10-10d Application for CHAMPVA

Estimated Burden: 10 minutes
OMB Number 2900-0219
Expiration Date xx/xx/xxxx

Application for CHAMPVA Benefits
VA Health
Administration Center

CHAMPVA
Eligibility

PO Box
469028

Denver, CO
80246-9028

1-800-733-8387

FAX
303-331-7809

Attention: After reviewing the reverse side, complete form in its entirety (print or typewritten only) and return with a
copy of the veteran's DD214 (Report of separation from Active Duty) along with other required documentation.
Please do NOT exceed the designated space (i.e., do NOT extend Last Name into First Name area).
Section I - Sponsor Information
Veteran's Last Name
First Name
MI Social Security Number VA File Number (Claim Number)
Street Address

City

Telephone Number (include area code)

State Zip Code

Date of Birth (mm-dd-yyyy)

Date of Marriage (mm-dd-yyyy)

Date of Death (mm-dd-yyyy) Did veteran die while
Yes
Yes If yes →
Is veteran
If
no
go
to
sect.
II
No
No
on active military service?
deceased?
Section II - Applicant Information (if necessary, continue on additional 10-10d and complete in its entirety)
Last Name
First Name
MI Social Security Number
Male
Sex
Female

Street Address
Telephone Number
(include area code)
Last Name

City
Date of Birth Children age
(mm-dd-yyyy) 18 to 23
(see reverse)
First Name

Street Address
Telephone Number
(include area code)
Last Name

Eligible for
Medicare?

Yes Relationship to the veteran
No (i.e., spouse, child, stepchild)

If yes, attach copy of
Medicare card

MI Social Security Number
City

Date of Birth Children age
(mm-dd-yyyy) 18 to 23
(see reverse)
First Name

Street Address
Telephone Number
(include area code)

State Zip Code

Male
Female

State Zip Code
Eligible for
Medicare?

Yes Relationship to the veteran
No (i.e., spouse, child, stepchild)

If yes, attach copy of
Medicare card

MI Social Security Number
City

Date of Birth Children age
(mm-dd-yyyy) 18 to 23
(see page 3)

Sex

Sex

Male
Female

State Zip Code
Eligible for
Medicare?

Yes Relationship to the veteran
No (i.e., spouse, child, stepchild)

If yes, attach copy of
Medicare card

Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement
or representation. (See 18 U.S.C. 287 and 1001).
l declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I
Date
understand that any materially false, fictitious, or fraudulent statement or representation, made knowingly, is Signature
punishable by a fine and/or imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.
X
(Sign and date on right.) If certification is signed by a person other than an applicant, complete the following.

Section III - Certification

Last Name

First Name

Street Address
VA FORM
JUN 2005

MI Telephone Number (include area code) Relationship to Applicant(s)
City

10-10d

State

Zip Code

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 2003 Compilation of
Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/
aces/2003_pa.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. 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 serviceconnected 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 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 JUN 2005 (R)

10-10d

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 eligibility purposes is
established based on school terms for up to one year. For high schools, this period is the normal beginning and
ending school year. For colleges and vocational schools full-time enrollment requires a minimum of 12 credit
hours per semester or equivalent number of credit hours on any academic calendar year.
School certifications must be on school letterhead and include the following:
• student's name
• student's social security number
• exact beginning and ending dates of each semester or enrollment term
• 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 Health Administration Center 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* are not considered an interruption in full-time attendance and will not create a break
in CHAMPVA eligibility.
*providing the student attends school on a full-time basis both before and after the summer break
VA FORM JUN 2005 (R)

10-10d