VA Form 10-10D Application for CHAMPVA Benefits

VA Form 10-10D Instructions

The form is distributed without any filling guidelines provided. Step-by-step instructions can be found below.

How to Fill Out VA Form 10-10D?

The CHAMPVA Form 10-10D consists of three sections:

1. Section 1 covers Sponsor Information. A veteran, upon whom CHAMPVA eligibility of the applicant is based, is a sponsor. This Section must include the veteran's full name, their social security number, veterans affairs file number, mailing address with ZIP code, telephone number, date of birth, date of marriage, and date of death, if applicable. The form requires the applicant to state whether the veteran is deceased or not and whether they died while on active military service.
2. Section 2 requires information about the applicant. This includes their full name, social security number, mailing address with ZIP code, telephone number, date of birth, and relationship to the veteran. The applicant must indicate if they are enrolled in Medicare and if they have other health insurance. Positive answers require completion of the VA form 10-7959c and attachment of a Medicare Card to the VA Form 10-10D.
3. Section 3 is for 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. The applicant states the student's full name, telephone number, relationship to the applicant, and the address, including street address, city, state, and zip code.

VA 10-10D Related Forms:

• VA Form 10-10M, Medical Certificate is a document attesting to the result of a medical examination of a veteran. It is completed and signed by both doctor and patient;
• VA Form 10-10EZR, Health Benefits Renewal Form is completed by veterans and used by VA to update veterans' personal, insurance, or financial information after they are enrolled;
• VA Form 10-10SH, State Home Program Application for Veteran Care Medical Certification is completed to apply for the State Home program. It includes quality care for veterans in a nursing home, domiciliary, and adult day health care;
• VA Form 10-10EC, Application for Extended Care Services is necessary for veterans who need assisted living, residential (live-in), or home health care through VA. These services include 24/7 nursing and medical care, physical therapy, help with daily tasks, and managing pain;
• VA Form 10-10HS, Request for Hardship Determination is used by veterans whose gross household income has decreased. They may be qualified for copayment exemption for the remaining calendar year;
• VA Form 10-10EZ, Application for Health Benefits, and its equivalent in Spanish (VA Form 10-10EZ, Solicitud De Beneficios Medicos) are used by veterans to apply for enrollment in the VA health care system.