Fillable Application For CHAMPVA Benefits (VA Form 10-10d) (U.S. Department of Veterans Affairs)

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Application For CHAMPVA Benefits (VA Form 10-10d) (U.S. Department of Veterans Affairs)

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Application for CHAMPVA Benefits
Chief Business Office
Purchased Care
CHAMPVA
Eligibility
PO Box
469028
Denver, CO
80246-9028
Customer Service Center
1-800-733-8387
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.
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
deceased?
No
Yes
If yes →
If no go to sect. II
Date of Death (mm-dd-yyyy)
Did veteran die while
on active military service?
No
Yes
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
Female
Male
Email Address
Street Address
City
State
Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Last Name
First Name
MI Social Security Number
Sex
Female
Male
Email Address
Street Address
City State Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Last Name
First Name
MI Social Security Number
Sex
Female
Male
Email Address
Street Address
City State Zip Code
Telephone Number
(include area code)
Date of Birth
(mm-dd-yyyy)
Enrolled in
Medicare?
If yes, complete VA Form
10-7959c and attach a copy of
Medicare Card
No
Yes
Other Health
Insurance?
If yes, complete VA Form
10-7959c and attach a copy of
Insurance card
No
Yes
Relationship to the veteran
(i.e., spouse, child, stepchild)
Section III - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious, or fraudulent statements or claims
Signature
X
Date
Last Name
First Name
MI
Telephone Number (include area code)
Relationship to Applicant(s)
Street Address City State Zip Code
VA FORM
JUL 2014
10-10d
OMB Number 2900-0219
Estimated Burden: 10 minutes
Expiration Date: 01/31/2017
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED
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 on right). If certification is signed
by a person other than an applicant, complete the following:
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.
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.
Page 2 of 3
Application for CHAMPVA Benefits – Important Notes and Definitions
VA FORM JUL 2014 10-10d
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED
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.
Application for CHAMPVA Benefits – Important Notes and Definitions
Page 3 of 3
VA FORM JUL 2014 10-10d
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
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Application For CHAMPVA Benefits (VA Form 10-10d) (U.S. Department of Veterans Affairs)

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Completed 21 July 2020

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