Free VA Form 10-10d - Application for CHAMPVA Benefits- Fillable - Federal


File Size: 500.6 kB
Pages: 3
Date: December 19, 2005
File Format: PDF
State: Federal
Category: Veterans Forms
Word Count: 1,508 Words, 9,483 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.va.gov/vaforms/medical/pdf/vha-10-10d-fill.pdf

Download VA Form 10-10d - Application for CHAMPVA Benefits- Fillable ( 500.6 kB)


Preview VA Form 10-10d - Application for CHAMPVA Benefits- Fillable
Estimated Burden: 10 minutes OMB Number 2900-0219

Attention: After reviewing the reverse side, complete form in its entirety (print or typewritten only) and return with a copy of the veteran's DD214 (Report of separation from Active Duty) along with other required documentation. Please do NOT exceed the designated space (i.e., do NOT extend Last Name into First Name area). Veteran's Last Name Street Address Telephone Number (include area code) Section I - Sponsor Information First Name MI Social Security Number VA File Number (Claim Number) City Date of Birth (mm-dd-yyyy) State Zip Code Date of Marriage (mm-dd-yyyy)

VA Health Administration Center

CHAMPVA Eligibility

PO Box 469028

Application for CHAMPVA Benefits
Denver, CO 80246-9028 1-800-733-8387

FAX 303-331-7809

Date of Death (mm-dd-yyyy) Did veteran die while Yes Yes If yes ? Is veteran If no go to sect. II No No on active military service? deceased? Section II - Applicant Information (if necessary, continue on additional 10-10d and complete in its entirety) Last Name First Name MI Social Security Number Male Sex Female

Street Address Telephone Number (include area code) Last Name Street Address Telephone Number (include area code) Last Name Street Address Telephone Number (include area code)

City Date of Birth Children age (mm-dd-yyyy) 18 to 23 (see reverse) First Name Eligible for Medicare?

State Zip Code Yes Relationship to the veteran No (i.e., spouse, child, stepchild) Male Female

If yes, attach copy of Medicare card

MI Social Security Number City

Sex

State Zip Code Eligible for Medicare? Yes Relationship to the veteran No (i.e., spouse, child, stepchild) Male Female

Date of Birth Children age (mm-dd-yyyy) 18 to 23 (see reverse) First Name

If yes, attach copy of Medicare card

MI Social Security Number City

Sex

State Zip Code Eligible for Medicare? Yes Relationship to the veteran No (i.e., spouse, child, stepchild)

Date of Birth Children age (mm-dd-yyyy) 18 to 23 (see reverse)

If yes, attach copy of Medicare card

Section III - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious, or fraudulent statements or claims Date I certify that the above information is correct and true to the best of my knowledge and belief. (Sign and Signature
date on right.) If certification is signed by a person other than an applicant, complete the following.

X

Last Name Street Address

First Name

MI Telephone Number (include area code) Relationship to Applicant(s) City State Zip Code

VA FORM JUN 2005

10-10d

Page 2 of 3 Notice: Termination of marriage by divorce or annulment to the qualifying sponsor ends CHAMPVA eligibility as of midnight on the effective date of the dissolution of marriage. Changes in status should be reported immediately to CHAMPVA, ATTN: Eligibility Unit, PO Box 469028, Denver, CO 80246-9028 or call 1-800-733-8387. Privacy Act Information: The authority for collection of the requested information on this form is 38 USC 501 and 1781. The purpose of collecting this information is to determine your eligibility for CHAMPVA benefits. The information you provide may be verified by a computer matching program at any time. You are requested to provide your social security number as your VA record is filed and retrieved by this number. You do not have to provide the requested information on this form but if any or all of the requested information is not provided, it may delay or result in denial of your request for CHAMPVA benefits. Failure to furnish the requested information will have no adverse impact on any other VA benefit to which you may be entitled. The responses you submit are considered confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in the VA system of records number 54VA16, titled "Health Administration Center Civilian Health and Medical Program Records VA", as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html. For example, information including your social security number may be disclosed to contractors, trading partners, health care providers and other suppliers of health care services to determine your eligibility for medical benefits and payment for services. The Paperwork Reduction Act: This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that nothwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. The purpose of this data collection is to determine eligibility for CHAMPVA benefits.

Application for CHAMPVA Benefits Important Notes and Definitions
CHAMPVA Eligibility Criteria The following persons are eligible for CHAMPVA benefits, providing they are NOT eligible for DoD's TRICARE benefits: the spouse or child of a veteran who has been rated by a VA regional office as having a permanent and total service-connected condition/disability; the surviving spouse or child of a veteran who died as a result of a VA-rated service-connected condition; or who, at the time of death, was rated permanently and totally disabled from a service-connected condition; and the surviving spouse or child of a person who died in the line of duty and not due to misconduct. Medicare Impact. If you are eligible for Medicare Part A and you are under age 65, you MUST have Part B to be covered by CHAMPVA. Effective October 1, 2001, CHAMPVA benefits were extended to beneficiaries age 65 or older. If you are eligible for Medicare Part A and you are age 65 or older, you are required to have Part B to be covered by CHAMPVA if your 65th birthday was on or after June 5, 2001, or if you were already enrolled in Part B prior to June 5, 2001.
VA FORM JUN 2005 (R) 10-10d

Application for CHAMPVA Benefits Important Notes and Definitions

Page 3 of 3

Eligibility Definitions Service-connected condition/disability refers to a VA determination that a veteran's illness or injury was incurred or aggravated while on active duty in military service and resulted in some degree of disability. Sponsor refers to the veteran upon whom CHAMPVA eligibility for the applicant is based. Spouse Refers to a wife/husband or widow(er) of an eligible CHAMPVA sponsor - If the spouse remarries prior to age 55, CHAMPVA benefits end on the date of the remarriage. Effective February 4, 2003, if the spouse remarries on or after age 55, CHAMPVA benefits continue. Additionally, in some instances, a remarried surviving spouse whose remarriage is either terminated by death, divorce or annulment is CHAMPVA eligible when supported by a copy of the appropriate documentation (death certificate/divorce decree/annulment certification). Child Includes legitimate, adopted, illegitimate, and stepchildren. To be eligible, the child must be unmarried and: 1) under the age of 18; or 2) who, before reaching age 18, became permanently incapable of self-support as rated by a VA regional office; or 3) who, after reaching age 18 and continuing up to age 23, is enrolled in a full-time course of instruction at an approved educational institution---school certification required (see below). NOTE: Except for stepchildren, the eligibility of children is not affected by divorce or remarriage of the spouse or surviving spouse. School Certification In order to extend CHAMPVA benefits to students age 18 to 23, school certification of full-time enrollment must be submitted by the college, vocational or high school, etc. Student status for CHAMPVA eligibility purposes is established based on school terms for up to one year. For high schools, this period is the normal beginning and ending school year. For colleges and vocational schools full-time enrollment requires a minimum of 12 credit hours per semester or equivalent number of credit hours on any academic calendar year. School certifications must be on school letterhead and include the following: student's name student's social security number exact beginning and ending dates of each semester or enrollment term number of semester hours or equivalent (high schools excluded) certification of full time status School generated forms are acceptable as long as they provide the above information. While certifications submitted in a foreign language are acceptable, additional time will be required for translation. Certifications may be submitted by mail to the address on the front or by FAX to 1-303-331-7809. NOTE: It is important to notify the Health Administration Center of any change in student status such as withdrawal or change from full-time to part-time status. School vacation periods, holidays, and summer breaks* are not considered an interruption in full-time attendance and will not create a break in CHAMPVA eligibility. *providing the student attends school on a full-time basis both before and after the summer break
VA FORM JUN 2005 (R) 10-10d