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About VA Form 10-10d

Form name: Application for CHAMPVA Benefits
Related to: Family member benefits, Health care
Form revision date: July 2014

When to use this form

If you’re the spouse or child of a Veteran with disabilities, or the surviving spouse or child of a Veteran who has died, use VA Form 10-10d to apply for health insurance through CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs). 

Downloadable PDF

VA Form 10-7959C

Form name: CHAMPVA—Other Health Insurance (OHI) Certification

Use VA Form 10-7959C or Formulario VA 10-7959c (español) when: 

  • You’re applying for CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), and have other health insurance to declare as part of your VA Form 10-10d application. 
  • Or you need to report changes in your other non-VA health insurance, such as new beneficiaries or coverage changes.

Helpful links related to VA Form 10-10d

  • Learn how eligible spouses and children of Veterans can get health insurance through CHAMPVA (the Civilian Health and Medical Program of the Department of Veterans Affairs).

  • Find out about VA benefits for spouses, dependents, survivors, and family caregivers.

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