VA · Official form

VA Form 10-10d: Application for CHAMPVA Benefits

VA Form 10-10d is the application for CHAMPVA, the VA health insurance program for certain family members and survivors of Veterans. It collects the sponsor Veteran's details and information about each family member applying.

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What is VA Form 10-10d?

CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs) covers eligible spouses and children of Veterans who are permanently and totally disabled from a service-connected condition, and certain survivors of Veterans who died from a service-connected disability. VA Form 10-10d is how those family members apply for the program.

The form asks for the Veteran sponsor's identifying and service information, then details for each applicant: name, Social Security number, date of birth, relationship to the Veteran, and Medicare status. VA also uses the form to update personal information or report changes for people already connected to CHAMPVA.

Who files VA Form 10-10d?

Spouses of Veterans rated permanently and totally disabled from a service-connected condition
Children, including stepchildren and adopted children, of qualifying Veterans
Surviving spouses and children of Veterans who died from a service-connected disability or who were rated permanently and totally disabled at death
Caregivers or representatives completing the application on behalf of an eligible family member

How to fill out VA Form 10-10d

Gather the Veteran sponsor's Social Security number, VA file number, and service details, plus each applicant's Social Security number and date of birth.
Complete the sponsor section first, then one applicant block for each family member applying.
Answer the Medicare questions for every applicant; applicants with Medicare must usually include a copy of their Medicare card.
Attach VA Form 10-7959c if any applicant has other health insurance, then sign and date the application.
Mail the package to the CHAMPVA address listed in the form instructions, or apply online through the CHAMPVA application tool on VA.gov.

Quick fill VA Form 10-10d on this page

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Page 1 72 fields

Read information above. SECTION 1 - SPONSOR INFORMATION. VETERAN'S LAST NAME.

VETERAN'S FIRST NAME

MIDDLE INITIAL.

SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

STREET ADDRESS

CITY

STATE

ZIP CODE. Enter 5 digit zip code, with optional hyphen and last 4 digits.

STREET ADDRESS.

PHONE NUMBER. Please use digits formatted as (999) 999-9999.

VETERAN'S EMAIL ADDRESS

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

DATE OF MARRIAGE. Enter 2 digit month, 2 digit day and 4 digit year.

IS THE VETERAN DECEASED? YES.

DATE OF DEATH. Enter 2 digit month, 2 digit day and 4 digit year.

DID THE VETERAN DIE WHILE ON ACTIVE MILITARY SERVICE? YES.

SECTION 2 - APPLICANT INFORMATION. LAST NAME. 1 of 3.

FIRST NAME.

MIDDLE INITIAL.

SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

STREET ADDRESS.

CITY.

STATE.

ZIP CODE. Enter 5 digit zip code, with optional hyphen and last 4 digits.

EMAIL ADDRESS.

PHONE NUMBER. Please use digits formatted as (999) 999-9999.

SEX. MALE.

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

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

RELATIONSHIP TO VETERAN (i. e., spouse, child).

LAST NAME. 2 of 3.

FIRST NAME.

MIDDLE INITIAL.

SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

STREET ADDRESS.

CITY.

STATE.

ZIP CODE. Enter 5 digit zip code, with optional hyphen and last 4 digits.

EMAIL ADDRESS.

PHONE NUMBER. Please use digits formatted as (999) 999-9999.

SEX. MALE.

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

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

RELATIONSHIP TO VETERAN (i. e., spouse, child).

LAST NAME. 3 of 3.

FIRST NAME.

MIDDLE INITIAL.

SOCIAL SECURITY NUMBER. Enter 9 digit social security number.

DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

STREET ADDRESS.

CITY.

STATE.

ZIP CODE. Enter 5 digit zip code, with optional hyphen and last 4 digits.

EMAIL ADDRESS.

PHONE NUMBER. Please use digits formatted as (999) 999-9999.

SEX. MALE.

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

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

RELATIONSHIP TO VETERAN (i. e., spouse, child).

DATE SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.

EMAIL ADDRESS

If certification is signed by a person other than an applicant, complete the following. LAST NAME.

FIRST NAME.

MIDDLE INITIAL.

RELATIONSHIP TO APPLICANT(S)

STREET ADDRESS.

CITY.

STATE.

ZIP CODE. Enter 5 digit zip code, with optional hyphen and last 4 digits.

PHONE NUMBER. Please use digits formatted as (999) 999-9999.

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Frequently asked questions

Can I apply for CHAMPVA online instead of mailing this form?

Yes. VA offers an online CHAMPVA application on VA.gov that covers the same information as the paper 10-10d. If you apply online you generally do not need to mail the paper form.

Do I need to send anything with VA Form 10-10d?

Applicants with Medicare typically need to include a copy of their Medicare card, and anyone with other health insurance should include VA Form 10-7959c. School certification may be requested for children over 18 who are enrolled as students. Check the current instructions on the form for the full list.

Is CHAMPVA the same as TRICARE?

No. TRICARE serves active duty families and military retirees, while CHAMPVA serves family members and survivors of certain disabled or deceased Veterans. If you are eligible for TRICARE you are generally not eligible for CHAMPVA.

VA Form 10-10d: Application for CHAMPVA Benefits

What is VA Form 10-10d?

Who files VA Form 10-10d?

How to fill out VA Form 10-10d

Quick fill VA Form 10-10d on this page

Frequently asked questions

Related forms

VA Form 10-7959a: CHAMPVA Claim Form

VA Form 10-7959c: CHAMPVA Other Health Insurance (OHI) Certification

VA Form 10-10EZ, Application for Health Benefits