What Is VA Form 10-10 Series?
This series of forms issued by the Department of Veterans Affairs (VA) includes:
- VA Form 10-10D, Application for CHAMPVA Benefits, is a document used to apply for the health benefits program. With the help of this application the VA shares the cost of certain health care services and supplies with eligible beneficiaries;
- VA Form 10-10CG, Application for Comprehensive Assistance for Family Caregivers Program, is used to apply for VA's Comprehensive Assistance for Family Caregivers Program by submitting personal information;
- VA Form 10-10M, Medical Certificate, is a document attesting the result of a medical examination of a veteran;
- VA Form 10-10EZR, Health Benefits Renewal Form, is completed by the veterans to update their personal, insurance, or financial information;
- VA Form 10-10SH, State Home Program Application for Veteran Care Medical Certification, is necessary to apply for quality care for the veterans in a nursing home, domiciliary, and adult day health care;
- VA Form 10-10EC, Application For Extended Care Services, is a form for the veterans who need assisted living, residential (live-in) or home health care through VA.;
- VA Form 10-10HS, Request for Hardship Determination, is used by the veterans whose gross household income has decreased;
- VA Form 10-10EZ, Application for Health Benefits (VA Form 10-10EZ Spanish), is used by veterans to apply for enrollment in the VA health care system.
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care benefits program. With the help of this program, the VA shares the cost of covered health care services and supplies with eligible beneficiaries. An individual can apply for VA services and supplies using the CHAMPVA forms. The VA will determine whether the services were medically necessary and if they were received from an authorized provider.
The services under coverage include ambulance service, ambulatory surgery, durable medical equipment, family planning, and maternity, hospice, inpatient services, mental health service, outpatient services, pharmacy (prescription medicines), skilled nursing care, and transplants.
To be considered eligible for the CHAMPVA benefits, an individual must be in one of the following categories:
- The spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office;
- The surviving spouse or child of a veteran who died from a VA-rated service-connected disability;
- The surviving spouse or child of the veteran who was assessed as permanently and totally disabled; and
- The surviving spouse or child of a military member who died on active duty, however, not due to misconduct.
Comprehensive Assistance for Family Caregivers
The VA Program of Comprehensive Assistance for Family Caregivers is a clinical program focusing on the needs of both the veteran and the primary and secondary family caregivers. Participation in the program must be in the best interest of the veteran, including consideration of whether this participation contributes to the veteran's rehabilitation and well-being.
The Comprehensive Assistance for Family Caregivers Program is not a VA benefits program. Eligibility is reassessed annually or as needed. When appropriate, the long-term goal is for the veteran to be able to safely meet their own care needs.
A person should fill out the Comprehensive Assistance for Family Caregivers Application (VA Caregiver Form 10-10CG) in case:
- They are a veteran or service member who has been issued date of medical discharge from the military;
- They require ongoing supervision or assistance with performing basic functions of everyday life due to a serious injury or mental disorder (including traumatic brain injury, psychological trauma or other mental disorder) incurred or aggravated in the line of duty on or after September 11, 2001; and
- They require at least 6 months of continuous caregiver support.
Use this form to apply for certain health benefits program, shared by the Department of Veterans Affairs (VA) with eligible beneficiaries.
The information provided on this form is used by the VA to determine eligibility for certain medical benefits.
Download this form if you wish to apply for the Program of Comprehensive Assistance for Family Caregivers (PCAFC) maintained by the Department of Veterans Affairs (VA).