10-10d Application for CHAMPVA

VA Health
Administration Center

CHAMPVA
Eligibilty

Application for CHAMPVA Benefits

PO Box
469028

Denver, CO
80246-9028

Customer Service Center
1-800-733-8387

OMB Number 2900-0091
Estimated Burden: 10minutes
Expiration: XX/XX/XXXX

FAX
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.

Veteran's Last Name

Section I - Sponsor Information
First Name
MI Social Security Number VA File Number (Claim Number)
City

Street Address
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
MI Social Security Number
First Name
Male
Sex
Female

Email Address
Telephone Number
(include area code)

City

Street Address
Date of Birth Eligible for
(mm-dd-yyyy) Medicare?

If yes, complete VA Form 107959c and attach a copy of
Medicare Card

First Name

Last Name
Email Address
Telephone Number
(include area code)
Last Name

Telephone Number
(include area code)

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

If yes, complete VA Form 107959c and attach a copy of
Insurance card

MI Social Security Number
City

Street Address
Date of Birth Eligible for
(mm-dd-yyyy) Medicare?

Yes Other Health
No Insurance?

If yes, complete VA Form 107959c and attach a copy of
Medicare Card

First Name

Email Address

Yes Other Health
No Insurance?

State Zip Code

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

If yes, complete VA Form 107959c and attach a copy of
Insurance card

City

Date of Birth Eligible for
(mm-dd-yyyy) Medicare?

Yes Other Health
No Insurance?

If yes, complete VA Form 107959c and attach a copy of
Medicare Card

Male
Female

State Zip Code

MI Social Security Number

Street Address

Sex

Sex

Male
Female

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

If yes, complete VA Form 107959c and attach a copy of
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

l declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that
any 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

Street Address
VA FORM
June, 2014

Date

X

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

10-10d

Signature

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 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 June 2014 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 wife/husband or widow(er) of an eligible CHAMPVA sponsor - 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 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 (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 June 2014 10-10d