The following information about this VA form comes from the VA forms database, and any changes are updated here nightly. Contact the form administration for further information.
Link to form
https://www.va.gov/vaforms/medical/pdf/vha-10-10d-fill.pdf
Form number
10-10d
Row ID
3903
Form title
Application for CHAMPVA Benefits- Fillable
Issue date
Revision date
Form administration
VHA
Number of pages
3
Deleted
False
Form name
Application for CHAMPVA Benefits
Form Language
English
Related to
Benefits
VA benefits for spouses, dependents, survivors, and family caregivers
VA health care
When to use

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). 

Related forms
About VA Form 10-7959C
Helpful links
CHAMPVA benefits
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).
Family member benefits
Find out about VA benefits for spouses, dependents, survivors, and family caregivers.