Fill in a Valid Va 10 10D Template

The VA Form 10-10D is an essential application used to request CHAMPVA benefits, designed for the spouses and children of veterans with specific service-connected disabilities. This form plays a crucial role in determining eligibility for medical coverage under the Civilian Health and Medical Program of the Department of Veterans Affairs. If you’re ready to take the next step in securing these benefits, fill out the form by clicking the button below.

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The VA Form 10-10D is an essential document for individuals seeking benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This application is designed for the spouses and children of veterans who have been rated as having a permanent and total service-connected disability, as well as for surviving family members of veterans who have died due to service-related conditions. Completing this form accurately is crucial, as it determines eligibility for valuable healthcare benefits. The application consists of several sections, including sponsor information, applicant details, and a certification statement. Each applicant must provide specific personal information, such as Social Security numbers, dates of birth, and addresses. If the applicant has other health insurance or Medicare, additional forms must be submitted to ensure comprehensive coverage. It's important to note that any changes in marital status or eligibility must be reported promptly to maintain benefits. With an estimated completion time of just ten minutes, this form is a straightforward yet vital step in accessing healthcare services for eligible families of veterans.

Va 10 10D 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

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

Click for Va 10 10D File

File Breakdown

Fact Name	Details
OMB Number	2900-0219
Estimated Burden	10 minutes
Expiration Date	01/31/2017
Governing Law	38 USC 501 and 1781
Eligibility Criteria	Spouses and children of veterans rated permanently and totally disabled or who died from a service-connected condition are eligible.
Medicare Impact	Applicants under age 65 must have Medicare Part B to be covered by CHAMPVA.
Submission Requirements	Complete the form in its entirety and return it to the specified address.
Privacy Act Information	Information collected is confidential and may be disclosed only as authorized under the Privacy Act.
School Certification	Required for students aged 18 to 23 to extend CHAMPVA benefits; must be submitted by the educational institution.

Guide to Using Va 10 10D

Filling out the VA Form 10-10D is a straightforward process, but it’s important to provide accurate information. Once completed, this form will help determine eligibility for CHAMPVA benefits. Make sure to review the instructions carefully before starting. Here’s how to fill out the form step by step.

Begin with Section I, which asks for 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 street address, city, state, and zip code of the veteran.
Include a telephone number with area code and the veteran's date of birth in mm-dd-yyyy format.
If applicable, enter the date of marriage in mm-dd-yyyy format. Indicate if the veteran is deceased and provide the date of death if yes.
Move to Section II for Applicant Information. Fill in the last name, first name, and middle initial of the applicant.
Provide the applicant's Social Security Number, sex, email address, street address, city, state, zip code, and telephone number.
Include the applicant's date of birth and indicate if they are enrolled in Medicare or other health insurance.
If the applicant has other health insurance, complete VA Form 10-7959c and attach a copy of the insurance card.
If there are additional applicants, repeat the steps for each one in Section II.
Proceed to Section III for Certification. Sign and date the form, confirming that the information provided is true and accurate.
If someone else is signing on behalf of the applicant, provide their last name, first name, middle initial, telephone number, relationship to the applicant, and address.
Review the entire form for accuracy and completeness before submitting it.

Once you have filled out the form, gather any additional documents that may be required, such as insurance cards. Then, send the completed form to the address provided on the form. If you have any questions during the process, don’t hesitate to reach out to the customer service center for assistance.

Get Answers on Va 10 10D

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

The VA Form 10-10D is an application for CHAMPVA benefits. CHAMPVA, which stands for the Civilian Health and Medical Program of the Department of Veterans Affairs, provides health care coverage to eligible dependents 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 must be completed and submitted to determine eligibility for these benefits.

Who is eligible to apply for CHAMPVA benefits using the 10-10D form?

Eligibility for CHAMPVA benefits includes:

The spouse or child of a veteran rated as having a permanent and total service-connected disability.
The surviving spouse or child of a veteran who died due to a service-connected condition or who was rated permanently and totally disabled 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.

It is important to note that applicants must not be eligible for DoD's TRICARE benefits to qualify for CHAMPVA.

What information is required to complete the 10-10D form?

Applicants need to provide detailed information in several sections of the form. This includes:

Veteran's information such as name, Social Security number, and VA file number.
Applicant's information including name, Social Security number, date of birth, and relationship to the veteran.
Details regarding any other health insurance coverage, including Medicare.

Completing the form accurately is crucial, as missing information can delay or result in denial of benefits.

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

If you have Medicare or other health insurance, you must complete an additional form, VA Form 10-7959c, and attach the relevant insurance card. This requirement ensures that the VA can coordinate benefits effectively and determine the extent of coverage available to you.

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

The estimated burden for completing the VA Form 10-10D is about 10 minutes. However, the processing time for the application may vary. Factors such as the completeness of the application, the volume of applications being processed, and the verification of provided information can influence the overall timeline. It is advisable to submit all required documents promptly to avoid delays.

What happens if my marital status changes after submitting the form?

If there is a change in marital status, such as divorce or annulment, it is critical to report this change immediately to CHAMPVA. Eligibility for benefits can end as of midnight on the effective date of the dissolution of marriage. Keeping CHAMPVA informed ensures that your benefits are managed correctly and that there are no interruptions in coverage.

Common mistakes

Filling out the VA Form 10-10D can be a straightforward process, but there are common mistakes that applicants often make. One significant error occurs when individuals fail to provide complete information in Section I, which pertains to the sponsor's details. Incomplete entries, such as omitting the veteran's Social Security number or date of birth, can lead to delays in processing. Ensure that every field is filled out accurately and thoroughly to avoid unnecessary complications.

Another frequent mistake involves the misunderstanding of eligibility criteria. Some applicants may not realize that if they have Medicare or other health insurance, they must also submit VA Form 10-7959c. Skipping this step can result in a denial of benefits. It is crucial to read the instructions carefully and include all required forms to ensure a smooth application process.

Additionally, applicants often overlook the importance of signing and dating the certification section. This signature confirms the accuracy of the information provided. Without it, the application may be deemed incomplete. Take a moment to review the entire form before submission, ensuring that all necessary signatures are present.

Lastly, many people fail to keep copies of their submitted forms and any supporting documents. This oversight can create challenges if there are questions or issues later on. Maintaining a personal record of what has been submitted can provide peace of mind and facilitate any necessary follow-up communications with the VA.

Documents used along the form

The VA Form 10-10D is essential for those seeking CHAMPVA benefits, but it often requires additional documentation to complete the application process. Here are four important forms that are commonly used alongside the VA Form 10-10D. Each plays a unique role in ensuring that applicants provide the necessary information to determine their eligibility for benefits.

VA Form 10-7959c: This form is required if the applicant has Medicare or other health insurance. It collects information about the applicant's insurance coverage, which is vital for processing CHAMPVA benefits.
School Certification: For applicants who are dependents aged 18 to 23, a school certification is necessary. This document verifies full-time enrollment in an educational institution and must include specific details such as the student's name, Social Security number, and enrollment dates.
Death Certificate: If the applicant is a surviving spouse or child of a veteran, a death certificate may be needed. This document serves to confirm the veteran's passing and supports the application for benefits.
Divorce Decree: In cases where the applicant's eligibility is affected by a divorce from the veteran, a divorce decree must be submitted. This document provides legal proof of the dissolution of marriage, which is important for determining ongoing eligibility for CHAMPVA benefits.

Completing the VA Form 10-10D along with these additional documents helps streamline the application process for CHAMPVA benefits. Ensuring that all required information is submitted can significantly improve the chances of a timely and favorable outcome.

Similar forms

The VA Form 10-10D is an application for CHAMPVA benefits, and it shares similarities with several other forms used in the healthcare and benefits application process. Below is a list of nine documents that are comparable to the VA Form 10-10D, along with a brief description of how they relate to it.

VA Form 10-7959c: This form is required when applicants have Medicare or other health insurance. It collects information about the applicant's health coverage, similar to how the 10-10D gathers information for CHAMPVA eligibility.
VA Form 21-526EZ: This is a claim form for disability compensation and related compensation benefits. Like the 10-10D, it requires personal information and documentation to establish eligibility.
VA Form 21-534EZ: This form is used for applying for Dependency and Indemnity Compensation (DIC) benefits for surviving spouses and children. It shares the purpose of determining eligibility based on veteran status.
VA Form 10-10EZ: This is an application for health benefits, similar to the 10-10D, but specifically for veterans seeking VA healthcare services rather than CHAMPVA benefits.
VA Form 21-4142: This form allows applicants to authorize the release of medical records. It serves a similar function in gathering necessary information for the processing of claims, akin to the information requested on the 10-10D.
VA Form 10-10SH: This is the application for the Spina Bifida Health Care Benefits Program. It is similar in that it seeks to determine eligibility for specific health benefits related to a veteran's service.
VA Form 10-10P: This is the application for the Patient Advocate Program. It also collects information to assist in healthcare services, paralleling the data collection aspect of the 10-10D.
VA Form 21-527EZ: This form is used to apply for pension benefits, which, like the 10-10D, requires personal and financial information to assess eligibility.
VA Form 10-10068: This form is used for the CHAMPVA In-house Treatment Initiative (CITI). It is related to CHAMPVA benefits and requires similar applicant information as the 10-10D.

Dos and Don'ts

When filling out the VA Form 10-10D for CHAMPVA benefits, following the right steps can make a big difference. Here’s a helpful list of things you should and shouldn’t do.

Do read the instructions carefully before starting the form.
Do fill out the form completely, using either print or type.
Do provide accurate information, especially your Social Security number.
Do include any necessary additional documents, like the VA Form 10-7959c if you have other health insurance.
Do check your work for any errors before submitting.

Don’t leave any required fields blank; this could delay your application.
Don’t forget to sign and date the form; an unsigned form is not valid.
Don’t submit the form without reviewing the eligibility criteria first.
Don’t assume that previous applications are still valid; always submit a new form when necessary.
Don’t ignore any requests for additional information from the VA.

Misconceptions

Understanding the VA Form 10-10D, which is used to apply for CHAMPVA benefits, can be challenging. Here are some common misconceptions about this form, along with clarifications to help clear up any confusion.

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

This form is not exclusively for veterans. It is designed for their eligible dependents, such as spouses and children, to apply for CHAMPVA benefits.

Misconception 2: Submitting the form guarantees benefits.

Completing and submitting the form does not automatically ensure that benefits will be granted. Eligibility is determined based on specific criteria outlined by the VA.

Misconception 3: Only one form is needed for multiple applicants.

If there are multiple applicants, each person must complete a separate VA Form 10-10D. Additional forms can be filled out if needed.

Misconception 4: Medicare coverage is not relevant for CHAMPVA applicants.

Medicare coverage is indeed relevant. If an applicant is eligible for Medicare, they must also have Part B to receive CHAMPVA benefits.

Misconception 5: The form must be completed in person.

The form can be completed and submitted by mail or fax. It is not necessary to visit a VA office in person to submit the application.

Misconception 6: The information provided on the form is not confidential.

All information submitted on the VA Form 10-10D is treated as confidential and is protected under privacy laws.

Misconception 7: Changes in marital status do not need to be reported.

Any changes in marital status, such as divorce or remarriage, must be reported to CHAMPVA immediately, as they can affect eligibility.

Misconception 8: The form does not expire.

The VA Form 10-10D has an expiration date, and applicants should ensure they are using the most current version to avoid delays in processing.

By addressing these misconceptions, individuals can better navigate the process of applying for CHAMPVA benefits and understand the requirements associated with the VA Form 10-10D.

Key takeaways

Filling out the VA Form 10-10D is a crucial step in applying for CHAMPVA benefits. Here are some key takeaways to ensure a smooth application process:

Complete the Form Accurately: Take the time to fill out the form in its entirety. Use clear print or type to avoid any confusion.
Include Required Information: Make sure to provide all necessary details, including the veteran's information and any health insurance details. Missing information can delay your application.
Submit Additional Forms if Necessary: If you have Medicare or other health insurance, you must also submit VA Form 10-7959c for each applicant. This is essential for processing your application.
Report Changes Promptly: If there are any changes in your marital status or other eligibility criteria, report these changes immediately to avoid losing benefits.
Understand Eligibility Criteria: Familiarize yourself with who qualifies for CHAMPVA benefits. This includes spouses and children of veterans with specific service-connected disabilities.

By keeping these points in mind, you can help ensure that your application for CHAMPVA benefits is processed efficiently and effectively.