VA Form 10-10d: Line-by-Line CHAMPVA Application Guide

Quick answer

VA Form 10-10d is the paper Application for CHAMPVA Benefits. VA's current form page lists the paper revision as April 2025. If you are applying by mail or fax, use the current form rather than an older saved copy. If you prefer to apply electronically, VA also provides an online application instead of requiring you to fill out and send the paper form.

The paper form has three main sections: sponsor information, applicant information, and certification. The current form has space for three applicants. If you need more space, its instructions say to complete another Form 10-10d in its entirety, sign it, and submit it with the application.

This guide explains what each field is asking for and where applicants most often miss a required attachment. It does not determine whether you are eligible for CHAMPVA; eligibility is governed by 38 CFR §17.271 and VA's eligibility rules.

Before you start

Use VA's current Form 10-10d page to get the latest paper application. You can also review the current fillable Form 10-10d PDF before you begin.

Gather the sponsor and applicant information first. If you want a document-focused preparation list, use the CHAMPVA application checklist.

Two instructions printed on the current form are especially important:

• If an applicant reports Medicare or other health insurance in Section II, that applicant must also submit VA Form 10-7959c and the applicable insurance information with a paper application.
• If you need space for more than three applicants, complete an additional Form 10-10d completely and sign it. Do not use only the extra applicant boxes on an otherwise incomplete second form.

If you are unsure whether the person applying has a qualifying CHAMPVA pathway, review Who Qualifies for CHAMPVA? before treating the application form as proof of eligibility.

Section I: Sponsor information

Section I is about the Veteran sponsor on whose status the CHAMPVA application is based.

Field on the form	What to enter	Common issue to avoid
Veteran's last name	The Veteran sponsor's last name	Do not put the applicant's name here unless the applicant is also the Veteran sponsor
Veteran's first name	The Veteran sponsor's first name	Keep the name consistent with the identifying records you submit
MI	Middle initial, if applicable	Do not substitute a nickname
Social Security number	The Veteran sponsor's SSN in the format requested by the form	Recheck every digit before submitting
Street address	Sponsor's street address	Make sure it is current
City	Sponsor's city	Keep the city, state, and ZIP together with the same address
State	Sponsor's state	Use the current address
ZIP code	Sponsor's ZIP code	The form allows the ZIP+4 format
Country code	The country code requested by the form, when applicable	Do not guess if you are unsure what applies to an international contact
Phone number	Sponsor contact number, including area code	Use a number where VA can reach the household if follow-up is needed
Veteran's email address	Sponsor's email address	Check spelling carefully
Date of birth	Veteran sponsor's date of birth in MM/DD/YYYY format	Avoid swapping month and day
Date of marriage	Complete this field when it applies to the relationship on which the application is based	Do not invent a date if you are unsure; verify the record first
Is the Veteran deceased?	Check Yes or No	If No, the form directs you to continue to Section II
Date of death	Complete if the Veteran is deceased	Use MM/DD/YYYY
Did the Veteran die while on active military service?	Check Yes or No when the Veteran is deceased	This is a separate question from whether the Veteran had a service-connected condition

The form's later instruction pages summarize CHAMPVA eligibility concepts, but the boxes in Section I are for identifying the sponsor and the relevant sponsor facts. If a sponsor-status or survivor rule is unclear, resolve that question before trying to make the form fit a situation it was not designed to decide.

Section II: Applicant information

Section II repeats the same block for up to three applicants. Complete a separate block for each person who is applying for CHAMPVA.

Field on the form	What to enter	What to check
Last name	Applicant's last name	Keep it consistent with supporting records
First name	Applicant's first name	Use the applicant's own information, not the sponsor's
MI	Applicant's middle initial, if applicable	Check for transcription errors
Social Security number	Applicant's SSN	Recheck all digits
Date of birth	Applicant's date of birth	Use MM/DD/YYYY
Street address	Applicant's current street address	Do not assume it is the same as the sponsor's if it is not
City, state, ZIP code	Applicant's current address information	Keep the address internally consistent
Email address	Applicant's email address	Check spelling
Phone number	Applicant's phone number, including area code	Use a current number
Sex	Select the option provided on the current form	Use the form's current choices
Enrolled in Medicare	Check the box when the applicant is enrolled in Medicare	A checked box triggers additional paper-application documentation
Has other health insurance	Check the box when the applicant has other health insurance	A checked box triggers additional paper-application documentation
Relationship to Veteran	State the applicant's relationship to the Veteran, such as spouse or child	Make sure it matches the eligibility path and supporting records

If you check Medicare

The current Form 10-10d instructs each applicant who reports Medicare to complete VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification, and attach a copy of the Medicare card with a paper application.

VA's current CHAMPVA application guidance also says to include the front and back of the Medicare card. If the applicant has Medicare Part D, VA says to include the front and back of the Part D card as well.

If an applicant is age 65 or older and is not entitled to Medicare Part A, VA's current guidance and 38 CFR §17.271 describe additional proof, including a Social Security Administration Notice of Disallowance when applicable. A complex Medicare eligibility issue should be resolved separately from simply checking a box on Form 10-10d.

If you check other health insurance

For a paper application, the current Form 10-10d instructs the applicant to complete VA Form 10-7959c and attach a copy of the insurance card. VA's current application page says to submit the front and back of the health insurance card.

Use VA's current Form 10-7959c page for the OHI form and current instructions. The OHI page also distinguishes paper and online submission.

If you have more than three applicants

Do not squeeze a fourth applicant into unused space. The current Form 10-10d says that when additional space is needed, you should complete another Form 10-10d in its entirety, sign it, and submit it with the first form.

Section III: Certification and signature

Section III is not a routine contact-information block. It is the certification that the information provided is true and accurate to the best of the signer's knowledge.

Complete these fields:

• Signature: the current form identifies this as a typed or digital signature.
• Date: enter the date in MM/DD/YYYY format.
• Email address: enter the email requested in the certification block.

Do not submit an unsigned or undated paper application.

If someone other than an applicant signs

The form contains an additional signer section when the certification is signed by a person other than an applicant. Complete all of the requested signer fields:

• last name;
• first name;
• middle initial;
• relationship to the applicant or applicants;
• street address;
• city;
• state;
• ZIP code; and
• phone number including area code.

Leaving the signer-identification block incomplete can make it unclear who certified the application.

Pages 2 and 3: instructions you should not skip

The first page contains the fill-in application fields, but pages 2 and 3 contain instructions that can change what you need to submit.

Status and eligibility notes

Page 2 includes eligibility definitions and a notice about changes in marital status. The form says that divorce or annulment from the qualifying sponsor ends CHAMPVA eligibility at midnight on the effective date of the dissolution and directs beneficiaries to report status changes promptly.

The application itself is not the final eligibility decision. VA evaluates eligibility under the governing law and regulation, including 38 CFR §17.271.

School certification for students ages 18 to 23

Page 3 explains the school certification requirements for a dependent student who is continuing CHAMPVA eligibility between ages 18 and 23.

The current form says a school certification letter should be on school letterhead and include:

• the student's full name;
• the student's Social Security number;
• the exact beginning date; and
• the projected graduation date.

The form also states that a school-generated form is acceptable if it provides the required information. For the broader continuation and recertification rules, see CHAMPVA for Full-Time Students Ages 18–23.

Attachments: what may need to go with Form 10-10d

The attachment list depends on the applicant's circumstances. VA distinguishes between documents that are required in a particular situation and documents that are optional but may help processing.

Situation	Current VA guidance
Applicant has Medicare or other health insurance	Submit the applicable insurance-card copies and OHI information; with a paper Form 10-10d, the current form directs each affected applicant to submit Form 10-7959c
Applicant has Medicare Part D	Include front and back of the Part D card
Applicant is age 65+ and not entitled to Medicare Part A	A Social Security Administration Notice of Disallowance may be required to document Medicare ineligibility
Spouse or surviving spouse	Marriage certificate, civil-union certificate, or common-law marriage affidavit is optional supporting evidence that VA says may speed processing
Surviving spouse whose pre-55 remarriage ended	Applicable divorce decree, annulment decree, or death certificate is listed by VA as optional supporting evidence
Dependent child	Birth certificate is optional supporting evidence that may speed processing
Adopted child	Adoption papers are required when applicable
Stepchild	Proof of the marriage between the Veteran sponsor and the child's other parent is required when applicable
Student age 18–23	School certification is required when applicable
Child who became permanently unable to support themselves before age 18	VA says a disability rating letter can help processing

For a complete preparation list, use the CHAMPVA application checklist.

How to submit the application

VA currently allows CHAMPVA applications online, by mail, or by fax.

Online

If you apply online, VA's Form 10-10d page says you can use the online tool instead of filling out and sending the paper form. See How to Apply for CHAMPVA Online.

Mail

VA's current CHAMPVA application page lists the paper-application destination as:

CHAMPVA Eligibility
PO Box 137
Spring City, PA 19475

The organizational label differs slightly between the current VA.gov application page and the current PDF, but both use the same CHAMPVA Eligibility Box 137 destination in Spring City.

Fax

The current April 2025 Form 10-10d lists the CHAMPVA Eligibility fax number as 303-331-7809.

Because addresses and fax routing are operational details that can change, recheck the current VA form immediately before sending. For the full paper-submission workflow and proof-of-submission tips, see How to Apply for CHAMPVA by Mail or Fax.

Common Form 10-10d mistakes to avoid

• Using an older saved copy instead of the current VA form.
• Putting applicant information in the sponsor section, or sponsor information in an applicant block.
• Transposing Social Security numbers or dates of birth.
• Leaving a Medicare or other-health-insurance box checked without the required OHI form and card copies for a paper application.
• Copying only one side of an insurance or Medicare card.
• Trying to add a fourth applicant without completing and signing another Form 10-10d in full.
• Forgetting the certification signature or date.
• Having someone other than an applicant sign but leaving the signer-identification fields incomplete.
• Submitting a school certification that is missing the student's full name, SSN, exact beginning date, or projected graduation date.
• Sending the eligibility application to a CHAMPVA claims address instead of the current eligibility destination.

A final review should compare the names, Social Security numbers, dates, addresses, and insurance information across the application and supporting documents. Consistency does not replace VA's eligibility review, but it reduces avoidable ambiguity in the packet.

Final pre-submission check

Before you send the paper form:

1. Confirm you are using the current Form 10-10d.
2. Review every sponsor field in Section I.
3. Review every applicant block in Section II.
4. Add Form 10-7959c and insurance-card copies for each applicant who reports Medicare or other health insurance.
5. Add any relationship, adoption, stepchild, school, or Medicare documentation that applies.
6. Complete Section III, including the signature and date.
7. If another person signed, complete the full alternate-signer block.
8. Keep a copy of the completed form and supporting documents.
9. Recheck VA's current submission instructions before mailing or faxing.

That final pass catches most errors that can be identified before VA begins its eligibility review.