1. Applicant Information
Name, Social Security number, date of birth, mailing address, an address outside the United States if any, email, sex, preferred way to get correspondence, phone numbers and relationship to the Veteran.
10-10068
Camp Lejeune Family Member Program Application
- Agency
- VA
- Revision
- September 2025
- Fillable fields
- 84
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10068: Camp Lejeune Family Member Program Application
VA Form 10-10068 is the U.S. Department of Veterans Affairs Camp Lejeune Family Member Program Application. VA's form page says to use it to apply for health care benefits through the Camp Lejeune Family Member Program. The form's Privacy Act notice says the information is used to determine eligibility for reimbursement of health care related to conditions determined to result from contaminated water at Camp Lejeune, North Carolina.
The form is three pages. Sections 1 to 6 cover the applicant, residency on Camp Lejeune, conditions and illnesses, health care coverage, the Veteran and a certification. Page 3 has directions for each section, contact details and the Privacy Act notice.
The form says applications can be submitted online for expedited processing or mailed for standard processing. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10068
2. Residency Information
Whether you resided on Camp Lejeune for 30 days or more between August 1, 1953 and December 31, 1987, the dates and address there, and whether you have documentation such as a utility bill, pay stub or tax forms.
3. Conditions/Illnesses
Checkboxes for the listed conditions, from bladder, breast, esophageal, kidney and lung cancer to leukemia, scleroderma, renal toxicity and neurobehavioral effects, with dates for female infertility and miscarriage.
4. Health Care Coverage
Whether you have coverage and its type with effective dates: Medicare Part A, B, D or Advantage, Medicaid/State Assistance, TRICARE, CHAMPVA, other primary and secondary insurance, and pharmacy benefits.
5. Veteran Information
The Veteran's name, Social Security number and phone if known, date of birth, sex, whether the Veteran is deceased, dates stationed at Camp Lejeune, and units and ranks there.
6. Certification
Permission for Federal agencies and contractors to use your information to check eligibility, a fraud warning, signature and date, and details of anyone signing for the applicant.
How to apply with VA Form 10-10068
- 1
Read the page 3 directions
Page 3 has a table titled Should you apply for the Camp Lejeune Family Member Program, and directions for each section. The form says to answer all questions.
- 2
Fill in applicant and residency details
Complete Sections 1 and 2 and enclose copies of the relationship documents and, if possible, documents verifying residency on Camp Lejeune.
- 3
Check any diagnosed conditions
Mark each listed condition you have been diagnosed with. The directions say a Treating Physician Report form is enclosed for your physician to complete and return with the application.
- 4
Add coverage and Veteran details
List your health care coverage with effective dates in Section 4, and the Veteran's details in Section 5, if known.
- 5
Sign and date it
Sign and date the Section 6 certification. A person signing for the applicant adds their name, mailing address and phone number.
- 6
Submit online or by mail
The form says to submit online for expedited processing, or mail the completed form to the Financial Services Center in Austin, Texas, for standard processing.
Why fill Form 10-10068 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Where to send it and getting help
Online
The form says for expedited processing, submit the application online at https://www.clfamilymembers.fsc.va.gov/.
By mail
For standard processing: Department of Veterans Affairs, Financial Services Center, PO Box 149200, Austin, TX 78714-9200.
Customer Service Center
The form lists 1-866-372-1144 and fax 512-460-5536 for the Camp Lejeune Family Member Program.
More information
The form points to www.publichealth.va.gov/exposures/camp-lejeune/index.asp.
Edition
The edition is dated SEP 2025. The form carries OMB Control No. 2900-0822, which expires 09/30/2028, and an estimated burden of 30 minutes.
Related forms
10-10068a
Camp Lejeune Family Member Program Claim Form
40 fields, 2 pages
10-10068b
Camp Lejeune Family Member Program Treating Physician Report
53 fields, 2 pages
10-10068c
Camp Lejeune Family Member Program Information Update Form (VA Form 10-10068c)
60 fields, 2 pages
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fields, 3 pages
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fields, 2 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
Who uses VA Form 10-10068?
The form asks for the applicant's relationship to the Veteran during the period August 1, 1953 through December 31, 1987.
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Questions about Form 10-10068
What is VA Form 10-10068 used for?
VA's form page says to use it to apply for health care benefits through the Camp Lejeune Family Member Program.
Can I apply online instead?
The form says that for expedited processing you can submit the application online at https://www.clfamilymembers.fsc.va.gov/, or mail it for standard processing.
Which dates does the form ask about?
The form asks about residence on Camp Lejeune for 30 days or more between August 1, 1953 and December 31, 1987, and about the applicant's relationship to the Veteran during that period.
What documents go with the application?
The form asks for a marriage certificate for a spouse, a birth certificate for a child or stepchild, documentation for another legal dependent, and, if available, documents verifying residency such as a utility bill, pay stub or tax forms.
Do I need a diagnosis before applying?
Section 3 says to check any condition you have received a diagnosis for, and adds that you do not need to have been previously diagnosed to be eligible.
Does submitting the form mean I am accepted?
No. The form's note to applicants says the program's eligibility criteria will be determined through VA and that submission of the application does not guarantee acceptance.
Who do I contact with questions?
The form lists the Customer Service Center at 1-866-372-1144, fax 512-460-5536.