Form 10-10d CHAMPVA Application for Benefits

OMB Number 2900-0219
Estimated Burden: 10 minutes
Expiration Date: 07/20/2017

Application for CHAMPVA Benefits
Chief Business Office Purchased Care, CHAMPVA Eligibility, PO Box 469028, Denver CO 80246-9028
Customer Service Center: 1-800-733-8387 | FAX: 303-331-7809
ATTENTION: Please refer to the information on the following pages for assistance completing 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 VA Form 10-7959c, CHAMPVA Other Health
Insurance (OHI) Certification. If additional space is needed, complete another VA Form 10-10d in its entirety, sign and submit.

Section I - Sponsor Information
Veteran's Last Name

First Name

MI Social Security Number

Street Address

VA File Number (Claim Number)

City

Phone Number (include area code)
Is veteran deceased?
Yes
No

State

Date of Birth (mm-dd-yyyy)

If yes, continue →
If no, go to Section II

Date of Death (mm-dd-yyyy)

Zip Code

Date of Marriage (mm-dd-yyyy)
Did veteran die while on active military service?
Yes

No

Section II - Applicant Information
Last Name

First Name

Street Address

MI

City

Gender
Phone Number
(include area code)
Male

Social Security Number
State

Enrolled in Medicare

Date of Birth (mm-dd-yyyy)

Zip Code

Email Address

Has other health insurance

If checked, complete VA Form 10-7959c If checked, complete VA Form 10-7959c
and attach a copy of insurance card

Relationship to veteran
(i.e., spouse, child)

Female and attach a copy of Medicare Card
Last Name

First Name

Street Address

MI

City

Gender
Phone Number
(include area code)
Male

Social Security Number
State

Enrolled in Medicare

Date of Birth (mm-dd-yyyy)

Zip Code

Email Address

Has other health insurance

If checked, complete VA Form 10-7959c If checked, complete VA Form 10-7959c
and attach a copy of insurance card

Relationship to veteran
(i.e., spouse, child)

Female and attach a copy of Medicare Card
Last Name

First Name

Street Address

MI

City

Gender
Phone Number
(include area code)
Male

Enrolled in Medicare

Social Security Number
State

Date of Birth (mm-dd-yyyy)

Zip Code

Email Address

Has other health insurance

If checked, complete VA Form 10-7959c If checked, complete VA Form 10-7959c
and attach a copy of insurance card

Relationship to veteran
(i.e., spouse, child)

Female and attach a copy of Medicare Card

Section III - Certification
I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any
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 below.)
If certification is signed by a person other
than an applicant, complete the following:
Last Name

First Name

Street Address

City

VA FORM
JUL 2014

10-10d

Date

Signature
MI
State

Zip Code

Relationship to Applicant(s)
Phone Number (with area code)

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 at 1-800-733-8387 or via mail to:
CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver CO 80246-9028.
Privacy Act Information: Privacy Act Information: Information on this form is collected in accordance with the
System of Records Notice 54VA10NB3, Veterans and Beneficiaries Purchased Care Community Health Care
Claims, Correspondence, Eligibility, Inquiry and Payment Files-VA (Published March 3, 2015, FR 80, number
41). Category: Records maintained in the system include program applications, eligibility information
concerning the Veteran, family members, caregivers, other health insurance information to include information
regarding eligibility or entitlement to other federal medical programs. Authority: 38 USC 501 and 1781.
Purpose: Records may be used for purposes of establishing and monitoring eligibility to receive VA benefits,
processing claims for medical care and services, and processing stipends. Routine Use: The Privacy Act
permits VA to disclose information about individuals without their consent under the Privacy Act Routine Use
Disclosure when the information will be used for a purpose that is compatible with the purpose for which VA
collected the information. Disclosure: Voluntary. 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 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 notwithstanding 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.

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Application for CHAMPVA Benefits – Important Notes and Definitions
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 (4) years for traditional schooling programs, two (2) years 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 break) are not
considered an interruption in full-time attendance and will not create a break in CHAMPVA eligibility.
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