VA Form 10-10D Application for CHAMPVA Benefits

What Is VA Form 10-10d?

VA Form 10-10d, Application for CHAMPVA Benefits is a form used to apply for health benefits program, in which the Department of Veterans Affairs (VA) shares the cost of some health care services and supplies with eligible veterans.

The latest version of the application - sometimes incorrectly referred to as the DD Form 10-10d - was released by the VA in July 2014 with all previous editions obsolete. An up-to-date VA Form 10-10d fillable version is available for download below and can be found through the VA website.

There are three categories of eligible people for the Civilian Health and Medical Program of the Veterans Health Administration (CHAMPVA) 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 or 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.
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Download VA Form 10-10D Application for CHAMPVA Benefits

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VA Form 10-10D Application for CHAMPVA Benefits
VA Form 10-10D Application for CHAMPVA Benefits
VA Form 10-10D Application for CHAMPVA Benefits
VA Form 10-10D Application for CHAMPVA Benefits
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VA Form 10-10d Instructions

The form is distributed without any filling guidelines provided. Step-by-step instructions can be found below.

How to Fill out VA Form 10-10d?

The CHAMPVA Form 10-10d consists of three sections:

  1. Section 1 covers Sponsor Information. A veteran, upon whom CHAMPVA eligibility of the applicant is based, is a sponsor. This Section must include the veteran's full name, their social security number, veterans affairs file number, mailing address with ZIP code, telephone number, date of birth, date of marriage, and date of death, if applicable. The form requires the applicant to state whether the veteran is deceased or not and whether they died while on active military service.
  2. Section 2 requires information about the applicant. This includes their full name, social security number, mailing address with ZIP code, telephone number, date of birth, and relationship to the veteran. The applicant must indicate if they are enrolled in Medicare and if they have other health insurance. Positive answers require completion of the VA form 10-7959c and attachment of a Medicare Card to the VA Form 10-10d.
  3. Section 3 is for 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. The applicant states student's full name, telephone number, relationship to the applicant and the address, including street address, city, state, and zip code.

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