The VA Form 10-10D, known as the Application for CHAMPVA Benefits, is a document that individuals fill out to determine eligibility for health care benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This form serves as a vital tool for spouses and children of veterans who have either been rated permanently and totally disabled due to a service-connected condition, or for survivors of veterans who died from service-connected disabilities or in the line of duty. Eligibility for CHAMPVA extends to those who are not already covered under TRICARE, highlighting the form's role in facilitating access to medical benefits for qualifying family members.
The intricacies of the VA Form 10-10D, pivotal for those seeking benefits under CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), reflect the necessity of meticulous attention to detail in its completion and submission. At the heart of this form lies the provision for eligible beneficiaries, primarily spouses and children of veterans who either have been assessed with a permanent and total service-connected disability, have succumbed to a service-connected condition, or were fatally injured in the line of duty, thereby not due to misconduct. Eligibility intricacies extend to the realms of Medicare and other health insurance nuances, demanding careful consideration and declaration of such coverages by the applicants. Notably, adherence to stipulated guidelines ensures the accurate procession of applications, whilst any deviation or omission could potentially delay or deny the entitlement to CHAMPVA benefits. The form also encapsulates significant legal declarations, emphasizing the severe repercussions of falsification, underlining the gravity federal laws impose on truthful submissions. Embedded within, privacy and information collection notices outline the safeguarding of submitted data alongside the intended use, aimed at determining eligibility while ensuring confidentiality. Additionally, the form serves as a reminder of the implications of life events like marriage dissolution on CHAMPVA eligibility, mandating prompt communication of such changes to maintain the veracity of the beneficiary's status. By navigating through these facets with due diligence, applicants engage in a process that underscores the intersection of healthcare eligibility and legal compliance, anchored by the VA Form 10-10D.
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
deceased?
No
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
Sex
Male
Female
Email Address
Telephone Number
Date of Birth
Enrolled in
Other Health
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
Social
Security Number
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:
Relationship to Applicant(s)
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
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.
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
Completing the VA 10-10D form is an important step for qualifying individuals to receive CHAMPVA benefits. This form is designed to capture all necessary information to determine eligibility and ensure that benefits are provided to those who are entitled. To make this process smoother, applicants are encouraged to gather all required information beforehand, including the veteran's details, as well as any Medicare or other health insurance information that might be pertinent. Following these detailed steps will help in accurately completing the form and facilitating a timely assessment of your application.
After submitting the VA 10-10D form, the application will be reviewed to determine eligibility for CHAMPVA benefits. It is advised to wait for communication from the CHAMPVA office regarding the status of the application. During this period, ensure that all contact information provided is accurate and check for any correspondence from CHAMPVA, as additional information may be requested. Prompt response to such requests can aid in the efficient processing of your application.
What is the VA Form 10-10d Application for CHAMPVA Benefits?
The VA Form 10-10d is used to apply for CHAMPVA benefits, which are provided to the spouse, child, or stepchild of a veteran who has been rated as having a permanent and total service-connected condition/disability, or the surviving spouse or child of a veteran who died from a VA-rated service-connected condition or was rated permanently and totally disabled at the time of death. It's also available to the family members of a person who died in the line of duty, provided they're not eligible for TRICARE benefits.
How do I complete the VA Form 10-10d?
To complete the form, you need to provide detailed information about the veteran (sponsor), including their full name, social security number, VA file number, and other personal details. Additionally, the applicant must provide their information and specify their relationship to the veteran. If the applicant has Medicare or other health insurance, they must include a VA Form 10-7959c and a copy of their Medicare or insurance card.
What documents are required when submitting VA Form 10-10d?
When submitting the VA Form 10-10d, you must include any required VA Forms (like the 10-7959c if you have Medicare or other health insurance), and copies of Medicare or insurance cards. You might also need to provide documentation proving the relationship to the veteran, such as marriage certificates or birth certificates.
Who is eligible for CHAMPVA benefits?
Eligibility for CHAMPVA benefits extends to the spouse or child of a veteran who has a permanent and total service-connected disability, the surviving spouse or child of a veteran who died from a VA-rated service-connected condition or who was rated permanently and totally disabled at the time of death, as well as family members of individuals who died in the line of duty not due to misconduct.
What impact does Medicare have on CHAMPVA benefits?
If you are eligible for or become eligible for Medicare Part A, and you are under 65, you must also have Part B to be covered by CHAMPVA. If you are 65 or older and eligible for Medicare Part A, you are required to have Part B to be covered by CHAMPVA, provided your 65th birthday was on or after June 5, 2001, or you were enrolled in Part B prior to this date.
Does a divorce or remarriage affect CHAMPVA eligibility?
Yes, 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. If a CHAMPVA beneficiary remarries before age 55, benefits end. However, if the beneficiary remarries at age 55 or older, CHAMPVA benefits continue.
How does one submit VA Form 10-10d?
The completed form, along with any necessary attachments, should be sent to the address provided on the form: CHAMPVA, PO Box 469028, Denver, CO 80246-9028. You may also fax it to the number provided, which is 1-303-331-7809.
What happens if I fail to provide all the requested information on VA Form 10-10d?
Failure to provide all the requested information may lead to delays or denial of your request for CHAMPVA benefits. It's important to fill out the form accurately and completely to ensure your application is processed without delays.
How can I check the status of my CHAMPVA application?
After submitting your application, you can check the status by calling the CHAMPVA Customer Service Center at 1-800-733-8387.
Can CHAMPVA beneficiaries attend school and retain benefits?
Yes, CHAMPVA benefits can be extended to students aged 18 to 23, provided they are enrolled in a full-time course of instruction at an approved educational institution. Full-time student status must be recertified for each term or year until graduation or until the beneficiary reaches age 23. Documentation confirming enrollment and full-time status is required.
Filling out the VA Form 10-10d for CHAMPVA benefits is a crucial step for eligible applicants seeking healthcare support. Despite its importance, some common errors can lead to delays or outright denials. Understanding these mistakes can significantly streamline the application process.
One common oversight involves not providing complete information about Medicare or other health insurance coverages. Applicants often overlook Section II, which requires indicating whether the applicant is enrolled in Medicare or has other health insurance. If affirmative, it's mandatory to attach a copy of the Medicare card or the insurance card by completing VA Form 10-7959c. Missing this step can halt the processing of the application, delaying access to much-needed benefits.
Another area where errors frequently occur is the sponsor information section. Accurate and complete sponsor information is vital for establishing eligibility for CHAMPVA benefits. This includes the veteran's last name, first name, SSN, VA file number, and other related details. Failing to provide all the requested details or entering incorrect information can disrupt the verification process, potentially leading to the refusal of the application.
Additionally, many applicants forget or incorrectly handle the certification section at the end of the form. This section requires the applicant's signature to attest to the accuracy of the provided information under penalty of perjury. Neglecting to sign, date, or incorrectly completing this section undermines the application's validity. Furthermore, if the certification is signed by someone other than the applicant, it is necessary to complete the additional required fields detailing the signer's relationship with the applicant. This oversight is not just a procedural formality; it legally binds the information provided, and inaccuracies here can have serious consequences.
Also, it is not uncommon for applicants to not report changes in marital status, especially concerning divorce or annulment. According to CHAMPVA eligibility criteria, the termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility from the effective date of the marital dissolution. Failing to report these changes promptly can lead to complications, including the potential recoupment of benefits paid incorrectly.
To ensure a smooth and error-free application process for CHAMPVA benefits, meticulous attention to detail is required throughout the VA Form 10-10d. Recognizing and avoiding these common mistakes can significantly ease and expedite the benefits acquisition journey, ensuring eligible applicants receive the support they deserve promptly.
When applying for CHAMPVA benefits using the VA Form 10-10d, it’s important to gather and prepare any additional forms and documents that may be necessary to ensure a smooth and uninterrupted processing of your application. These documents are crucial for verifying information and ensuring eligibility. Here is a list of forms and documents that are often required alongside the VA Form 10-10d:
Gathering and completing these documents in conjunction with your VA Form 10-10d can feel overwhelming, but they are essential in ensuring that you or your family members have access to the health care benefits you need. Remember, it's always a good idea to double-check which forms are required for your specific situation as this can vary depending on individual circumstances. Filling out these forms accurately and providing all the requested documentation will help prevent any delays in the processing of your application.
The VA Form 10-10EZ, used for enrollment in the VA healthcare system, is quite similar to the VA Form 10-10D in that both are essential for accessing medical benefits provided by the Department of Veterans Affairs. The 10-10EZ form is designed for veterans seeking to join the VA health care system and necessitates detailed personal, insurance, and financial information to determine eligibility and priority for specific programs, similar to how the 10-10D form collects comprehensive information to determine eligibility for CHAMPVA benefits.
Comparable to the VA Form 10-10D is the VA Form 21-686c, Declaration of Status of Dependents, which is employed to add eligible family members to a veteran's benefit record, potentially increasing the veteran's compensation. Like the 10-10D form, it requires detailed information about dependents, such as marriage, children, and school attendance, to accurately assess benefit eligibility and ensure appropriate coverage.
VA Form 10-2850a, Application for Nurses and Nurse Anesthetists, also shares similarities with the VA Form 10-10D, particularly in its requirement for detailed personal information. Although the 10-2850a form is specifically for employment purposes within VA medical facilities, both forms necessitate thorough documentation of personal details and qualifications or entitlements (in the case of CHAMPVA benefits) to process applications effectively.
Another related document is the VA Form 22-1990, Application for Education Benefits, used by veterans and their beneficiaries to apply for education benefits under the GI Bill. Similar to the 10-10D, the 22-1990 form facilitates access to vital benefits for eligible individuals, requiring extensive information about the applicant’s service, education history, and desired educational program to determine eligibility and benefits level.
The VA Form 21-530, Application for Burial Benefits, has parallels to the VA Form 10-10D in its aim to assist veterans' families, offering financial assistance with burial and funeral expenses. Both forms ensure that families of veterans are supported by benefits they are entitled to, requiring comprehensive documentation to process and approve claims for assistance.
Similarly, the VA Form 21-534, Application for Dependency and Indemnity Compensation by a Surviving Spouse or Child, aligns with the VA Form 10-10D in providing benefits to dependents of veterans. Both forms help survivors access VA benefits, requiring detailed information about the veteran, the applicant, and their relationship, to secure financial support following the veteran's death.
The VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, while not an application form for benefits like the VA Form 10-10D, serves a crucial role in assisting veterans and their families in navigating the complexities of VA benefits. It authorizes representation for managing claims, echoing the 10-10D’s purpose of ensuring applicants receive the support and benefits for which they are eligible.
Last but not least, the VA Form 26-1880, Request for a Certificate of Eligibility for VA Home Loan Benefits, shares the goal of the VA Form 10-10D in facilitating access to significant benefits for veterans and their families. This form pertains to home loans instead of medical benefits but similarly requires detailed information on military service and personal data to confirm entitlement to VA-supported home financing.
Filling out the VA Form 10-10d, the Application for CHAMPVA Benefits, is a critical step in accessing the healthcare benefits available for the families of veterans with service-connected conditions. Like navigating a labyrinth, the process can be intricate. Knowing what to do—and what not to do—can make a substantial difference. Here's a roadmap to guide you through this journey:
Remember, patience and attention to detail are your allies in this process. The benefits derived from successfully navigating this application can be significant for you and your family, offering a crucial support system in managing healthcare needs. Reaching out to a veteran's service organization for assistance or guidance can also demystify the process and provide valuable support along the way. Good luck!
When it comes to the VA Form 10-10d, also known as the Application for CHAMPVA Benefits, there are several misconceptions that can lead to confusion and potentially missed opportunities for eligible individuals. Let's clear up some of the most common misunderstandings about this form and the benefits it pertains to:
Eligibility is only based on the veteran being deceased. While it’s true that the surviving spouses and children of veterans who have died as a result of VA-rated service-connected conditions are eligible, CHAMPVA benefits also extend to family members of living veterans who are rated as permanently and totally disabled due to a service-connected condition.
Medicare eligibility automatically disqualifies you from CHAMPVA benefits. This isn't the case; eligible beneficiaries who are also entitled to Medicare must have Medicare Part A and Part B to maintain their CHAMPVA benefits.
Remarriage always ends CHAMPVA benefits for a surviving spouse. While remarriage prior to age 55 does end CHAMPVA benefits, if the surviving spouse remarries at age 55 or older, they can retain their CHAMPVA benefits.
Stepchildren of veterans are not eligible for CHAMPVA. Actually, stepchildren can be eligible as long as the marriage creating the stepchild relationship is considered valid and the child meets all other eligibility criteria.
You must reapply for CHAMPVA benefits annually. Once you are found eligible and enrolled in CHAMPVA, you do not need to reapply every year. However, certain changes, such as school status or marriage status, need to be reported to ensure continued eligibility.
Only traditional schooling is covered for children 18-23. CHAMPVA eligibility for children between the ages of 18 and 23 extends to full-time students in approved educational institutions, which can include vocational schools and technical schools, not just traditional colleges or universities.
Divorce from the qualifying veteran always ends CHAMPVA benefits. For children, eligibility is not affected by the divorce of their parents. Surviving spouses also retain CHAMPVA benefits after a divorce unless they remarry before the age of 55.
All health services are covered under CHAMPVA. Like most health insurance, CHAMPVA has limitations and exclusions. Beneficiaries may be responsible for co-payments and deductibles, and some services may require pre-authorization.
Filing the VA Form 10-10D is complicated and time-consuming. With an estimated completion time of just 10 minutes, the form is designed to be straightforward. Following the instructions and having all necessary information on hand can simplify the process significantly.
Understanding these key points can help eligible veterans and their families navigate the CHAMPVA benefits process more effectively and take full advantage of the support available to them.
Filling out the VA Form 10-10d is a necessary step to access CHAMPVA benefits, which provide health care support to the families of veterans. Here are key takeaways to ensure the process is as smooth as possible:
Processing the form promptly and accurately, along with awareness of conditions affecting eligibility, ensures you can maximize the benefits provided by CHAMPVA. Make use of the given customer service numbers and addresses if you need assistance during the application process.
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