteran's date of birth using the format (mm-dd-yyyy) and, if applicable, the date of marriage in the same format.
  4. If the veteran is deceased, mark "Yes" and supply the date of death. If the veteran died while on active military service, acknowledge by marking "Yes" next to the relevant question.
  5. Moving to Section II - Applicant Information, repeat the process for all necessary applicants. Begin with last name, first name, and MI, followed by the applicant's SSN and gender.
  6. Provide the applicant's email address, street address, city, state, zip code, and telephone number, including the area code and date of birth.
  7. Indicate if the applicant is enrolled in Medicare or has other health insurance by marking "Yes" or "No". If "Yes" for either, remember to include a completed VA Form 10-7959c and attach a copy of the Medicare or insurance card.
  8. Specify the relationship of the applicant to the veteran.
  9. In Section III - Certification, read the statement regarding federal laws concerning false statements. Sign and date the form to certify that all provided information is true to the best of your knowledge.
  10. If someone other than the applicant is signing the form, provide their last name, first name, MI, telephone number, and relationship to the applicant. Also, include their street address, city, state, and zip code.

After completing the form, review all information to ensure accuracy and completeness. Gather any additional required documents, such as Medicare or insurance cards, and include them with your application package. Send the completed form and attachments to the specified address or via the provided fax number. Upon submission, your application will be reviewed for eligibility. You will be contacted if additional information is required or to notify you of your eligibility status.

Important Details about Va 10 10D

What is the VA Form 10-10d?

The VA Form 10-10d is an application used to apply for CHAMPVA benefits. It is required for individuals seeking health care benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This form is used to determine eligibility for spouses, children, and stepchildren of veterans who have been rated by the VA as having a permanent and total service-connected disability, those who died as a result of a service-connected condition, or those who died in the line of duty.

How do I apply for CHAMPVA benefits using the VA Form 10-10d?

To apply for CHAMPVA benefits, you must complete the VA Form 10-10d in its entirety, which involves providing detailed information on the veteran (the sponsor), and any applicants such as spouse or children. If the applicant has Medicare or other health insurance, a VA Form 10-7959c must also be submitted, along with a copy of the Medicare and/or insurance card. The completed form, along with any required additional information, should be sent to the CHAMPVA PO Box in Denver, CO, as specified on the form.

What information do I need to provide on the VA Form 10-10d?

The form requires detailed information about the veteran and the applicant, including names, Social Security numbers, birth dates, addresses, and information about Medicare or other health insurance coverage. It's crucial to review the instructions carefully and furnish all requested data to ensure the application is processed promptly.

Where do I send my completed VA Form 10-10d?

Once completed, the form should be mailed to the CHAMPVA office at the PO Box address given in Denver, CO. This address can be found directly on the form, ensuring the application reaches the designated processing center.

Who is eligible to apply for CHAMPVA benefits?

Eligibility for CHAMPVA benefits extends to the spouse or child of a veteran who has been rated by a VA regional office as having a permanent and total service-connected disability, the surviving spouse or child of a veteran who died from a VA-rated service-connected condition, or was permanently and totally disabled at the time of death, and the surviving spouse or child of a person who died in the line of duty and not due to misconduct, provided they are not eligible for TRICARE benefits.

What happens if I am eligible for Medicare?

If you are eligible or become eligible for Medicare Part A, and you are under age 65, you must also have Medicare Part B to be covered by CHAMPVA. For those over age 65, having Medicare Part B is required if your 65th birthday was on or after June 5, 2001, or if you were already enrolled in Medicare Part B prior to that date.

Can I fax my VA Form 10-10d for CHAMPVA benefits?

Yes, you can fax the completed VA Form 10-10d along with any required additional documents, such as VA Form 10-7959c and copies of Medicare or insurance cards, to the fax number provided on the form. Ensure that all pages of the documents are legible and complete to avoid delays in processing.

Common mistakes

Filling out the VA Form 10-10D, an application for CHAMPVA benefits, requires careful attention to detail. A common mistake is not providing complete information in Section I, which asks for the veteran's details. This can include leaving out the veteran’s social security number or VA file number. Accurate and complete information ensures the application is processed efficiently.

In Section II, where it asks for the applicant's information, a frequent oversight is not indicating whether the applicant is enrolled in Medicare or has other health insurance. This section requires that if the applicant has Medicare or other health insurance, a VA Form 10-7959c must be submitted along with the insurance card copies. Failing to attach these documents can delay the application process.

Another error involves the certification section. Applicants must sign and date the application, declaring the information provided is true to the best of their knowledge. Sometimes, applications are submitted without the necessary signature and date. This omission can lead to the application being returned and thus, delays in receiving benefits. Additionally, if someone other than the applicant signs the form, their information must be filled out completely. Missing this step can invalidate the certification.

It's also crucial not to overlook the instructions provided with the form. These instructions are designed to guide applicants through the process and help avoid common mistakes. Yet, many applicants neglect to review this guidance thoroughly before submitting their form.

Regarding changes in marital status, applicants often forget to report such changes immediately to CHAMPVA. As the notice on the form states, 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. Failure to report changes in time can affect benefits eligibility.

For applicants with school-aged children between 18 and 23, a common error is failing to provide school certification for full-time enrollment. This oversight can lead to ineligible dependents missing out on benefits. Proper documentation of a dependant’s student status is essential for the extension of CHAMPVA benefits.

Last but not least, applicants often disregard the expiration date of the form, which is clearly stated at the beginning. Using an expired form can result in the rejection of the application. Always ensure that the form is current to avoid unnecessary delays.

Documents used along the form

When applying for CHAMPVA benefits with the VA Form 10-10d, applicants often need to gather additional documentation to ensure a comprehensive and successful submission. These documents not only strengthen the application but also expedite the decision-making process by the Veterans Affairs office. Let’s go over some of these key documents you might need.

  • VA Form 10-7959c: This is the CHAMPVA Other Health Insurance (OHI) Certification form. It’s required if you have any health insurance other than Medicare. This form helps to determine how CHAMPVA benefits coordinate with your other health insurance.
  • Medicare Card: If you are enrolled in Medicare, a copy of your Medicare card will need to be included with your application. This ensures that CHAMPVA can coordinate benefits with Medicare effectively, especially for those over 65 or those who have certain disabilities.
  • Proof of Service-Connected Disability: Documentation or a letter from the VA that shows the veteran's service-connected disability rating is crucial. This establishes eligibility for CHAMPVA based on the veteran's status.
  • Death Certificate: If applying as the surviving spouse or child of a veteran, you’ll need to provide a copy of the veteran’s death certificate. This is to confirm the relationship to the deceased veteran and that their death is service-connected.
  • Marriage Certificate: For spouses of veterans, a marriage certificate is necessary to prove the marital relationship to the veteran. This is essential for determining eligibility.
  • School Certification: For children between 18 to 23 years old who are applying as dependents, documentation proving full-time student status is required. This must come from an accredited educational institution and confirm the student’s enrollment and expected graduation date.

Gathering these documents can seem daunting, but they are vital for a thorough review and processing of your CHAMPVA benefits application. Each plays a crucial role in establishing eligibility and ensuring that all possible benefits are received. It’s advisable to review each document carefully and ensure they are complete and up-to-date before submitting your application.

Similar forms

The VA Form 10-10EZ, Application for Health Benefits, shares similarities with the VA 10-10D form as both are used by veterans and their family members to apply for health care benefits. The 10-10EZ is specifically for veterans seeking to enroll in the VA health care system, capturing information about military service, health insurance, and financial status to establish eligibility and priority for benefits.

VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, is akin to the 10-10D form in that it is also used by veterans and their families. However, the focus here is on applying for disability benefits due to service-connected injuries or diseases. Like the 10-10D, it requires detailed personal and service-related information to process the claim.

The Application for Dependency and Indemnity Compensation (DIC), Death Pension, and/or Accrued Benefits (VA Form 21-534EZ) is utilized by surviving spouses and children of deceased veterans. This form is comparable to the 10-10D as it involves applying for benefits due to the veteran’s death. It necessitates comprehensive details about the veteran’s service, cause of death, and the applicant's relationship to the veteran.

VA Form 22-1990, Application for Education Benefits, is used by veterans and their dependents to apply for educational benefits under the various GI Bill programs. Similar to the 10-10D, it is intended for beneficiaries of a veteran, but in this case, focuses on financial assistance for education rather than medical benefits.

VA Form 10-10CG, Application for the Program of Comprehensive Assistance for Family Caregivers, parallels the 10-10D form as it is designed for veterans’ family members. This application is for caregivers of veterans to receive support and benefits, demonstrating the VA’s multifaceted approach to veterans’ health and well-being, encompassing not just the veterans but those who care for them.

The Health Benefits Renewal (VA Form 10-10EZR) is a form used by veterans enrolled in the VA health care system to update their personal, insurance, or financial information. Like the 10-10D, it ensures that beneficiaries' details are current, but it is specifically for those already receiving health benefits, allowing for the continuation of care.

VA Form 21-686c, Declaration of Status of Dependents, is used by veterans to add dependents to their benefit claims, potentially increasing their compensation. Similar to the 10-10D's function of establishing eligibility for dependent benefits, this form ensures veterans receive accurate compensation based on their family size.

The Application for Furnishing Nursing Home Care to Beneficiaries of VA- VA Form 10-1170, is for veterans seeking long-term nursing home care through VA facilities or private care paid for by the VA. While focused on a specific type of care, it shares the goal of the 10-10D of providing health-related benefits to veterans and their eligible family members.

Individual Unemployability (IU) application, through VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, is designed for veterans unable to maintain employment due to service-connected conditions. This form, while specifically for compensation adjustments, shares the goal with the 10-10D of supporting veterans and their families based on changes in their health status.

Finally, VA Form 28-1900, Disabled Veterans Application for Vocational Rehabilitation, is for service-disabled veterans seeking employment and independent living support. Though its focus is more on career assistance than direct health benefits, like the 10-10D, it reflects the VA's comprehensive approach to veteran welfare, emphasizing support beyond just medical care.

Dos and Don'ts

Filling out the VA Form 10-10d, the Application for CHAMPVA Benefits, is an important step for eligible beneficiaries to receive their health benefits. This process requires attention to detail to ensure the information provided is accurate and complete. Below are some key dos and don'ts to help guide you through the form completion process.

  • Do thoroughly read the instructions on the reverse side of the form before beginning. This can help you understand the requirements and provide accurate information.
  • Do print or type the information clearly. This ensures that your application is processed efficiently without unnecessary delays due to illegibility.
  • Do review your and the veteran's eligibility for CHAMPVA benefits to ensure you're entitled before applying. This saves time and effort for both you and the processing office.
  • Do attach a copy of your Medicare Card and Insurance card if you have indicated that you have Medicare or Other Health Insurance in Section II. This is crucial for the processing of your application.
  • Do sign and date the certification section. Your signature verifies that the information provided is true and correct to the best of your knowledge.
  • Do report any change in status, such as a divorce or remarriage, to CHAMPVA as soon as possible, as this can affect eligibility.
  • Don't skip sections or leave blanks unless the form instructs you to do so. Incomplete applications may be delayed or denied.
  • Don't forget to submit VA Form 10-7959c if you've indicated that you have Medicare or Other Health Insurance. This form is essential for determining your eligibility.
  • Don't provide false information knowingly. Misrepresentation can lead to criminal penalties under Federal Laws (18 USC 287 and 1001).
  • Don't hesitate to contact the Customer Service Center if you have questions or require assistance with the form. They are there to help you.
  • Don't overlook the necessity of including the veteran's Social Security Number and VA File Number. These identifiers are critical for processing your application.
  • Don't send your application without checking for accuracy and completeness. A quick review could save time by avoiding the need for corrections.

By carefully following these guidelines, you can ensure a smoother process for applying for CHAMPVA benefits. Remember, the goal is to provide thorough and accurate information to facilitate a quick and positive outcome for your benefits application.

Misconceptions

Understanding the VA Form 10-10d, commonly associated with the application process for CHAMPVA benefits, is crucial for eligible individuals seeking healthcare coverage. However, there are several misconceptions about this form and the related CHAMPVA benefits. Addressing these misunderstandings can help streamline the application process and ensure that beneficiaries receive the support they are entitled to.

  • Only Veterans Can Apply: Many believe that the VA Form 10-10d is strictly for veterans. However, this application is specifically designed for their dependents, such as spouses or children, to apply for CHAMPVA benefits.

  • Automatic Enrollment for Dependents: Some assume that being a dependent of a veteran automatically enrolls them in CHAMPVA benefits. Eligible dependents must actively apply using the VA Form 10-10d to receive coverage.

  • Medicare Ineligibility: It's a common misconception that being enrolled in Medicare disqualifies you from CHAMPVA benefits. In reality, if you have Medicare Part A, you must also have Medicare Part B to obtain CHAMPVA, except under specific conditions for those over 65.

  • Dependency on Veterans’ Disability Rating: Many believe CHAMPVA eligibility solely depends on the veteran's disability rating. While it's true that the veteran must have a service-connected disability rated as permanently and totally disabling, eligibility also extends to surviving spouses and children under certain circumstances.

  • Health Insurance Conflicts: Some applicants think that having other health insurance disqualifies them from CHAMPVA. In fact, having other health insurance does not disqualify you but CHAMPVA generally acts as the secondary payer.

  • Unlimited Coverage for Children: A misunderstanding exists that children of eligible veterans are covered by CHAMPVA regardless of their age or status. Children are covered until age 18, up to age 23 if attending school full-time, or indefinitely if they become incapacitated before age 18.

  • Eligibility Through Any Veteran: There's a misconception that being related to any veteran qualifies you for CHAMPVA. The veteran’s service-connected conditions and their rating by a VA regional office play a significant role in determining eligibility.

  • No Need to Renew: Some beneficiaries mistakenly believe once they are accepted into CHAMPVA, they do not need to update their information. Changes in marital status, school attendance for dependents, or other health insurance coverage must be reported to maintain eligibility.

  • Immediate Coverage Upon Application: Applicants often expect that submission of the VA Form 10-10d results in immediate coverage. Processing times can vary, and submitting complete and accurate information is crucial to avoid delays.

  • CHAMPVA Provides Full Coverage for All Healthcare Needs: A common misconception is that CHAMPVA covers all healthcare expenses fully. While CHAMPVA provides comprehensive coverage, there are co-payments and some exclusions, similar to other health insurance programs.

Addressing these misconceptions about the VA Form 10-10d and CHAMPVA benefits is essential for ensuring that eligible dependents of veterans fully understand their entitlements and the application process. Proper knowledge and setting realistic expectations can significantly enhance the experience and outcomes of those seeking healthcare benefits through this VA program.

Key takeaways

Filling out and utilizing the VA 10-10d form is essential for individuals seeking CHAMPVA benefits. Understanding this form and its requirements can make the process smoother and ensure that eligible dependents of veterans obtain the healthcare benefits they are entitled to. Here are key takeaways about this process:

  • Complete Accuracy is Crucial: When filling out the VA 10-10d form, every section must be completed with precision. Inaccuracies or missing information can delay the processing time or lead to a denial of CHAMPVA benefits.
  • Medicare and Other Health Insurance: If the applicant has Medicare or other health insurance, they must inform CHAMPVA by submitting a VA Form 10-7959c along with a copy of their Medicare and/or health insurance card(s).
  • Proof of Relationship: The applicant's relationship to the veteran, whether as a spouse, child, stepchild, etc., needs to be clearly indicated, as CHAMPVA eligibility greatly depends on this connection.
  • Service-connected Conditions: Eligibility for CHAMPVA benefits extends to those who are not eligible for TRICARE and are either spouses or children of veterans with VA-rated permanent and total service-connected disabilities, or who died from or while rated permanently and totally disabled from a service-connected condition.
  • Medicare Part B Requirement: For those eligible for Medicare due to age or disability, enrollment in Medicare Part B is mandatory to maintain CHAMPVA coverage.
  • Student Status and CHAMPVA: Dependents aged 18 to 23 must verify their full-time student status to extend CHAMPVA eligibility. This is done through school certification, which needs to be submitted for every term or academic year until the dependent graduates or turns 23.
  • Notification of Status Changes: Any change in marital status, especially a divorce or annulment from the qualifying veteran sponsor, should be reported to CHAMPVA immediately as this affects eligibility.
  • Privacy and Information Use: Collected personal information is protected under the Privacy Act and is used mainly to determine eligibility for CHAMPVA benefits. However, it may be disclosed outside VA under certain conditions laid down by the Privacy Act and its routine uses.

Understanding these aspects ensures that applicants provide all the necessary information and documentation, reducing the likelihood of errors and delays in the processing of their applications for CHAMPVA benefits.

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