VA Form 10-10d applies for CHAMPVA health coverage for eligible family members. The veteran is usually the sponsor, while the spouse or child seeking coverage is the applicant. Mixing those roles can put the right information in the wrong place.

Download the current VA Form 10-10d PDF

Download the official April 2025 PDF from VA's form page. I verified the three-page edition on October 2, 2026. Page 1 contains the application, page 2 explains eligibility, and page 3 covers school certification.

The current form has Sections I, II and III, with unnumbered fields. This walkthrough follows those printed labels rather than adding item numbers that are not on the PDF. VA also offers an online CHAMPVA application.

Who uses this application?

CHAMPVA stands for the Civilian Health and Medical Program of the Department of Veterans Affairs. It shares covered medical costs with eligible beneficiaries. It is separate from the veteran's own VA health care enrollment.

VA's eligibility guidance lists these main family categories:

  • A spouse or dependent child of a veteran with a permanent and total service-connected disability.
  • A surviving spouse or dependent child of a veteran who died from a service-connected disability.
  • A surviving spouse or dependent child of a veteran who had a permanent and total service-connected disability at death.
  • Certain survivors of service members who died in the line of duty, subject to the program's requirements.

You must not be eligible for TRICARE. Choosing not to enroll in TRICARE does not remove that eligibility restriction. A 100% disability award also needs the required permanence finding to support the permanent-and-total category.

Claim Raven's CHAMPVA glossary page explains coverage, family eligibility and how CHAMPVA differs from TRICARE. Check the actual disability decision rather than relying on the percentage alone.

Qualifying primary family caregivers use a different route through VA's Program of Comprehensive Assistance for Family Caregivers. VA's CHAMPVA page says an eligible caregiver is enrolled automatically through that program; this family application is not a substitute for applying to the caregiver program.

Section I: sponsor information

The sponsor is the veteran whose service establishes the applicant's possible eligibility. Complete each printed field from the veteran's records:

  • Last name, first name and middle initial: Identify the veteran, even if a surviving spouse is preparing the application.
  • Social Security number: Enter the veteran's number in the sponsor field.
  • Street address, city, state and ZIP code: Supply the sponsor information requested by the form.
  • Country code, phone number and email: Complete the applicable contact details, including the phone area code.
  • Date of birth: Use month/day/year format.
  • Date of marriage: Enter the applicable marriage date.
  • Is the veteran deceased? Answer Yes or No. If No, proceed to Section II. If Yes, supply the date of death and answer whether the veteran died while on active military service.

The final question is about the circumstances of the veteran's death. It does not ask whether the veteran ever served on active duty. Use the records that describe the actual event.

For a spouse applying after a marriage, make sure the marriage date agrees with the supporting document and dependency records. The VA Form 21-686c guide explains adding and removing dependents for applicable VA benefits. Filing 21-686c does not, by itself, enroll a family member in CHAMPVA.

Section II: applicant information

Page 1 has three repeated applicant blocks. Complete a block for each person seeking CHAMPVA coverage. The form says that if you need more space, complete another 10-10d in its entirety, sign it and submit it.

For each applicant, enter:

  • Name and middle initial: The family member applying for coverage.
  • Social Security number and date of birth: That applicant's identifiers, not the sponsor's.
  • Street address, city, state and ZIP code: The applicant's address, even if it differs from the veteran's.
  • Email address and telephone number: The contact information requested for that applicant.
  • Sex: Select the applicable box.
  • Enrolled in Medicare: Check this when applicable. Complete 10-7959c and attach a copy of the Medicare card.
  • Has other health insurance: Check this when applicable. Complete 10-7959c and attach the insurance card.
  • Relationship to veteran: State the actual relationship, such as spouse or child.

Insurance must be checked person by person. An employer plan may cover the spouse but not a child; Medicare may cover one applicant and not the others. One person's insurance answer should not be copied across all three blocks.

VA Form 10-7959c, the Other Health Insurance certification, requires a separate form for each family member. If an applicant has Medicare and another plan, report both rather than choosing whichever card is easiest to find.

Section III: certification and signature

Read the certification, then complete the signature, date and email address fields. The current PDF expressly provides for a typed or digital signature.

If someone other than an applicant signs, complete the additional fields below: that person's last name, first name, middle initial, relationship to the applicants, street address, city, state, ZIP code and telephone number.

Those fields explain who certified the application. They do not replace the applicant blocks above. Review every listed family member and the insurance attachments before signing, especially when someone prepared the form for you.

Attach the documents for your situation

Use the supporting-document list on VA's CHAMPVA page. Required documents and optional documents that may help processing are not the same thing.

Other insurance or Medicare: Include copies of the front and back of the relevant cards. Include a Medicare Part D card when applicable. For a paper application, send the signed 10-7959c with those copies. The online application allows you to submit the insurance information and documents as part of the application.

Age 65 or older without Medicare eligibility: VA asks for a Social Security Administration notice of disallowance confirming that the applicant does not qualify for Medicare under anyone's Social Security number. The form also explains Medicare Part A and Part B requirements. Do not assume CHAMPVA lets an otherwise Medicare-eligible person drop required Part B coverage.

Spouse or surviving spouse: VA lists marriage documentation as optional evidence that can help it process the application. Where a surviving spouse's remarriage before age 55 has ended, the relevant divorce, annulment or death document may help establish the circumstances.

Child: A birth certificate can help processing. Adoption papers are required for an adopted child, and a stepchild needs proof of the marriage between the veteran and the child's other parent. A child who became permanently incapable of self-support before 18 has separate eligibility requirements; VA identifies a disability rating letter as helpful evidence.

For a qualifying newborn, VA instructs families to obtain the child's Social Security number and add the child as the veteran's dependent before applying. Medical claims cannot be paid for the child until the child is enrolled.

School certification for ages 18 through 23

The PDF requires school certification for an eligible child continuing in full-time education after 18 and before 23. VA's current CHAMPVA care instructions say to obtain a letter on school letterhead containing the student's name, last four Social Security digits, estimated graduation date, term dates, and the school official's signature and title.

VA's web instructions say to submit certification within one month after the first school term begins and recertify at least annually. A college acceptance letter can help avoid a gap before that first term. Report a withdrawal or other change in student status promptly.

There is a source difference worth checking: the April 2025 PDF requests the student's Social Security number, while the current web guidance specifies the last four digits for the school letter. Follow current CHAMPVA instructions and confirm any conflicting request with the program. Do not omit the applicant's Social Security number from the application itself.

Fictional example: a spouse with employer insurance

This is a fictional form exercise, not an actual family or coverage decision. It contains no names, identification numbers or personal medical history.

Assume a veteran has a permanent and total service-connected disability and the veteran's spouse is applying for CHAMPVA. The spouse is not eligible for TRICARE and already has employer health insurance.

  • Section I identifies the veteran sponsor and the marriage date.
  • One Section II block identifies the spouse.
  • The spouse checks other health insurance and reports the actual Medicare situation separately.
  • The spouse completes a separate 10-7959c and includes both sides of the employer-plan card.
  • The spouse signs and dates Section III.
  • A copy of the marriage certificate accompanies the application as helpful relationship evidence.

The employer policy does not automatically prevent CHAMPVA eligibility. It does affect how covered claims are coordinated. Keep that policy's information current after enrollment.

Where to submit the application

The current PDF and VA's application guidance provide these routes:

  • Online: Complete VA's online 10-10d application and upload the relevant documents.
  • Mail: VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, PO Box 137, Spring City, PA 19475.
  • Fax: 303-331-7809, printed at the top of the application and in its school-certification instructions.

VA's webpage uses the office label “Office of Community Care”; the PDF uses “Office of Integrated Veteran Care.” Both give CHAMPVA Eligibility at Box 137 in Spring City. The address above follows the PDF's office name.

Keep a copy of the entire packet and the online, mailing or fax receipt. The paperwork-comment email on page 2 is not an application submission address.

Mistakes to catch, and what happens after

Before submitting, check for missing applicant identifiers, insurance cards without their reverse sides, absent 10-7959c forms, and an unsigned certification. For an adult student, check the school letter. For permanent-and-total eligibility, check the award language rather than assuming every 100% rating qualifies.

After approval, VA mails a welcome letter and CHAMPVA ID card. Respond to requests for additional information and review the effective coverage information in the packet. Apply for reimbursement separately when needed; 10-7959a is the beneficiary claim form, not the enrollment application.

If you need help understanding the veteran's disability award, Raven Eye offers a free starter review of a decision letter or DBQ, with plain-language findings and source passages. Use it to identify questions to take to VA about the decision behind the family benefit. CHAMPVA determines enrollment eligibility.

Sources and scope

Verified October 2, 2026: all three pages of the April 2025 PDF, VA's form page, CHAMPVA eligibility and supporting-document instructions, and the current care page. The school-letter identifier difference is disclosed above. The example demonstrates preparation, not guaranteed coverage or reimbursement.

Where to go next

Claim Raven is data analysis, not legal, medical, or VA-accredited advice. CHAMPVA can answer questions about insurance coordination and eligibility at 800-733-8387.

-Landon Founder, Claim Raven | U.S. Army Veteran