Champva Form 10 10D Details

The Department of Veterans Affairs (VA) provides health care services to military veterans through the VA Champva Program. If you are a military veteran or the spouse or dependent of a military veteran, you may be eligible for health care services through the Champva Program. You can apply for the Champva Program by completing the VA Champva Application Form 10 10D. The application process is simple and easy to complete. In this blog post, we will provide an overview of the Champva Program and provide instructions on how to complete the VA Champva Application Form 10 10D. We hope that this information will help you get the health care services that you need and deserve.

You will find information regarding the type of form you wish to fill out in the table. It can show you the amount of time you'll need to finish va champva application form 10 10d, exactly what fields you will have to fill in and a few other specific details.

QuestionAnswer
Form NameVa Champva Application Form 10 10D
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameschampva insurance, champ va, form 10 10d, champva application

Form Preview 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

deceased?

 

No

 

 

If yes

Date of Death (mm-dd-yyyy)

If no go to sect. II

Did veteran die while

 

Yes

 

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

Male

Sex Female

Email Address

Street Address

City

State Zip Code

Telephone Number (include area code)

Date of Birth

Enrolled in

 

Yes

 

(mm-dd-yyyy)

Medicare?

No

 

 

If yes, complete VA Form

 

 

 

 

 

10-7959c and attach a copy of

 

 

Medicare Card

 

 

Other Health Yes Insurance? No

If yes, complete VA Form

10-7959c and attach a copy of Insurance card

Relationship to the veteran

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

Last Name

First Name

MI Social Security Number

Male

Sex Female

Email Address

Street Address

City

State Zip Code

Telephone Number (include area code)

Date of Birth

Enrolled in

 

Yes

 

(mm-dd-yyyy)

Medicare?

 

No

 

 

If yes, complete VA Form

 

 

10-7959c and attach a copy of

 

 

Medicare Card

 

 

 

Other Health Yes Insurance? No

If yes, complete VA Form

10-7959c and attach a copy of Insurance card

Relationship to the veteran

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

 

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

 

(include area code)

 

(mm-dd-yyyy)

Medicare?

No

Insurance?

No

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

 

 

 

 

 

 

 

 

 

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 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:

Signature

X

Date

Last Name

First Name

MI

Telephone Number (include area code)

Relationship to Applicant(s)

Street Address

City

State

Zip Code

VA FORM

10-10d

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

JUL 2014

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 eligibilitySchoolf childCertificationen is not affected by divorce or remarriage of

the spouse or surviving spouse.

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