You will find information regarding the type of form you want to prepare in the table. It will tell you the time you will require to complete va form 10 10d, exactly what parts you will have to fill in and a few other specific facts.
Question | Answer |
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Form Name | Va Form 10 10D |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | 10 10d va form, 10 10d champva, va form 10 10d champva, va form 1010d |
OMB Number
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 |
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
Section I - Sponsor Information
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Veteran's Last Name |
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First Name |
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MI |
Social Security Number |
VA File Number (Claim Number) |
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Telephone Number (include area code) |
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Date of Birth |
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Date of Marriage |
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Is veteran |
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If yes → |
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Date of Death |
Did veteran die while |
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deceased? |
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No |
If no go to sect. II |
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on active military service? |
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No |
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Section II - Applicant |
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Information (if |
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Last Name |
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MI |
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Email Address |
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Telephone Number |
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Date of Birth |
Enrolled in |
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Other Health |
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Medicare? |
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(include area code) |
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If yes, complete VA |
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If yes, complete VA |
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Medicare Card |
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Insurance card |
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Last Name |
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First Name |
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MI |
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Social |
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Security Number |
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Email Address |
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Telephone Number |
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Date of Birth |
Enrolled in |
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Other Health |
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Medicare? |
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If yes, complete VA |
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If yes, complete VA |
Form |
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Medicare Card |
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Insurance card |
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Last Name |
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First Name |
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MI |
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Social Security Number |
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Email Address |
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Telephone Number |
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Date of Birth |
Enrolled in |
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Other Health |
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Relationship to the veteran |
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Medicare? |
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Insurance? |
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If yes, complete VA |
Form |
If yes, complete VA |
Form |
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Medicare Card |
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Insurance card |
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Section III - Certification |
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Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious, or fraudulent statements or claims |
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I declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any |
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Signature |
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materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or |
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imprisonment pursuant to title 18, United States Code, Sections 287 and 1001 (Sign and date on right). If certification is signed |
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by a person other than an applicant, complete the following: |
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Last Name |
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VA FORM |
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SUPERSEDES VA FORM |
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JUL 2014 |
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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
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
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,
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
•the surviving spouse or child of a veteran who died as a result of a
•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
SUPERSEDES VA FORM
Application for CHAMPVA Benefits – Important Notes and Definitions |
Page 3 of 3 |
Eligibility Definitions
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
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
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
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
NOTE: It is important to notify the Chief Business Office Purchased Care of any change in student status such as withdrawal or change from
break in CHAMPVA eligibility.
VA FORM JUL 2014 |
SUPERSEDES VA FORM |