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Designed to support those closely connected to the sacrifices made by military service members, the VA Form 10-10d serves as a critical pathway for accessing the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) benefits. Entrusted to the Chief Business Office CHAMPVA in Denver, Colorado, this form embodies a straightforward yet impactful procedure for spouses, children, and other dependents of veterans who have either suffered service-connected disabilities deemed permanent and total or who have made the ultimate sacrifice in the line of duty. Applicants are tasked with completing the form meticulously, ensuring correct information is provided, particularly in sections devoted to personal identifiers, Medicare, and other health insurance statuses, which could necessitate the attachment of additional documentation, such as the VA Form 10-7959c for those possessing supplementary health coverage. This establishment of eligibility is predicated on several factors neatly outlined within the form, not least the necessity of Part B Medicare for certain applicants and the nuanced definitions regarding service-connected conditions, the sponsor (veteran), and the applicant's relationship to them. Furthermore, this document underscores the stringent requirements for honesty and accuracy under penalty of perjury, emphasizing the weight of the information provided and its potential implications under federal law. By navigating these procedural and regulatory mandates, eligible individuals connect to a network of health care benefits, reinforcing the nation's commitment to its veterans and their families.

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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
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Document Attributes

Fact Name Description
Form Purpose The VA Form 10-10d is used to apply for CHAMPVA benefits, which provide health care benefits to the spouses and children of veterans who are permanently and totally disabled due to service-connected conditions, or who died in the line of duty or from a service-connected condition.
OMB Number and Burden The form carries an Office of Management and Budget (OMB) number of 2900-0219, with an estimated completion time of 10 minutes.
Expiration Date The current form's expiration date is January 31, 2017.
Governing Law The collection of information on this form is authorized by 38 U.S.C. 501 and 1781, aimed at determining eligibility for CHAMPVA benefits.
Privacy and Information Act Applicants are informed about the Privacy Act of 1974, which outlines how the collected information can be used and protected. The VA may verify the information provided via computer matching programs at any time to ensure accuracy and eligibility.

How to Fill Out Va 10 10D

Completing the VA Form 10-10D is an important step for individuals applying for CHAMPVA benefits. Before starting the form, it's helpful to gather all necessary documents, including Medicare or other health insurance information if applicable, to ensure the process is smooth and accurate. Once completed and submitted, this form will be reviewed to determine eligibility for CHAMPVA benefits. Follow the steps below to complete the form correctly.

  1. Begin with Section I - Sponsor Information.
    • Enter the veteran's last name, first name, and middle initial.
    • Provide the veteran's Social Security Number and VA File Number (Claim Number).
    • Fill out the veteran's street address, city, state, and zip code.
    • Input the veteran's telephone number, including the area code, and date of birth using the mm-dd-yyyy format.
    • Enter the date of marriage using the mm-dd-yyyy format.
    • Indicate if the veteran is deceased. If yes, provide the date of death; if the veteran died while on active military service, answer accordingly.
  2. Move to Section II - Applicant Information. If more than one applicant, use additional forms.
    • Enter the applicant's last name, first name, middle initial, Social Security Number, gender, and email address.
    • Complete the applicant's street address, city, state, and zip code.
    • Provide the applicant's telephone number and date of birth.
    • Indicate whether the applicant is enrolled in Medicare or has other health insurance. If yes, complete VA Form 10-7959c for each and attach copies of the Medicare card and insurance card.
    • Specify the applicant's relationship to the veteran.
  3. In Section III - Certification, read the statement regarding federal laws on submitting false information.
    • Sign and date the form to certify that all information provided is true and accurate to the best of your knowledge.
    • If someone other than the applicant completes the form, they must provide their name, telephone number, relationship to the applicant(s), and their address.
  4. Before sending, review the form to ensure all sections are completed and accompanied by necessary documents.
  5. Return the completed form and any additional requested information to the CHAMPVA PO Box in Denver, CO, as indicated at the top of the form.

Once submitted, the information provided will be verified and processed to determine the applicant's eligibility for CHAMPVA benefits. Remember, keeping a copy of the completed form and any correspondence for your records is always a good practice.

More About Va 10 10D

  1. What is the VA Form 10-10d?

    VA Form 10-10d is an application for healthcare benefits through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). CHAMPVA is a program that provides health care benefits to the spouse or child of a veteran who has been rated by the VA 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 the surviving spouse or child of a service member who died in the line of duty.

  2. Who needs to complete VA Form 10-10d?

    This form should be completed by or on behalf of individuals seeking to apply for CHAMPVA benefits. Eligible individuals include spouses, children, and stepchildren of qualifying veterans or service members.

  3. What information is needed to complete the form?

    To complete VA Form 10-10d, you will need the veteran's personal information, including their full name, social security number, VA file number, and date of birth, as well as the applicant’s relationship to the veteran, their own personal details, and information regarding their current health insurance status. If the applicant has Medicare or other health insurance, additional forms and proof of insurance must also be submitted.

  4. What are the consequences of submitting false information on this form?

    Submitting false, fictitious, or fraudulent statements or claims on this form is a criminal offense. Such actions are punishable by fine and/or imprisonment under federal law (18 USC 287 and 1001), and the application would be subject to denial or revocation of benefits.

  5. Is there a deadline for submitting VA Form 10-10d?

    While there is no strict deadline for submitting the VA Form 10-10d, it is advisable to submit it as soon as you believe you are eligible to ensure timely processing and access to benefits.

  6. How does having Medicare impact eligibility for CHAMPVA?

    If you are eligible for Medicare Part A, you must also have Medicare Part B to qualify for CHAMPVA benefits. This requirement applies if you are under 65 and eligible for Medicare, or if you are 65 or older, regardless of when you became eligible for Medicare Part A, unless you were enrolled in Medicare Part B before June 5, 2001.

  7. What happens if the marital status changes after applying for CHAMPVA?

    If the CHAMPVA beneficiary’s marital status changes, such as through divorce or annulment, it is critical to report this change to the CHAMPVA Eligibility Unit immediately. Termination of marriage to the qualifying veteran will result in the termination of CHAMPVA benefits as of midnight on the effective date of the divorce or annulment.

  8. Where do I submit the completed VA Form 10-10d?

    The completed form and any necessary additional information should be sent to the CHAMPVA Center at the address provided on the form. It can also be faxed to the number given. This will initiate the process to determine eligibility and enrollment in the CHAMPVA program.

Common mistakes

Filling out government forms can sometimes feel like navigating a maze, where one wrong turn can lead you back to the start. The VA Form 10-10D, required to apply for CHAMPVA benefits, is no exception. People often make several common mistakes while completing this form. By being aware of these pitfalls, you can ensure your application process is smoother.

  1. Not reviewing the instructions: This might seem like a no-brainer, but many individuals skip the step of reviewing the instructions provided on the reverse side of the form. These instructions are intended to guide you through each section, ensuring accurate and complete information.

  2. Incomplete sections: Every section of the VA Form 10-10D is important. Leaving sections incomplete can delay the processing of your application, or worse, lead to a denial of benefits.

  3. Forgetting to include additional forms: If you indicate that you have Medicare or other health insurance in Section II, you must also submit a VA Form 10-7959c. Failing to attach this can stall your application process.

  4. Not using additional space when needed: Sometimes, the space provided on the form is not enough. If you find yourself running out of room, it is crucial to complete another 10-10D form for the additional information. Remember to sign each form you submit.

  5. Incorrect information: Double-check your personal details like social security numbers, addresses, and dates. Typos or inaccurate information can lead to significant delays or issues with benefit eligibility.

  6. Omitting the certification section: The certification section at the end of the form is not just a formality. It's a legal declaration of the accuracy and truthfulness of the information provided. Skipping this step can render your application incomplete.

  7. Failure to sign and date: A signature and date are mandatory. An unsigned application is like sending a letter without postage – it won't get very far.

  8. Not reporting changes in status: If your marital status has changed through divorce or annulment, resulting in a loss of eligibility, not updating this information can affect the accuracy of your application and your benefits.

  9. Incorrectly documenting school certification: If applying for benefits that extend to students between ages 18 to 23, ensure the school certification is accurate and complete. Missing or incorrect information here can disrupt eligibility.

To avoid these common hiccups, take your time filling out the form, review your answers, and ensure you're including all necessary documentation. The effort you put in upfront can pay off by making the process smoother and helping you access the benefits meant to assist you or your loved ones.

Documents used along the form

When individuals or their families submit the VA Form 10-10D for CHAMPVA benefits, understanding related forms and documentation can streamline the process, ensuring smoother navigation through necessary bureaucratic pathways. These forms help provide a full picture of an applicant’s status, need, and eligibility for benefits.

  • VA Form 10-7959c: Often submitted alongside the VA Form 10-10D, this form is specifically for applicants who already have Medicare or other health insurance. It requires applicants to attach a copy of their Medicare and/or health insurance card, ensuring that all health coverage is assessed and coordinated properly.
  • School Certification Letter: For children aged 18 to 23 seeking CHAMPVA benefits, a school certification letter must be provided. This document, which verifies full-time student status, includes information such as the student’s full name, social security number, study dates, and certification of full-time status. Schools typically provide these certifications, which are essential for extending CHAMPVA eligibility to students within this age group.
  • Death Certificate: In cases where CHAMPVA eligibility is based on the applicant being the surviving spouse or child of a veteran, a copy of the veteran’s death certificate must be provided. This document serves as proof of the applicant’s eligibility status through their relationship to the deceased veteran.
  • Marriage Certificate: Spouses applying for CHAMPVA benefits need to submit a marriage certificate as evidence of their legal marriage to the veteran. This document is crucial for establishing the spousal relationship required for eligibility.
  • Proof of Permanent and Total Disability: If eligibility for CHAMPVA is based on the veteran having a permanent and total service-connected disability, documentation from the VA rating that confirms the disability status is required. This evidence ensures that applicants receive benefits aligned with the veteran’s level of service-connected disability.

Completing and submitting the appropriate documents with the VA Form 10-10D is important for a successful application for CHAMPVA benefits. These documents validate the applicant's eligibility and circumstances, helping the VA make informed decisions about healthcare benefits. By thoroughly preparing and including all necessary forms and documentation, applicants can help ensure a smoother and more efficient review process.

Similar forms

  • The VA Form 10-10EZ, Application for Health Benefits, is quite similar to the VA Form 10-10D, as both are used within the Department of Veterans Affairs to determine eligibility for healthcare benefits. The 10-10EZ is specifically for enrolling in the VA healthcare system, where people need to provide personal, insurance, and financial information, somewhat echoing the detail needed on the 10-10D for CHAMPVA benefits application.

  • The VA Form 21-686c, Declaration of Status of Dependents, bears resemblance to the VA Form 10-10D in that it collects information on a veteran’s family members to adjust benefits appropriately. While the 21-686c is used mainly for compensation or pension benefits, both forms require detailed information about dependents, which influences the benefits for which they may be eligible.

  • VA Form 21-674, Request for Approval of School Attendance, compares to the VA Form 10-10D especially in scenarios where continuing education impacts benefit eligibility. The Form 21-674 is used to report a child over the age of 18 is attending school, affecting their dependent status. Similar to parts of the 10-10D, it impacts benefits by updating dependent statuses based on education.

  • The VA Form 10-10EC, Application for Extended Care Services, shares similarities with the VA Form 10-10D as they both involve applications for specific VA benefits. The 10-10EC is for veterans applying for long-term care services, requiring personal and financial information to assess the applicant's contribution towards care. This parallels the 10-10D’s aim to gather comprehensive details for benefit determination.

  • VA Form 22-5490, Dependents’ Application for VA Education Benefits, is akin to the VA Form 10-10D in the context of dependents seeking benefits. The 22-5490 is used by dependents (spouses or children) of a veteran to apply for education benefits, necessitating detailed information on the veteran and the applicant. This is similar to the 10-10D’s requirement for detailed dependent information to process CHAMPVA benefits.

Dos and Don'ts

When filling out the VA Form 10-10d for CHAMPVA benefits, ensuring accuracy and completeness is critical. Here is a guide to help navigate the do’s and don’ts during this process:

  • Do review all instructions carefully before beginning to fill out the form. This ensures you understand each section and its requirements.
  • Do complete the form in its entirety, using either print or type. Incomplete forms may result in delays or denials.
  • Do include all necessary additional documentation, such as VA Form 10-7959c if you have Medicare or other health insurance coverage, along with a copy of your Medicare or insurance card.
  • Do double-check all information for accuracy, including personal details and eligibility criteria, before submitting.
  • Don't leave any required fields blank. If a section does not apply to you, write "N/A" to indicate this.
  • Don't forget to sign and date the certification section. Unsigned forms will not be processed.
  • Don't submit the form without first verifying that you meet the eligibility requirements for CHAMPVA benefits.
  • Don't hesitate to contact the CHAMPVA Customer Service Center if you have questions or need clarification on how to properly fill out the form.

Filling out the VA Form 10-10d correctly and completely is crucial for a smooth process in obtaining CHAMPVA benefits for eligible individuals and their families. By following these do’s and don’ts, applicants can avoid common pitfalls that may delay or impact their benefits.

Misconceptions

Many individuals navigating the process of applying for CHAMPVA benefits encounter misconceptions about the VA Form 10-10d. This document is critical for securing medical coverage for the family members of veterans who meet specific criteria. Here, we elucidate and correct four common misunderstandings about this form to aid applicants in their journey toward accessing these benefits.

  • Misconception 1: Eligibility for CHAMPVA is based solely on the veteran's military service. While a veteran's service is integral to eligibility, it is not the sole criterion. Eligible individuals include the spouse or child of a veteran who has been determined by a VA regional office to have a permanent and total service-connected disability. Additionally, the surviving spouse or child of a veteran who died from a service-connected condition, or who, at the time of death, was rated permanently and totally disabled from a service-connected condition, is eligible. Moreover, eligibility extends to the surviving spouse or child of a person who died in the line of duty, provided they are not entitled to DoD's TRICARE benefits.
  • Misconception 2: Submission of the VA Form 10-10d alone is sufficient to determine CHAMPVA eligibility. While the VA Form 10-10d is a critical part of the application process, it's often just the starting point. If applicants indicate in Section II that they have Medicare or Other Health Insurance, they must also submit a VA Form 10-7959c, which is not always clear to the applicants. Moreover, the form requires detailed and accurate information about the veteran's and applicant's statuses, and any inaccuracy or omission could delay or result in denial of the benefits.
  • Misconception 3: Once deemed eligible, CHAMPVA coverage is automatic and does not require renewal. This is not true. While initial eligibility is a major step, there are circumstances, such as reaching a certain age or changes in student status, that require the beneficiary to update their information to maintain their CHAMPVA benefits. Specifically, if a beneficiary's circumstances change, such as a change in marital status or no longer being enrolled as a full-time student between the ages of 18 and 23, it is imperative to communicate these changes to the CHAMPVA Eligibility Unit promptly to avoid interruptions in coverage.
  • Misconception 4: CHAMPVA coverage supersedes the need for Medicare Part B for beneficiaries over 65. In reality, CHAMPVA beneficiaries who are 65 or older and eligible for Medicare are required to have Medicare Part A and Part B to retain their CHAMPVA benefits. The confusion often arises from thinking that CHAMPVA, as a form of veteran benefit, naturally takes precedence over Medicare. However, CHAMPVA serves as a secondary payer to Medicare, emphasizing the necessity for eligible beneficiaries to enroll in both Medicare Part A and Part B.

Understanding the intricacies of the VA Form 10-10d and the CHAMPVA benefits eligibility criteria is crucial for applicants. By dispelling these misconceptions, applicants can better navigate the process, ensuring they accurately complete their applications and maintain their eligibility for the valuable medical coverage CHAMPVA offers.

Key takeaways

Filling out the VA 10-10D form is essential for applying for CHAMPVA benefits, which provide valuable medical coverage. To ensure a smooth application process, here are four key takeaways to keep in mind:

  • Complete the form accurately: Every section of the VA 10-10D form must be filled out completely and accurately. It's important to print or type the information clearly to avoid any potential delays or issues with processing the application. If Medicare or other health insurance is indicated in Section II, applicants must also submit a VA Form 10-7959c.
  • Understand the eligibility criteria: CHAMPVA benefits are available to the spouse or child of a veteran who has been rated by the VA 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 the surviving spouse or child of a service member who died in the line of duty.
  • Medicare impact: If eligible for Medicare Part A, applicants under the age of 65 must also have Medicare Part B to be covered by CHAMPVA. This requirement also applies to beneficiaries age 65 or older, with specific conditions based on the date of turning 65 or existing enrolment in Part B prior to a specified date, to ensure continuous CHAMPVA coverage.
  • Provide updated information: Changes in marital status or other significant life events should be reported immediately to CHAMPVA to avoid any disruption in benefits. Maintaining accurate and current information is crucial for the continuation of benefits under CHAMPVA guidelines.

Understanding and following these key points can help navigate the CHAMPVA application process more effectively and ensure that eligible individuals receive the benefits they need.

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