Form 10-10d CHAMPVA Application for Benefits

OMB Control No. 2900-0219
Respondent Burden: 10 Minutes
Expiration Date: 10/31/2024

APPLICATION FOR CHAMPVA BENEFITS
Champ VA Program Office, Office of Integrated Veteran Care, CHAMPVA Eligibility, PO Box 469028, Denver CO 80246-9028
Customer Service Center: 1-800-733-8387 | FAX: 303-331-7809
ATTENTION: Please refer to the information on the following pages for assistance completing 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 VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification. If additional space is needed, complete another VA Form
10-10d in its entirety, sign and submit.

SECTION I - SPONSOR INFORMATION
VETERAN'S LAST NAME

FIRST NAME

MI

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

PHONE NUMBER (Include Area Code)

DATE OF BIRTH (MM/DD/YYYY)

DATE OF MARRIAGE (MM/DD/YYYY)

IS THE VETERAN DECEASED?

DATE OF DEATH (MM/DD/YYYY)

DID THE VETERAN DIE WHILE ON ACTIVE
MILITARY SERVICE?

YES

NO

IF "YES," CONTINUE
IF "NO," GO TO SECTION II

STATE

VA FILE NUMBER

(Claim Number)

YES

ZIP CODE

NO

SECTION II - APPLICANT INFORMATION
LAST NAME

FIRST NAME

MI

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

EMAIL ADDRESS

PHONE NUMBER (Include Area Code)

STATE

DATE OF BIRTH

(MM/DD/YYYY)
ZIP CODE
GENDER
MALE

ENROLLED IN MEDICARE

If checked, complete VA Form 10-7959c and
attach a copy of Medicare Card
LAST NAME

RELATIONSHIP TO VETERAN (i.e., spouse, child)

HAS OTHER HEALTH INSURANCE

If checked, complete VA Form 10-7959c and
attach a copy of insurance card
FIRST NAME

MI

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

EMAIL ADDRESS

PHONE NUMBER (Include Area Code)

STATE

DATE OF BIRTH

(MM/DD/YYYY)
ZIP CODE
GENDER
MALE

ENROLLED IN MEDICARE

If checked, complete VA Form 10-7959c and
attach a copy of Medicare Card
LAST NAME

FEMALE

RELATIONSHIP TO VETERAN (i.e., spouse, child)

HAS OTHER HEALTH INSURANCE

If checked, complete VA Form 10-7959c and
attach a copy of insurance card
FIRST NAME

MI

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

EMAIL ADDRESS

PHONE NUMBER (Include Area Code)

STATE

DATE OF BIRTH

(MM/DD/YYYY)
ZIP CODE
GENDER
MALE

ENROLLED IN MEDICARE

If checked, complete VA Form 10-7959c and
attach a copy of Medicare Card

FEMALE

FEMALE

RELATIONSHIP TO VETERAN (i.e., spouse, child)

HAS OTHER HEALTH INSURANCE

If checked, complete VA Form 10-7959c and
attach a copy of insurance card

SECTION III - CERTIFICATION

I 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 below.)
DATE (MM/DD/YYYY)

SIGNATURE:

If certification is signed by a person other than an applicant, complete the following:
LAST NAME

FIRST NAME

MI

RELATIONSHIP TO APPLICANT(S)

STREET ADDRESS

CITY

STATE

ZIP CODE

VA FORM
AUG 2024

10-10d

PHONE NUMBER (Include Area Code)

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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 at 1-800-733-8387 or via mail to:
CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver CO 80246-9028.
PRIVACY ACT INFORMATION: Information on this form is collected in accordance with the System of Records Notice 54VA10NB3, Veterans and
Beneficiaries Purchased Care Community Health Care Claims, Correspondence, Eligibility, Inquiry and Payment Files-VA (Published March 3, 2015, FR 80,
number 41). Category: Records maintained in the system include program applications, eligibility information concerning the Veteran, family members, caregivers,
other health insurance information to include information regarding eligibility or entitlement to other federal medical programs. Authority: 38 USC 501 and 1781.
Purpose: Records may be used for purposes of establishing and monitoring eligibility to receive VA benefits, processing claims for medical care and services, and
processing stipends. Routine Use: The Privacy Act permits VA to disclose information about individuals without their consent under the Privacy Act Routine Use
Disclosure when the information will be used for a purpose that is compatible with the purpose for which VA collected the information. Disclosure: Voluntary. 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.
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless is displays a
currently valid OMB control number. The OMB control number for this project is 2900-0219, and it expires 10/31/2024. Public reporting burden for this collection
of information is estimated to average 10 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to
OMB Control No. 2900-0219 in any correspondence. Do not send your completed VA Form 10-10d to this email address. If you have questions about your eligibility
for CHAMPVA benefits or how to complete this form, you may call the CHAMPVA Help Line at 800-733-8387.

APPLICATION FOR CHAMPVA BENEFITS - IMPORTNAT 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.
CHAMPVA Eligibility Definitions

Medical 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.
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.

VA FORM 10-10d, MAY 2023

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School Certification
In order to extend CHAMPVA benefits to students age 18 to 23, school certification of 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 (4) years for traditional schooling programs, two (2) years for technical schooling programs. School certification for
each term or a full year is required for recertification of 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
• Certification of enrollment 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 CHAMPVA Program Office, Office of Integrated Veteran Care, of any change in student status, such as withdrawal.
School vacation periods, holidays, and summer breaks (providing the student attends school both before and after the summer break) are not considered an
interruption in attendance and will not create a break in CHAMPVA eligibility.

VA FORM 10-10d, MAY 2023

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