The VA Form 10-10D is an application for CHAMPVA benefits, designed to assist eligible individuals in accessing healthcare services. This form collects essential information to determine eligibility for benefits related to a veteran's service-connected conditions. Completing the form accurately is crucial for a timely response from the VA.
The VA Form 10-10D, also known as the Application for CHAMPVA Benefits, is a crucial document for individuals seeking healthcare coverage through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). This form is designed for the spouses and children of veterans who have been rated as permanently and totally disabled due to service-connected conditions, or for those who have died as a result of such conditions. It is essential for applicants to complete the form accurately and in full, as any missing information can delay the processing of their request. The application requires detailed information about both the veteran and the applicant, including personal identification details, marital status, and any existing health insurance coverage. Notably, if an applicant has Medicare or other health insurance, they must also submit VA Form 10-7959c. The form includes sections for certification, ensuring that all information provided is truthful and accurate, as false statements can lead to serious penalties. Understanding the eligibility criteria and completing the form correctly is vital for those who wish to access these important health benefits.
What is the VA Form 10-10D used for?
The VA Form 10-10D is an application for CHAMPVA benefits. This program provides health care benefits to eligible family members of veterans who are permanently and totally disabled due to a service-connected condition, or who have died as a result of such a condition. Completing this form allows applicants to request coverage under this program.
Who is eligible to apply for CHAMPVA benefits?
Eligibility for CHAMPVA benefits includes the spouse or child of a veteran rated as having a permanent and total service-connected disability. It also covers the surviving spouse or child of a veteran who died from a VA-rated service-connected condition or while on active duty. Individuals must not be eligible for DoD's TRICARE benefits to qualify.
How long does it take to complete the VA Form 10-10D?
It is estimated that completing the VA Form 10-10D will take about 10 minutes. This includes the time needed to read the instructions, gather necessary information, and fill out the form. Ensuring that all required sections are completed accurately can help avoid delays in processing.
What information is required on the form?
The form requires personal information about both the veteran and the applicant. This includes names, Social Security numbers, addresses, dates of birth, and details about any other health insurance or Medicare coverage. If applicable, additional applicants can be added by completing another VA Form 10-10D.
What should I do if I have Medicare or other health insurance?
If you have Medicare or other health insurance, you must complete and submit VA Form 10-7959c along with the 10-10D form. This additional form helps the VA determine how your other coverage may impact your eligibility for CHAMPVA benefits.
How should I submit the completed VA Form 10-10D?
Once completed, the VA Form 10-10D should be mailed to the Chief Business Office CHAMPVA at the address provided on the form. Alternatively, it can be faxed to the designated number. Ensure that all required information is included to avoid any processing delays.
What happens if my marital status changes?
If there is a termination of marriage due to divorce or annulment, it is important to report this change immediately. CHAMPVA eligibility ends as of midnight on the effective date of the dissolution of marriage. Keeping the CHAMPVA office informed of any changes in status is essential for maintaining benefits.
What is the significance of the Privacy Act information on the form?
The Privacy Act information on the VA Form 10-10D outlines how the information collected will be used and protected. It emphasizes that the information is confidential and may only be disclosed under specific circumstances, such as for eligibility verification. Understanding this helps applicants know how their personal information will be handled.
Filling out and utilizing the VA Form 10-10D for CHAMPVA benefits can be a crucial step for eligible individuals. Here are some key takeaways to keep in mind:
These points emphasize the importance of careful completion and timely submission of the VA Form 10-10D. Ensuring accuracy and compliance can significantly impact the benefits received under the CHAMPVA program.
Here are some common misconceptions about the VA Form 10-10D, which is used to apply for CHAMPVA benefits:
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
If yes →
Date of Death (mm-dd-yyyy)
Did veteran die while
deceased?
No
If no go to sect. II
on active military service?
Section II - Applicant
Information (if
necessary, continue on additional 10-10d and complete in its entirety)
Last Name
Sex
Male
Female
Email Address
Telephone Number
Date of Birth
Enrolled in
Other Health
Relationship to the veteran
Medicare?
Insurance?
(i.e., spouse, child, stepchild)
(include area code)
(mm-dd-yyyy)
If yes, complete VA
Form
10-7959c and attach a copy of
Medicare Card
Insurance card
Social
Security Number
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
Signature
Date
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
X
by a person other than an applicant, complete the following:
Relationship to Applicant(s)
VA FORM
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH WILL NOT BE USED
JUL 2014 10-10d
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
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 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 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.
SUPERSEDES VA FORM 10-10D, JUN 2010, WHICH NOT BE USED
Dos 1246 - The DOS 1246 form is used for renewing your security guard registration in New York State.
College Credits Expire - Accurate contact information is crucial for receiving your transcript.
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Family Law Financial Affidavit (short Form Pdf) - This form is typically filled out by one or both parties in a family law case, depending on the situation.
When filling out the VA Form 10-10D for CHAMPVA benefits, applicants often make several common mistakes that can delay their application or even lead to denial. Here’s a detailed look at four frequent errors:
Many applicants fail to provide all the necessary details in the form. Each section must be filled out completely. Omitting information such as the veteran's Social Security number or date of birth can create significant delays.
If the applicant has Medicare or other health insurance, they must submit VA Form 10-7959c as well. Forgetting to include this form can result in the application being returned or denied.
Applicants sometimes misidentify their relationship to the veteran. This can lead to confusion and may affect eligibility. It is crucial to accurately describe the relationship (e.g., spouse, child, stepchild) to ensure proper processing.
Signing and dating the form is essential. Without a signature, the application cannot be processed. Additionally, if someone other than the applicant is signing, that person must provide their information, which is often overlooked.
By being aware of these common mistakes, applicants can improve their chances of a smooth and successful application process for CHAMPVA benefits.
When filling out the VA Form 10-10D for CHAMPVA benefits, there are several important dos and don’ts to keep in mind to ensure a smooth application process.
The VA Form 10-10D is similar to the Medicare Application for Health Insurance, also known as Form CMS-40B. Both documents serve as applications for health benefits. The Medicare application gathers personal information, such as name, address, and Social Security number, to determine eligibility for Medicare coverage. Like the VA Form 10-10D, it requires applicants to provide information about their marital status and any other health insurance they may have. Both forms emphasize the importance of accuracy, as providing false information can lead to penalties.
Another comparable document is the Social Security Administration's Application for Benefits, known as Form SSA-16. This form is used to apply for Social Security Disability Insurance (SSDI) and requires detailed personal information, including work history and medical conditions. Similar to the VA Form 10-10D, applicants must certify that the information provided is true and accurate. Both forms aim to assess eligibility for benefits based on the applicant's circumstances and health status.
For those looking into vehicle sales in Wisconsin, it is essential to have the correct documentation, and one key resource for this is the vehiclebillofsaleform.com/wisconsin-motor-vehicle-bill-of-sale-template, which provides a comprehensive bill of sale template. This ensures that the transaction is recorded efficiently and legally, protecting both the buyer and seller during the process.
The Application for Federal Student Aid (FAFSA) is another relevant document. While its primary purpose is to determine eligibility for federal financial aid for education, it shares similarities with the VA Form 10-10D in terms of collecting personal and financial information. Both forms require applicants to disclose information about their household and any other support they receive. Completing either form is crucial for accessing the benefits for which one may be eligible.
The Department of Defense's TRICARE Application for Benefits is also akin to the VA Form 10-10D. This document is used by military families to apply for healthcare coverage. It collects information regarding the applicant's relationship to the service member, similar to how the VA form requests details about the veteran. Both applications require proof of eligibility and emphasize the importance of accurate information to avoid complications in accessing benefits.
The Health Insurance Marketplace application is another similar document. This application is used to determine eligibility for health coverage under the Affordable Care Act. Like the VA Form 10-10D, it requires personal information and details about any existing health insurance. Both forms aim to assess the applicant's eligibility for government-sponsored health benefits, ensuring that individuals receive the necessary care.
The Supplemental Nutrition Assistance Program (SNAP) application shares similarities with the VA Form 10-10D in that it collects personal information to determine eligibility for benefits. Both forms require applicants to disclose household information and income levels. The goal of each application is to ensure that those in need receive the assistance they qualify for, based on their circumstances.
The Low-Income Home Energy Assistance Program (LIHEAP) application is yet another document with comparable features. This application is designed to assist low-income households with their energy costs. It requires personal and household information similar to the VA Form 10-10D. Both applications assess eligibility based on financial need, ensuring that assistance is directed to those who require it most.
Finally, the Veterans' Group Life Insurance (VGLI) application is similar in that it provides veterans with a means to apply for life insurance benefits. It collects personal information about the veteran and their beneficiaries, paralleling the data collection process of the VA Form 10-10D. Both forms require certification of the information provided, underscoring the importance of honesty in the application process.