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Blank Va 10 10D Form

The VA Form 10-10D is an application used to request benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This form is primarily for the spouses and children of veterans who have been rated permanently and totally disabled due to service-connected conditions. Completing this form accurately is essential for determining eligibility for CHAMPVA benefits.

Outline

The VA Form 10-10D is a crucial document for individuals seeking CHAMPVA benefits, which provide health care coverage to eligible dependents of veterans. This application form is designed for spouses and children of veterans who have been rated as having a permanent and total service-connected disability or who have died as a result of such conditions. It requires detailed information about both the veteran and the applicants, including names, Social Security numbers, and health insurance details. Applicants must also indicate if they have Medicare or other health insurance, as this can affect their eligibility for CHAMPVA benefits. The form includes a certification section where applicants affirm the accuracy of their information under penalty of perjury. It is essential to submit the completed form along with any necessary supporting documents, such as Medicare cards, to the designated address to ensure timely processing. Understanding the requirements and instructions outlined in the form is vital for a successful application process, as failure to provide accurate information may lead to delays or denials of benefits.

Sample - Va 10 10D Form

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

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?

If no go to sect. II

on active military service?

Section II - Applicant

Information (if

necessary, continue on additional 10-10d and complete in its entirety)

Last Name

First Name

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)

If yes, complete VA

Form

If yes, complete VA

Form

10-7959c and attach a copy of

Medicare Card

Insurance card

Last Name

First Name

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)

If yes, complete VA

Form

10-7959c and attach a copy of

Medicare Card

Insurance card

Last Name

First Name

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)

If yes, complete VA

Form

If yes, complete VA

Form

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

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

Last Name

First Name

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

Click for PDF

Form Information

Fact Name	Details
OMB Number	2900-0219
Estimated Burden	Completing the form typically takes about 10 minutes.
Expiration Date	This form is set to expire on 01/31/2017.
Governing Laws	The form is governed by 38 USC 501 and 1781, which outline the authority for collecting information.
Eligibility Criteria	Eligible individuals include spouses or children of veterans with a permanent and total service-connected disability.

Detailed Guide for Filling Out Va 10 10D

Completing the VA Form 10-10D is a necessary step for those seeking CHAMPVA benefits. It is important to provide accurate information to ensure proper processing of the application. Follow the steps below to fill out the form correctly.

Obtain the VA Form 10-10D. This form can be downloaded from the official VA website or requested from a VA office.
Begin with Section I, which requires Sponsor Information. Enter the veteran's last name, first name, and middle initial.
Provide the veteran's Social Security number and VA file number (claim number).
Fill in the veteran's street address, city, state, and zip code.
Include a telephone number with area code and the veteran's date of birth in mm-dd-yyyy format.
Enter the date of marriage in mm-dd-yyyy format. Indicate if the veteran is deceased and, if so, provide the date of death.
Proceed to Section II, Applicant Information. For each applicant, fill in the last name, first name, and middle initial.
Provide the applicant's Social Security number, sex, email address, street address, city, state, zip code, and telephone number.
Enter the applicant's date of birth in mm-dd-yyyy format. Indicate if the applicant is enrolled in Medicare or other health insurance.
If applicable, complete VA Form 10-7959c and attach a copy of the Medicare card or insurance card.
If there are additional applicants, repeat the information entry for each one as needed.
In Section III, sign and date the form. If someone else is signing on behalf of the applicant, provide their name, telephone number, relationship to the applicant, and address.
Review the completed form for accuracy and ensure all necessary information is included.
Submit the form along with any additional requested information to the address indicated on the form.

After submitting the form, it may take some time for the application to be processed. Keep a copy of the submitted form for your records. If further information is required, the VA will reach out to the contact information provided on the form.

Obtain Answers on Va 10 10D

What is the VA Form 10-10D used for?

The VA Form 10-10D is an application for CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) benefits. This form is specifically designed for the spouses and children of veterans who have been rated as having a permanent and total service-connected disability. It also applies to the surviving spouses and children of veterans who have died due to a service-connected condition. Completing this form is essential for those seeking to access health care benefits through CHAMPVA.
Who is eligible to apply for CHAMPVA benefits using this form?

Eligibility for CHAMPVA benefits through the VA Form 10-10D extends to:
- The spouse or child of a veteran with a permanent and total service-connected disability.
- The surviving spouse or child of a veteran who died from a service-connected condition or was rated permanently and totally disabled at the time of death.
- The surviving spouse or child of a person who died in the line of duty, provided the death was not due to misconduct.
It is important to note that applicants must not be eligible for DoD's TRICARE benefits to qualify for CHAMPVA.
What additional information must be submitted along with the VA Form 10-10D?

If an applicant has Medicare or other health insurance, they must also submit VA Form 10-7959c. This requirement ensures that the VA can accurately assess the applicant's eligibility and coordinate benefits. Furthermore, if additional space is needed for listing multiple applicants, another VA Form 10-10D should be completed and submitted.
What should I do if my marital status changes?

It is crucial to report any changes in marital status immediately to CHAMPVA. For instance, if a marriage is terminated by divorce or annulment, CHAMPVA eligibility ends as of midnight on the effective date of the dissolution. To report such changes, contact the Eligibility Unit at the provided address or call 1-800-733-8387. Keeping CHAMPVA informed ensures that benefits are managed correctly and avoids any potential issues with coverage.

Common mistakes

Filling out the VA Form 10-10D for CHAMPVA benefits can be a straightforward process, but many applicants encounter pitfalls that can delay their application. One common mistake is failing to provide complete information in the Sponsor Information section. Applicants often overlook critical details such as the veteran's Social Security Number or VA File Number. These identifiers are essential for processing the application efficiently. Leaving out this information can lead to unnecessary delays and complications.

Another frequent error involves not signing and dating the certification section. This section is crucial because it confirms that the information provided is accurate. Without a signature, the form may be deemed incomplete, resulting in rejection. Always double-check that the certification is signed, and if someone else is signing on behalf of the applicant, ensure that the relationship to the applicant is clearly stated.

Many applicants also neglect to review the instructions provided on the reverse side of the form. These instructions contain vital information about eligibility and documentation requirements. For instance, if an applicant indicates they have Medicare or other health insurance, they must submit VA Form 10-7959c. Failing to follow these instructions can lead to a denial of benefits.

Another mistake occurs when applicants provide outdated or incorrect contact information. This includes telephone numbers and addresses. If the VA needs to reach the applicant for any reason, incorrect information can hinder communication. Ensuring that all contact details are current is essential for a smooth application process.

Some applicants mistakenly assume that they do not need to provide additional forms or documentation. For example, if the applicant is enrolled in Medicare, they must attach a copy of their Medicare card. Not including this documentation can cause delays in processing the application or even result in denial of benefits.

Additionally, applicants often fail to specify their relationship to the veteran accurately. It is vital to clarify whether the applicant is a spouse, child, or stepchild, as this affects eligibility. Misidentifying the relationship can complicate the review process and may lead to questions that slow down approval.

Lastly, many people overlook the importance of keeping a copy of the completed form for their records. This can be crucial if any issues arise later in the application process. Having a record allows applicants to reference what they submitted, ensuring they can provide accurate information if contacted by the VA.

Documents used along the form

The VA Form 10-10D is an essential document for individuals seeking CHAMPVA benefits. Alongside this form, several other documents may be required to ensure a smooth application process. Below is a list of additional forms often used in conjunction with the VA Form 10-10D, each serving a specific purpose.

VA Form 10-7959c: This form is necessary for applicants who have Medicare or other health insurance. Each applicant must complete this form and attach a copy of their Medicare card or health insurance card to verify their coverage.
VA Form 21-534: This form is used to apply for Dependency and Indemnity Compensation (DIC) benefits. It is relevant for surviving spouses and children of veterans who have died due to service-related conditions, ensuring they receive the benefits they are entitled to.
VA Form 21-686c: This form is utilized to report the existence of dependents. It is crucial for veterans who are applying for benefits and need to disclose any dependents that may affect their eligibility or benefit amount.
VA Form 22-5490: This form is specifically for applying for vocational rehabilitation and employment services. It is applicable to veterans with service-connected disabilities who require assistance in obtaining suitable employment or training.

In summary, while the VA Form 10-10D is vital for applying for CHAMPVA benefits, these additional forms help clarify eligibility, ensure proper documentation, and support the application process. It is essential to gather all required documents to facilitate a timely and efficient review of the benefits request.

Similar forms

The VA Form 10-10D is an important document for applying for CHAMPVA benefits. Here are ten other documents that are similar in purpose or function:

VA Form 10-7959c: This form is required when applicants have Medicare or other health insurance. It helps to determine eligibility for benefits.
VA Form 21-526EZ: This is an application for disability compensation and related compensation benefits. It serves a similar purpose in assessing eligibility for benefits.
VA Form 21-534EZ: This form is for survivors' benefits. It is used by dependents of veterans to apply for benefits, just like the 10-10D is used by applicants for CHAMPVA.
VA Form 21-686c: This form is for adding dependents to a veteran’s benefits. It helps ensure that all eligible family members are accounted for in benefit applications.
VA Form 21-530: This is an application for burial benefits. It serves a similar function in providing benefits related to a veteran's service.
VA Form 10-10EZ: This form is used for applying for health benefits through the VA. It is similar in that it collects information to determine eligibility.
VA Form 10-10P: This form is for applying for patient financial assessment. It helps determine the financial responsibility of veterans for their care.
VA Form 21-22: This is a form for appointing a representative to assist with VA benefits. It is similar in that it facilitates the application process for benefits.
VA Form 10-10S: This form is for applying for CHAMPVA benefits for surviving spouses and children of veterans. It serves a similar purpose as the 10-10D.
VA Form 21-4142: This is a release form for obtaining private medical records. It is similar in that it collects necessary information to support a benefits application.

Dos and Don'ts

When filling out the VA Form 10-10D for CHAMPVA benefits, there are some important dos and don'ts to keep in mind. Here’s a helpful list:

Do read the instructions carefully before starting the form.
Do fill out the form completely. Make sure every section is filled in.
Do use clear and legible handwriting or type the information.
Do include any necessary supporting documents, like Medicare cards or insurance information.
Don't leave any required fields blank. If something doesn’t apply, write "N/A."
Don't submit the form without signing and dating it. This is crucial for processing.
Don't forget to check for errors before sending it in. Double-check all information.

Misconceptions

Understanding the VA Form 10-10D can be challenging, and several misconceptions often arise regarding its purpose and requirements. Below is a list of common misunderstandings along with clarifications to help you navigate this important form.

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

This form is actually for dependents of veterans, such as spouses and children, who are applying for CHAMPVA benefits. Veterans must be rated as having a permanent and total service-connected condition for their dependents to qualify.

Misconception 2: Submitting the 10-10D form guarantees CHAMPVA benefits.

While submitting the form is a crucial step, it does not automatically guarantee benefits. Eligibility is determined based on various factors, including the veteran's service-connected status and the applicant's relationship to the veteran.

Misconception 3: You do not need to provide any additional documentation with the 10-10D form.

In many cases, additional documentation is required. For example, if the applicant has Medicare or other health insurance, they must also submit VA Form 10-7959c along with their 10-10D application.

Misconception 4: The form can be submitted without a signature.

A signature is necessary for the application to be valid. The applicant must declare that the information provided is accurate under penalty of perjury.

Misconception 5: CHAMPVA benefits are available to all family members of veterans.

Eligibility is limited to specific family members, such as spouses and children, who meet certain criteria. Not all family members automatically qualify for these benefits.

Misconception 6: Once submitted, the application will be processed quickly.

Processing times can vary. Delays may occur if additional information is needed or if there are issues with the application. It is essential to ensure all information is complete and accurate to avoid delays.

Misconception 7: The 10-10D form is the only document needed for CHAMPVA benefits.

In addition to the 10-10D form, applicants may need to provide other forms or documentation depending on their specific circumstances, such as proof of relationship to the veteran or documentation of other health insurance.

Misconception 8: You can submit the form in any format.

The form must be completed in a specific format, either by printing or typing. Handwritten applications may not be accepted if they are difficult to read.

Misconception 9: CHAMPVA benefits continue indefinitely without any reporting requirements.

It is important to report any changes in status, such as marriage or divorce, as these can affect eligibility. Failure to report changes may result in the termination of benefits.

By addressing these misconceptions, applicants can better understand the VA Form 10-10D and navigate the process of applying for CHAMPVA benefits more effectively.

Key takeaways

Here are key takeaways regarding the VA Form 10-10D for CHAMPVA benefits:

The form is used to apply for CHAMPVA benefits, which are available to eligible spouses and children of veterans.
Applicants must complete the form in its entirety, ensuring all information is accurate and clearly printed or typed.
Section I requires information about the veteran, including their Social Security number and VA File Number.
Section II gathers information about the applicant, including their relationship to the veteran and any other health insurance they may have.
If the applicant has Medicare or other health insurance, they must also submit VA Form 10-7959c.
Certification at the end of the form confirms the truthfulness of the information provided and is subject to penalties for false statements.
Eligibility for CHAMPVA benefits requires that the applicant is not eligible for DoD's TRICARE benefits.
Changes in marital status, such as divorce, can affect CHAMPVA eligibility and should be reported immediately.
School certification is necessary for children aged 18 to 23 who are enrolled in full-time education to maintain CHAMPVA benefits.