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Fill Out a Valid Va 10 10D Form

The VA Form 10-10D is the application used to request CHAMPVA benefits, designed for eligible dependents of veterans. This form collects essential information to determine eligibility for healthcare coverage under the Civilian Health and Medical Program of the Department of Veterans Affairs. To ensure you receive the benefits you deserve, fill out the form by clicking the button below.

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Structure

The VA Form 10-10D is a crucial document for individuals seeking CHAMPVA benefits, which are available to certain family members of veterans. This application form allows eligible applicants to apply for health care coverage provided by the Department of Veterans Affairs. It is essential for completing the form accurately and thoroughly, as it includes sections for both sponsor and applicant information. The form requires details such as the veteran's name, Social Security number, and VA file number, along with the applicant's personal information, including their relationship to the veteran. Additionally, if the applicant has Medicare or other health insurance, they must submit a separate form, VA Form 10-7959c. The certification section emphasizes the importance of honesty, as providing false information can lead to serious penalties. Understanding the eligibility criteria is vital; benefits are available to spouses and children of veterans who have permanent and total service-connected disabilities or who have died as a result of such conditions. The form must be submitted to the designated address, and any changes in marital status or eligibility must be reported promptly to ensure continued benefits. Overall, the VA Form 10-10D serves as a gateway for eligible individuals to access vital health care services, making its proper completion and submission of utmost importance.

Common mistakes

Not reading the instructions thoroughly. Many applicants overlook the detailed instructions on the reverse side of the form, which can lead to incomplete submissions.
Failing to provide all required information. Omitting details such as Social Security numbers or addresses can result in delays or denials of benefits.
Incorrectly completing Section II. If applicants have other health insurance or Medicare, they must submit the VA Form 10-7959c. Not doing so can complicate the application process.
Using outdated forms. Submitting an old version of the VA 10-10D form can lead to rejection. Always ensure you are using the most current form.
Neglecting to sign and date the application. A missing signature or date in Section III can render the application invalid.
Providing inaccurate personal information. Errors in names, dates of birth, or other personal details can create confusion and delay processing.
Not notifying CHAMPVA of changes. Failing to report changes in marital status or eligibility can affect benefit coverage.
Ignoring the requirement for school certification. For applicants aged 18 to 23, not providing proof of full-time student status can jeopardize their eligibility for benefits.

Preview - Va 10 10D Form

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

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Documents used along the form

When applying for CHAMPVA benefits using the VA Form 10-10D, there are several other important forms and documents that may be required to complete the application process. Each of these documents plays a crucial role in determining eligibility and ensuring that all necessary information is provided. Below is a brief overview of four commonly used forms alongside the 10-10D.

VA Form 10-7959c: This form is necessary if the applicant has Medicare or other health insurance. It requires details about the insurance coverage and must be submitted along with the 10-10D form to confirm eligibility for CHAMPVA benefits.
VA Form 21-534: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits. It is particularly relevant for surviving spouses and children of veterans who have died from service-related conditions. Completing this form can help establish additional benefits for eligible family members.
Motorcycle Bill of Sale: To formalize the transfer of ownership for a motorcycle in Wisconsin, it's essential to use the https://autobillofsaleform.com/motorcycle-bill-of-sale-form/wisconsin-motorcycle-bill-of-sale-form, which serves as a legal document that protects the buyer and seller in the transaction.
VA Form 21-686c: This document is used to report changes in dependents, such as the addition of a new spouse or child. Keeping the VA informed of any changes is essential for maintaining accurate eligibility records and ensuring that benefits are correctly allocated.
School Certification: For children aged 18 to 23 who are pursuing full-time education, a school certification is required. This document must confirm the student’s enrollment status and is necessary to extend CHAMPVA benefits during their education.

Understanding these forms and their purposes can help streamline the application process for CHAMPVA benefits. Ensure that you have all required documents ready to avoid delays and to facilitate a smoother experience. If you have questions about any of these forms, reaching out to the CHAMPVA Help Line can provide clarity and assistance.

Similar forms

The VA Form 10-10D, which serves as an application for CHAMPVA benefits, shares similarities with the Medicare Application for Health Insurance (Form CMS-40B). Both forms require applicants to provide personal information, including Social Security numbers, addresses, and details about their health insurance status. The Medicare application also necessitates information about the applicant’s relationship to the veteran, similar to how the 10-10D form requests information about the veteran sponsor. Both forms aim to determine eligibility for healthcare benefits, ensuring that applicants understand their rights and responsibilities within the healthcare system.

Another document that parallels the VA Form 10-10D is the VA Form 21-526EZ, which is used to apply for VA disability compensation. Like the 10-10D, this form requires detailed personal and financial information to assess eligibility for benefits. Both forms emphasize the importance of accurate information, as providing false details can lead to penalties. While the 10-10D focuses on CHAMPVA benefits for dependents of veterans, the 21-526EZ is specifically for veterans seeking compensation for service-related disabilities.

For those involved in mobile home transactions in Indiana, it is important to ensure that all legal documentation is properly handled. A crucial part of this process is using the Mobile Home Bill of Sale, which provides essential details regarding the sale, such as buyer and seller information and the mobile home's description. Utilizing this document not only facilitates a smooth transfer of ownership but also helps protect the rights of both parties involved in the transaction.

The VA Form 10-10EZ is also comparable to the 10-10D. This form is used to apply for VA health care benefits and requires similar information regarding the applicant’s personal details and military history. Both forms are designed to gather necessary information to evaluate eligibility for healthcare services. The 10-10EZ, however, is specifically for veterans, while the 10-10D caters to dependents and survivors, reflecting the unique needs of each group.

Additionally, the VA Form 10-7959c, which is a Health Insurance Information form, closely resembles the 10-10D in that it collects details about the applicant’s existing health insurance coverage. This form is often required when applicants indicate they have other health insurance, just as the 10-10D necessitates additional documentation if the applicant has Medicare or other health insurance. Both forms aim to ensure that all health coverage is accounted for when determining eligibility for VA benefits.

The VA Form 21-534EZ is another document that shares similarities with the 10-10D. This form is used by surviving spouses and children of veterans to apply for Dependency and Indemnity Compensation (DIC). Like the 10-10D, it requires personal information about the applicant and their relationship to the veteran. Both forms serve to establish eligibility for benefits based on the veteran's service and the applicant's dependency status, illustrating the connection between the veteran’s service and the benefits available to their family members.

Finally, the VA Form 22-1990, which is the Application for VA Education Benefits, is similar in that it requires applicants to provide personal information and details about their relationship to a veteran. Both forms aim to determine eligibility for benefits based on the veteran’s service. While the 10-10D focuses on health care benefits, the 22-1990 is specifically for educational assistance, highlighting the various forms of support available to veterans and their families.

Dos and Don'ts

When filling out the VA 10-10D form, follow these guidelines:

Review all instructions carefully before starting.
Complete the form in its entirety, using either print or type.
Ensure all personal information is accurate and up-to-date.
Attach any necessary documents, such as Medicare or insurance cards, if applicable.
Double-check for any missing signatures or dates before submission.
Submit the form to the correct address provided in the instructions.
Keep a copy of the completed form for your records.
Respond promptly to any requests for additional information from CHAMPVA.
Notify CHAMPVA immediately of any changes in your eligibility status.

Additionally, avoid the following mistakes:

Do not leave any sections blank; fill out all applicable fields.
Avoid using correction fluid or tape on the form.
Do not submit the form without signing and dating it.
Do not send the form via untracked mail; use a secure method.
Do not ignore deadlines for submission or additional information requests.
Do not assume CHAMPVA has your information; verify all details.
Do not provide incomplete or inaccurate information.
Avoid submitting documents in a foreign language without translation.
Do not forget to include any additional applicants on separate forms if needed.

Key takeaways

Here are some key takeaways about filling out and using the VA Form 10-10D for CHAMPVA benefits:

Complete the Form Accurately: Ensure that all sections of the form are filled out completely and accurately. Use printed or typed text only.
Include Additional Information if Necessary: If you need more space for applicant information, attach another VA Form 10-10D.
Medicare and Other Insurance: If you have Medicare or other health insurance, you must also submit VA Form 10-7959c along with your application.
Provide Required Documentation: Attach copies of relevant insurance cards and other documents as specified in the instructions.
Understand the Certification Requirement: By signing the form, you declare that the information provided is true and may be subject to penalties for false statements.
Report Changes Promptly: If there are changes in your marital status or eligibility, report them immediately to avoid disruptions in benefits.

How to Use Va 10 10D

Completing the VA Form 10-10D is a straightforward process that requires accurate information about the veteran and the applicant. Once the form is filled out, it must be returned to the designated address along with any necessary supporting documents. Below are the steps to guide you through the completion of this form.

Begin with Section I, which focuses on the 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 the area code, the veteran's date of birth, and the date of marriage.
Indicate whether the veteran is deceased. If yes, provide the date of death. If no, proceed to Section II.

In Section II, fill out the applicant information. Start with the applicant's last name, first name, and middle initial.
Provide the applicant's Social Security Number, sex, and email address.
Enter the street address, city, state, and zip code for the applicant.
Include a telephone number with the area code and the applicant's date of birth.
Indicate if the applicant is enrolled in Medicare and any other health insurance. If yes, complete VA Form 10-7959c and attach the relevant insurance card.

If there are additional applicants, repeat the steps in Section II for each one.
In Section III, sign and date the certification statement. Ensure that the information is true and accurate to the best of your knowledge.
If someone other than the applicant is signing, provide their name, relationship to the applicant, and contact information.
Review the completed form for accuracy and completeness before submission.
Return the form and any additional requested information to the address provided at the top of the form.