VA Form 10-10d walkthrough, section by section

Educational information only, not medical, legal, or insurance advice. Confirm with CHAMPVA and your provider. Last verified against VA.gov: October 9, 2026 (VA page updated Aug 7, 2026). Changelog

VA Form 10-10d has three sections. You can also apply online, which asks the same questions. We don’t fill out forms for anyone; this explains what each part asks.

Section I: Sponsor information (the veteran)

The veteran’s name, Social Security number, address, phone, email, date of birth, and date of marriage (if applicable). It asks whether the veteran has died. If yes, it asks for the date of death and whether the veteran died on active duty.

Section II: Applicant information (each family member)

For each person applying: name, Social Security number, address, phone, email, date of birth, sex, and relationship to the veteran (for example, spouse or child). There are checkboxes for:

• Enrolled in Medicare: if checked, complete VA Form 10-7959c and attach a copy of the Medicare card.
• Has other health insurance: if checked, complete VA Form 10-7959c and attach a copy of the insurance card.

If you have more applicants than spaces, complete another 10-10d in full and sign it.

Section III: Certification

Sign and date. If someone other than the applicant signs, the form asks for their relationship to the applicant.

Attach (as they apply)

• VA Form 10-7959c and card copies (front and back) for anyone with Medicare or other insurance
• Spouse: marriage certificate (optional, speeds processing)
• Child: birth certificate (optional); adoption papers; for stepchildren, proof of marriage to the child’s parent
• Students 18–23: school certification letter
• Age 65+ without Medicare: Social Security notice of disallowance

Send it

Mail: VHA Office of Integrated Veteran Care, CHAMPVA Eligibility, PO Box 137, Spring City, PA 19475 · Fax: 303-331-7809 · Or apply online.

Printable: 10-10d checklist.