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The VA Form 10-10D, known as the Application for CHAMPVA Benefits, plays a significant role in assisting eligible dependents of veterans to secure health care coverage. This form helps individuals apply for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), which provides medical benefits to the spouse or child of a veteran who is rated as permanently and totally disabled due to a service-connected condition. Furthermore, this application is crucial for those who are the surviving spouse or child of a veteran who has died as a result of a service-connected condition or while on active duty. The form requires applicants to provide critical personal information, including their relationship to the veteran, social security numbers, and the date of birth, among other details. There are specific sections designed to capture the necessary information about both the veteran and the applicant, ensuring that all essential data is collected. An important aspect of the application includes verifying any existing Medicare or other health insurance coverage, as additional forms will need to be completed in such instances. Lastly, the form emphasizes the need for accuracy and honesty, as it includes a certification that highlights the legal implications of submitting false information. Proper completion and submission of the 10-10D form is foundational in determining eligibility for vital health care benefits for those who have sacrificed for our nation.

Va 10 10D Example

OMB Number 2900-0219

Estimated Burden: 10 minutes

Expiration Date: 01/31/2017

Application for CHAMPVA Benefits

Chief Business Office

CHAMPVA

PO Box

Denver, CO

Customer Service Center

FAX

Purchased Care

Eligibility

469028

80246-9028

1-800-733-8387

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

 

Yes

If yes →

 

Date of Death (mm-dd-yyyy)

Did veteran die while

 

 

Yes

 

 

 

 

 

 

 

deceased?

 

No

If no go to sect. II

 

 

 

 

 

 

 

 

 

 

 

 

on active military service?

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

Date of Birth

Enrolled in

 

 

Yes

 

Other Health

 

 

Yes

Relationship to the veteran

 

 

 

 

 

Medicare?

 

 

Insurance?

 

 

(i.e., spouse, child, stepchild)

 

 

(include area code)

 

 

 

(mm-dd-yyyy)

 

No

 

No

 

 

 

 

 

If yes, complete VA

Form

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

10-7959c and attach a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Card

 

Insurance card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

First Name

 

 

 

MI

 

Social

 

Security Number

 

 

 

Sex

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

Date of Birth

Enrolled in

 

 

Yes

 

Other Health

 

 

Yes

Relationship to the veteran

 

 

 

 

 

Medicare?

 

 

Insurance?

 

 

(i.e., spouse, child, stepchild)

 

 

(include area code)

 

 

 

(mm-dd-yyyy)

 

No

 

No

 

 

 

 

 

If yes, complete VA

 

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

10-7959c and attach a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Card

 

Insurance card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

First Name

 

 

 

 

MI

 

Social Security Number

 

 

 

Sex

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

Date of Birth

Enrolled in

 

 

Yes

 

Other Health

 

 

Yes

Relationship to the veteran

 

 

 

 

 

Medicare?

 

 

Insurance?

 

 

(i.e., spouse, child, stepchild)

 

 

(include area code)

 

 

 

(mm-dd-yyyy)

 

No

 

No

 

 

 

 

 

If yes, complete VA

Form

If yes, complete VA

Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-7959c and attach a copy of

10-7959c and attach a copy of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Card

 

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

 

 

 

 

 

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

 

Signature

 

 

 

 

 

 

 

 

 

 

Date

 

 

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

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

by a person other than an applicant, complete the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

First Name

 

 

MI

Telephone Number (include area code)

Relationship to Applicant(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA FORM

 

 

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED

 

 

 

 

JUL 2014 10-10d

 

 

 

 

 

 

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 JUL 2014 10-10d

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED

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 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.

VA FORM JUL 2014 10-10d

SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
Get Va 10 10D PDF Form

Form Characteristics

Fact Name Description
OMB Number The VA Form 10-10D is associated with OMB Number 2900-0219.
Estimated Completion Time It typically takes about 10 minutes to complete this application.
Expiration Date This form expired on January 31, 2017.
Submission Address Completed forms should be sent to CHAMPVA, PO Box 469028, Denver, CO 80246-9028.
Supporting Documentation Required If an applicant has Medicare or other health insurance, a VA Form 10-7959c must be submitted alongside this form.
Governing Law The Privacy Act of 1974, 38 USC 501, and 38 USC 1781 govern the collection and handling of information on this form.

Guidelines on Utilizing Va 10 10D

Once you've obtained the VA Form 10-10D, it's essential to complete it accurately to ensure that your application for CHAMPVA benefits is processed without delays. Follow the instructions carefully and provide all requested information, as incomplete submissions may result in a denial. After filling out the form, make sure to send it to the appropriate address to finalize your application.

  1. Begin by filling out Section I for Sponsor Information. Include the veteran's last name, first name, middle initial, social security number, and VA file number.
  2. Input the veteran's street address, city, state, and zip code, along with a telephone number that includes the area code.
  3. Provide the veteran's date of birth, and if applicable, the date of marriage also.
  4. Indicate whether the veteran is deceased. If yes, provide the date of death. If no, proceed to Section II.
  5. In Section II, fill in the applicant information. Each applicant must provide their last name, first name, middle initial, and social security number.
  6. State the applicant's sex, email address, street address, city, state, zip code, and telephone number, including the area code.
  7. Enter the applicant's date of birth and note if they are enrolled in Medicare or Other Health Insurance.
  8. For those enrolled in Medicare or other health insurance, complete VA Form 10-7959c and attach a copy of the Medicare or insurance card.
  9. If there are additional applicants, repeat the previous steps as necessary for each individual.
  10. In Section III, read the certification statement carefully. Sign and date the form to attest to the truthfulness of the information provided.
  11. If someone other than the applicant is signing, include their name, telephone number, relationship to the applicant(s), and address.
  12. Review the entire form for completeness and accuracy before submitting.
  13. Return the completed form to the Chief Business Office CHAMPVA at the provided address.

What You Should Know About This Form

What is the VA Form 10-10D?

The VA Form 10-10D is an application for CHAMPVA benefits, which are health care benefits for eligible dependents of veterans. To apply, individuals must fill out the form completely, providing essential information about the veteran and the applicant. This includes basic details like names, Social Security numbers, and contact information, as well as any relevant military service records. Proper completion of the form is critical for determining eligibility.

Who is eligible for CHAMPVA benefits?

Eligibility for CHAMPVA benefits pertains primarily to spouses and children of veterans who have a permanent and total service-connected condition. It also extends to the surviving spouse or child of a veteran who has died from a service-related condition, or those who died in service without misconduct. Notably, individuals must not be eligible for DoD's TRICARE benefits to qualify for CHAMPVA.

What information is needed to complete the form?

To complete the VA Form 10-10D, applicants must provide information about themselves and the veteran. This includes names, Social Security numbers, contact details, dates of birth, and current health insurance coverage, if applicable. If the applicant or veteran has Medicare or other health insurance, submitting VA Form 10-7959c is required. It's crucial to ensure that all information is accurate and complete to avoid delays in processing.

How does Medicare impact CHAMPVA eligibility?

For those eligible for Medicare, having both Medicare Part A and Part B is essential to maintain CHAMPVA benefits. Specifically, if individuals are under 65, they must possess Part B to be covered by CHAMPVA. For those aged 65 or older, the requirement for Part B applies if their 65th birthday falls on or after June 5, 2001. Understanding these Medicare requirements is crucial for maintaining healthcare coverage.

What should be done if there are changes in marital status?

Any termination of marriage due to divorce or annulment results in the end of CHAMPVA eligibility. This change takes effect immediately at midnight on the date of the dissolution. It's vital for individuals to report such changes promptly to CHAMPVA to ensure they receive appropriate guidance and assistance concerning their eligibility and benefits.

Common mistakes

Filling out the VA Form 10-10D can seem like a straightforward task, but many individuals stumble upon common mistakes that can delay their application for CHAMPVA benefits. Understanding these pitfalls might simplify the process and help applicants avoid unnecessary complications.

One frequent mistake is failing to provide complete information. The form demands detailed entries, such as the veteran’s Social Security number and VA File number. Leaving sections blank or entering incomplete details will likely lead to delays or even denials of benefits. It’s crucial to review the form for any missing information before submitting it.

Another common error involves not signing or dating the certification section. This section affirms the truthfulness of the information given. Omitting a signature or date can render the application invalid. An application without proper certification will be seen as incomplete, which can prolong the eligibility process.

Some applicants mistakenly assume that submitting additional documents is unnecessary. If applicants indicate that they have other health insurance or Medicare, they are required to submit VA Form 10-7959c alongside the 10-10D. Neglecting to attach this form can result in delays, as the reviewing body needs these documents to process the application correctly.

Providing incorrect or outdated personal information is yet another issue that arises often. Whether it's a change of address or a new phone number, any discrepancies in the provided details may lead to difficulty in correspondence or even eligible individuals missing out on benefits due to outdated records. Always ensure that all information is current and matches official documents.

In some cases, individuals misinterpret the eligibility criteria for CHAMPVA benefits. Eligibility is tied to specific conditions regarding the veteran’s service-connected disability status. Misunderstanding these nuances can result in unnecessary applications or appeals, consuming valuable time and resources.

Failure to read and follow the instructions on the form is also prevalent. Each section of the 10-10D has particular guidelines that need to be adhered to. Applicants may overlook important notes regarding how to type or print their answers. Ignoring these details can result in forms being rejected or returned for corrections.

Moreover, some applicants may forget to double-check for errors after completing the form. Simple typos or incorrect entries can lead to significant complications down the line. Taking the extra moment to proofread can prevent additional headaches during the processing of the application.

The timing of submitting the application can also be a critical factor. Some individuals fail to submit their forms promptly, especially if they are navigating personal circumstances like marriage dissolution or changes in health coverage. Transitioning situations can affect eligibility; thus, timely submission is essential to avoid missing out on benefits.

Finally, some may overlook the privacy information regarding how their data may be used and disclosed. Understanding this aspect is crucial, as it provides clarity on the confidentiality of their information. Staying informed can help applicants feel more secure about submitting their details and empower them to ask informed questions if needed.

By being aware of these common mistakes, applicants can enhance their chances of successfully navigating the VA Form 10-10D process. Attention to detail, timely submissions, and a thorough understanding of the requirements can significantly streamline their application for CHAMPVA benefits.

Documents used along the form

The VA Form 10-10D is essential for individuals seeking CHAMPVA benefits. However, several other documents are often required to ensure a complete application. Below is a summary of five commonly used forms that accompany the 10-10D.

  • VA Form 10-7959c: This form is required if the applicant indicates they have Medicare or other health insurance in Section II of the 10-10D. It helps collect additional essential information about the health insurance coverage.
  • VA Form 10-17: This form may be used to provide additional information for a CHAMPVA application, particularly for unique circumstances that don’t fit standard eligibility criteria.
  • Divorce Decree or Annulment Certificate: When applicable, this document proves a change in marital status affecting CHAMPVA eligibility. It is necessary to submit it if there has been a divorce or annulment of the qualifying sponsor.
  • Death Certificate: This is crucial for surviving spouses or children of veterans who are applying for benefits. The certificate establishes eligibility, confirming the veteran’s death related to service.
  • School Certification: Required for students aged 18-23, this document confirms full-time enrollment in an educational institution. It must outline specific details about the student’s status to qualify for continued benefits.

Gathering these documents ensures a smoother application process for CHAMPVA benefits. Any missing information can lead to delays or denials. Always review requirements closely and submit everything necessary as promptly as possible.

Similar forms

The VA Form 10-10D, Application for CHAMPVA Benefits, has several other forms that are similar in purpose or function. These forms all relate to either veteran benefits or healthcare eligibility processes. Below are eight documents that share similarities with the VA Form 10-10D:

  • VA Form 10-7959c: Used when applicants indicate they have Medicare or other health insurance. This form collects additional information about the applicant’s health coverage.
  • VA Form 21-526EZ: This is a simplified application for disability compensation. Like the 10-10D, it helps determine eligibility based on veteran service.
  • VA Form 21-534EZ: This form is for survivors benefits applications. It assists eligible dependents in obtaining benefits similar to CHAMPVA.
  • VA Form 22-5490: This application is for dependents’ education assistance. It parallels the 10-10D as it addresses benefits for family members of veterans.
  • VA Form 10-10EZ: Known as the Application for Health Benefits, this form is similar in that it helps establish eligibility for various health services provided by the VA.
  • VA Form 10-1076: This form assists in determining eligibility for the VA’s health care system, closely mirroring the intentions of the 10-10D.
  • VA Form 10-10P: This application allows veterans to apply for enrollment in the Patient-Centered Community Care program. It’s similar as it manages healthcare access.
  • VA Form 21-4142: This form is for authorizing the release of medical records to the VA. Like the 10-10D, it is critical for the claims process to verify health benefits eligibility.

Dos and Don'ts

When filling out the VA Form 10-10D, there are important dos and don’ts to consider. Following these guidelines can help ensure your application is processed smoothly.

  • Do read the instructions thoroughly before beginning to fill out the form.
  • Do print or type your responses clearly to avoid any misinterpretation.
  • Do include all required information, ensuring each section is complete.
  • Do provide copies of any necessary documents, such as Medicare or insurance cards, when required.
  • Do sign and date the certification section to confirm the information is true and accurate.
  • Don't leave any fields blank unless they are marked as optional.
  • Don't submit the form without checking for errors or missing information.
  • Don't include information that is not relevant to your application.
  • Don't disregard the expiration date and ensure that you are using the most current version of the form.

By following these guidelines, you can help facilitate the processing of your CHAMPVA benefits application.

Misconceptions

Misconceptions about the VA 10-10D form can lead to confusion when applying for CHAMPVA benefits. Here’s a list of common misunderstandings:

  • Misconception 1: The VA 10-10D form is only for veterans.

    • This form is also used by the spouses and children of veterans to apply for CHAMPVA benefits.

  • Misconception 2: Submitting the form guarantees automatic approval.

    • Filling out the form correctly does not guarantee benefits. Eligibility is based on specific criteria set by the VA.

  • Misconception 3: You can submit the form without any supporting documents.

    • Additional documents may be required, especially if the applicant has Medicare or other health insurance.

  • Misconception 4: Changes in status do not need to be reported immediately.

    • It is essential to report any changes, such as marriage or divorce, to avoid issues with CHAMPVA eligibility.

  • Misconception 5: The form must be mailed; no other submission methods are available.

    • You can also fax the completed form and any additional documents to the provided number.

  • Misconception 6: Only the veteran can sign the form.

    • A representative can sign the form on behalf of the applicant if the applicant is unable to do so, but this requires additional information.

  • Misconception 7: CHAMPVA benefits continue indefinitely regardless of circumstances.

    • There are specific eligibility requirements that may change due to factors like remarriage or the age of the dependent children.

  • Misconception 8: The 10-10D form is the only form needed for CHAMPVA benefits.

    • If there is other health insurance or Medicare involved, VA Form 10-7959c must also be submitted.

  • Misconception 9: All applicants must be enrolled in Medicare to apply for CHAMPVA benefits.

    • Only applicants who are eligible for Medicare or have other health insurance must enroll in those programs to qualify for CHAMPVA benefits.

Key takeaways

When filling out the VA Form 10-10D for CHAMPVA benefits, it is essential to understand some key points to avoid delays or issues with your application. Below are important takeaways:

  • Eligibility is Crucial: Ensure that the applicant meets the eligibility criteria for CHAMPVA benefits. These include being the spouse or child of a veteran with a permanent and total service-connected condition.
  • Complete All Sections: Fill out every section of the form accurately. If more space is needed, complete an additional 10-10D form.
  • Documentation for Other Insurances: If the applicant has Medicare or other health insurance, submit VA Form 10-7959c alongside the 10-10D. Attach a copy of the Medicare or insurance card as well.
  • Signature Matters: The certification part must be signed and dated. If someone else signs it, they should provide their relationship to the applicant.
  • Report Changes Promptly: Any change in circumstances, such as marriage termination, should be reported to CHAMPVA immediately to maintain eligibility.
  • Understand the Privacy Act: Information provided is confidential. It may be shared only if authorized under the Privacy Act, especially for verifying eligibility.
  • School Certification for Students: If the applicant is a child aged 18-23 and attending school, include certification of full-time enrollment from the educational institution.

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