Section I: sponsor information
The Veteran's name, Social Security number, address, phone, email, date of birth and date of marriage, and whether the Veteran is deceased, the date of death and whether the Veteran died on active military service.
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
- Agency
- VA
- Revision
- April 2025
- Fillable fields
- 73
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10d: Application for CHAMPVA Benefits
VA Form 10-10d is the Application for CHAMPVA Benefits from the U.S. Department of Veterans Affairs. CHAMPVA is the Civilian Health and Medical Program of the Department of Veterans Affairs. VA's form page says to use it if you're the spouse, dependent or survivor of a Veteran who meets certain requirements and want to apply for health care benefits through CHAMPVA.
The first page has three sections: sponsor information about the Veteran, applicant information with room for three applicants, and a certification with signature. Pages 2 and 3 hold notes and definitions: who the form lists as eligible, the Medicare rules, who counts as a sponsor, spouse or child, and the school certification used for students age 18 to 23.
VA's page says you can apply online instead of sending the paper form. 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 10-10d
Section II: applicant information
Room for three applicants, each with name, Social Security number, date of birth, address, email, phone, sex and relationship to the Veteran, such as spouse or child.
Medicare and other insurance boxes
Each applicant has boxes for Enrolled in Medicare and Has other health insurance. If either is checked, the form says to complete VA Form 10-7959c and attach a copy of the Medicare or insurance card.
Section III: certification
A typed or digital signature, the date and an email address. If someone other than an applicant signs, that person adds their name, relationship to the applicants, address and phone number.
Notes and definitions
Pages 2 and 3 explain the eligibility criteria, the Medicare Part B rules, and how the form defines service-connected condition, sponsor, spouse and child, plus school certification for students.
The form says to print or type only.
How to apply with VA Form 10-10d
- 1
Read the eligibility notes
Page 2 lists who the form says is eligible. It defines a child as unmarried and under 18, or permanently incapable of self-support before 18, or 18 to 23 and enrolled full time at an approved school.
- 2
Fill in the Veteran's details
Complete Section I. If the Veteran is deceased, add the date of death and whether the death happened on active military service. If not, the form says to go to Section II.
- 3
List each applicant
Enter up to three applicants in Section II. The form says to complete, sign and submit another VA Form 10-10d in its entirety if more space is needed.
- 4
Add VA Form 10-7959c if it applies
For each applicant enrolled in Medicare or with other health insurance, the form asks for VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification, and a copy of the card.
- 5
Sign Section III
Sign and date the certification. A person signing for the applicants fills in their own name, relationship, address and phone number.
- 6
Send it to CHAMPVA
Mail the form and any requested information to the CHAMPVA Eligibility address printed on the form, or apply online through VA's form page.
Why fill Form 10-10d 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 what happens next
By mail
VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475.
Online
VA's form page says you can apply online instead of filling out and sending the paper form.
School certifications
The form says school certifications can be sent by mail to the address on the front or by fax to 1-303-331-7809, and that certifications in a foreign language take additional time for translation.
Reporting changes
The form says divorce or annulment from the sponsor ends CHAMPVA eligibility as of midnight on the effective date, and that changes in status are reported to CHAMPVA at 1-800-733-8387 or by mail.
Help with the form
The form lists the CHAMPVA Help Line at 800-733-8387 for questions about eligibility or completing the form, and estimates an average of 10 minutes to complete it.
Related forms
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fields, 2 pages
10-10EZ
Instructions and Enrollment Application for Health Benefits
122 fields, 6 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-493b
CHAMPVA Benefits Election Affirmation
10 fields, 1 page
Who uses VA Form 10-10d?
Page 2 of the form lists these persons as eligible for CHAMPVA, providing they are not eligible for DoD's TRICARE benefits.
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Questions about Form 10-10d
Can I apply for CHAMPVA online?
Yes. VA's form page says you can apply online instead of filling out and sending the paper form. You can also fill out the PDF here free and print or download it.
Who does the form list as eligible for CHAMPVA?
The spouse or child of a Veteran rated permanently and totally disabled from a service-connected condition, the surviving spouse or child of a Veteran who died from a VA-rated service-connected condition or was rated permanently and totally disabled at death, and the surviving spouse or child of a person who died in the line of duty. The form adds that they are eligible providing they are not eligible for TRICARE.
Do I also need VA Form 10-7959c?
If an applicant is enrolled in Medicare or has other health insurance, the form says each such applicant submits VA Form 10-7959c, CHAMPVA Other Health Insurance (OHI) Certification, with a copy of the Medicare or insurance card.
What does the form say about Medicare Part B?
It says that applicants eligible for Medicare Part A and under age 65 need Part B to be covered by CHAMPVA. For those 65 or older and eligible for Part A, it says Part B is required if the 65th birthday was on or after June 5, 2001, or if they were already enrolled in Part B before June 5, 2001.
How many applicants fit on one form?
Section II has space for three applicants. The form says to complete, sign and submit another VA Form 10-10d in its entirety if more space is needed.
What happens to CHAMPVA if a spouse remarries?
The form says that if the spouse remarries before age 55, CHAMPVA benefits end on the date of remarriage, and that effective February 4, 2003, benefits continue if the spouse remarries on or after age 55.
Where do I mail VA Form 10-10d?
The form lists VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, Box 137, Spring City, PA 19475.