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About VA Form 10-10d

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

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

Online tool

You can apply online instead of filling out and sending us the paper form.

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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