VA Form 10-10d: Application for CHAMPVA Benefits

In SECTION I - SPONSOR INFORMATION, enter the Veteran's Last Name, Veteran's First Name, MI, Social Security Number (999-99-9999), Street Address, City, State, ZIP Code (99999-9999), Country Code, Phone Number ((999) 999-9999), Veteran's Email Address, Date of Birth (MM/DD/YYYY) and Date of Marriage (MM/DD/YYYY).

Sponsor refers to the veteran upon whom CHAMPVA eligibility for the applicant is based.

Mark YES or NO for IS THE VETERAN DECEASED? If "YES," continue: enter the Date of Death (MM/DD/YYYY) and mark YES or NO for DID THE VETERAN DIE WHILE ON ACTIVE MILITARY SERVICE? If "NO," go to Section II.

In SECTION II - APPLICANT INFORMATION, enter the Last Name, First Name, MI, Social Security Number (999-99-9999), Date of Birth (MM/DD/YYYY), Street Address, City, State, ZIP Code (99999-9999), Email Address and Phone Number (Include Area Code), mark the SEX, MALE or FEMALE, and enter the Relationship To Veteran (i.e., spouse, child).

If ENROLLED IN MEDICARE is checked, complete VA Form 10-7959c and attach a copy of Medicare Card.

If HAS OTHER HEALTH INSURANCE is checked, complete VA Form 10-7959c and attach a copy of insurance card.

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 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.

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.

If additional space is needed, complete another VA Form 10-10d in its entirety, sign and submit.

In SECTION III - CERTIFICATION, sign on the SIGNATURE line (Typed or digital signature), and enter the DATE (MM/DD/YYYY) and the EMAIL ADDRESS.

By signing you declare under penalty of perjury that what you entered is true and accurate to the best of your knowledge.

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, is eligible for CHAMPVA benefits, providing they are NOT eligible for DoD's TRICARE benefits.

The surviving spouse or child of a person who died in the line of duty and not due to misconduct is eligible for CHAMPVA benefits, providing they are NOT eligible for DoD's TRICARE benefits.

If certification is signed by a person other than an applicant, enter the Last Name, First Name, MI, Relationship To Applicant(s), Street Address, City, State, ZIP Code (99999-9999) and Phone Number (Include Area Code).

In order to extend CHAMPVA benefits to students age 18 to 23, school certification of 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 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.

Certifications may be submitted by mail to VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475 or by FAX to 1-303-331-7809.

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.

Return the form and any additional, requested information to VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475. The Customer Service Center is at 1-800-733-8387 and the FAX is 303-331-7809.

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.