The short answer
VA Form 10-10d has three parts: the Veteran's information, up to three applicants, and a signed certification. If any applicant has Medicare or other insurance, attach VA Form 10-7959c and copies of both sides of each card. Students 18 to 23 need a school letter. Sign and date it, then mail or fax it, or apply online instead.
What is Form 10-10d?
It's the Application for CHAMPVA Benefits. Get the current version from VA's Form 10-10d page. You can also skip paper and apply online, which uses the same questions.
The form doesn't decide eligibility. VA does that under 38 CFR 17.271. If you're not sure the person qualifies, check Who qualifies for CHAMPVA? first.
Section I: The Veteran (sponsor)
This is about the Veteran the application is based on, not the person applying.
- Name, Social Security number, date of birth. Recheck every digit. A swapped number is one of the most common reasons for delays.
- Address, phone, email. Use a current one where VA can reach the household.
- Date of marriage. Fill it in when the application is based on a marriage. Look it up instead of guessing.
- Is the Veteran deceased? If yes, add the date of death and answer whether the Veteran died on active service. That last question is about active duty, not about whether the death was service-connected.
Section II: Each applicant
There's a block for each of up to three applicants. Fill one out for every person applying.
- Name, Social Security number, date of birth, address, phone, email. The applicant's own information, not the Veteran's.
- Enrolled in Medicare? and Has other health insurance? Check these honestly. A checked box means you need to attach more (see below).
- Relationship to Veteran. Spouse, child, stepchild, and so on. It should match your documents.
More than three applicants? Fill out a second Form 10-10d completely, sign it, and send it together. Don't fill in only the applicant boxes on the second form.
Section III: Signature
This is where someone certifies everything is true. Sign, date (MM/DD/YYYY), and add an email.
If someone other than an applicant signs, such as a parent for a child or a representative, fill in the extra signer section completely: name, relationship, address, and phone. An unsigned or undated form will be sent back.
What do you attach?
| Situation | Attach |
|---|---|
| Applicant has Medicare or other insurance | VA Form 10-7959c for that person, plus front and back of each card (including Part D) |
| Applicant is 65+ and not entitled to Medicare Part A | Social Security Notice of Disallowance |
| Adopted child | Adoption papers |
| Stepchild | Proof of marriage between the Veteran and the child's parent |
| Student 18 to 23 | School certification letter |
| Spouse, or child | Marriage or birth certificate (optional, but helps) |
The full list is in our CHAMPVA application checklist.
What does the school letter need?
The form's instructions say it should be on school letterhead and include the student's full name, Social Security number, exact start date, and projected graduation date. A school's own form works if it has all four.
Don't skip pages 2 and 3
They explain eligibility, school certification, and an important rule: a divorce or annulment from the Veteran ends a spouse's CHAMPVA at midnight on the day it becomes final. Report changes like that right away.
How do you send it?
Mail to VHA Office of Community Care, CHAMPVA Eligibility, PO Box 137, Spring City, PA 19475, or fax to the eligibility number printed on the current form. More here: How to apply by mail or fax.
Common mistakes
- Putting the applicant's information in the Veteran's section.
- Checking the Medicare or insurance box without attaching Form 10-7959c and both sides of the card.
- Squeezing a fourth applicant onto one form.
- Forgetting to sign or date.
- A school letter missing the start date or graduation date.