Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

VA Health Care Enrollment Application: Instructions for Completing Section IV-VI, Study notes of Law

Instructions for completing the Financial Disclosure section of the VA Health Care Enrollment Application (Form 10-10EZ). It explains who is exempt from providing financial information, how to fill out Sections IV-VI, and what types of income and expenses to report. It also outlines VA's use of the information and the consequences of not providing it.

What you will learn

  • How will VA use the financial information provided in the VA Health Care Enrollment Application?
  • What financial disclosure requirements apply to VA Health Care Enrollment?
  • What types of income and expenses should be reported in Section VI of the VA Health Care Enrollment Application?

Typology: Study notes

2021/2022

Uploaded on 09/12/2022

attourney
attourney šŸ‡¬šŸ‡§

3.8

(11)

228 documents

1 / 5

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
Where can I get help filling out the form and if I have questions?
ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS SECTION
TO DETERMINE ELIGIBILITY FOR VA HEALTH CARE ENROLLMENT AND/OR CARE OR SERVICES.
Financial Disclosure:
Financial Disclosure Requirements Do Not Apply To:
• a former Prisoner of War; or
• those in receipt of a Purple Heart; or
• a recently discharged Combat Veteran; or
• those discharged for a disability incurred or aggravated in the line of duty; or
• those receiving VA SC disability compensation; or
• those receiving VA pension; or
• those in receipt of Medicaid benefits; or
• those who served in Vietnam between January 9, 1962 and May 7, 1975; or
• those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
• those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.
INSTRUCTIONS FOR COMPLETING ENROLLMENT
APPLICATION FOR HEALTH BENEFITS
Getting Started:
Definitions of terms used on this form:
You may use ANY of the following to request assistance:
• Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
• Go to www.va.gov/health-care for information about VA health benefits.
• Contact the Enrollment Coordinator at your local VA health care facility.
• Contact a National or State Veterans Service Organization.
For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA to
determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it will take to
read instructions, gather the necessary facts and fill out the form.
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
• SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the
active military, naval or air service.
• COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
• NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
• NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
Directions for Sections I - III:
Section I - General Information:
Section III - Insurance Information:
Section II - Military Service Information:
Answer all questions.
If you are not currently receiving benefits from VA, you may attach a copy of your
discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your signed
application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-reference your
information with VA data.
Include information for all health insurance companies that cover you, this includes
coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you to
each health care appointment.
Directions for Sections IV-VI:
You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to
provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to
determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used
to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose
your financial information, you will not be eligible for these benefits.
Section IV - Dependent Information: Include the following:
• Your spouse even if you did not live together, as long as you contributed support last calendar year.
• Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under 23 and
attending high school, college or vocational school (full or part-time), or became permanently unable to support themselves before age 18.
• Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
ALL VETERANS MUST COMPLETE SECTIONS I - III.
VA FORM
JUL 2021 10-10EZ Complete only the sections that apply to you; sign and date the form. PAGE 1 OF 5HEC
pf3
pf4
pf5

Partial preview of the text

Download VA Health Care Enrollment Application: Instructions for Completing Section IV-VI and more Study notes Law in PDF only on Docsity!

Where can I get help filling out the form and if I have questions?

ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS SECTION

TO DETERMINE ELIGIBILITY FOR VA HEALTH CARE ENROLLMENT AND/OR CARE OR SERVICES.

Financial Disclosure:

Financial Disclosure Requirements Do Not Apply To:

• a former Prisoner of War; or

• those in receipt of a Purple Heart; or

• a recently discharged Combat Veteran; or

• those discharged for a disability incurred or aggravated in the line of duty; or

• those receiving VA SC disability compensation; or

• those receiving VA pension; or

• those in receipt of Medicaid benefits; or

• those who served in Vietnam between January 9, 1962 and May 7, 1975; or

• those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or

• those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.

INSTRUCTIONS FOR COMPLETING ENROLLMENT

APPLICATION FOR HEALTH BENEFITS

Getting Started:

Definitions of terms used on this form:

You may use ANY of the following to request assistance:

• Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).

• Go to www.va.gov/health-care for information about VA health benefits.

• Contact the Enrollment Coordinator at your local VA health care facility.

• Contact a National or State Veterans Service Organization.

For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA to

determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it will take to

read instructions, gather the necessary facts and fill out the form.

Please Read Before You Start... What is VA Form 10-10EZ used for?

• SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the

active military, naval or air service.

• COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.

• NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary

compensation.

• NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.

Directions for Sections I - III:

Section I - General Information:

Section III - Insurance Information:

Section II - Military Service Information:

Answer all questions.

If you are not currently receiving benefits from VA, you may attach a copy of your

discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your signed

application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-reference your

information with VA data.

Include information for all health insurance companies that cover you, this includes

coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you to

each health care appointment.

Directions for Sections IV-VI:

You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to

provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to

determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used

to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose

your financial information, you will not be eligible for these benefits.

Section IV - Dependent Information: Include the following:

• Your spouse even if you did not live together, as long as you contributed support last calendar year.

• Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under 23 and

attending high school, college or vocational school (full or part-time), or became permanently unable to support themselves before age 18.

• Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.

ALL VETERANS MUST COMPLETE SECTIONS I - III.

VA FORM

JUL 2021 10-10EZ^ Complete only the sections that apply to you; sign and date the form.^

HEC PAGE 1 OF 5

Continued ...

PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

Report:

• Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages, bonuses,

tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay your household

expenses.

• Net income from your farm, ranch, property, or business.

• Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income,

compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends, including tax

exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.

Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children

Do Not Report:

Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI) and need-based payments

from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on Individual Retirement

Accounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement for casualty loss; loans; Radiation

Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims Settlement Acts Income, payments to

foster parent; amounts in joint accounts in banks and similar institutions acquired by reason of death of the other joint owner; Japanese

ancestry restitution under Public Law 100-383; cash surrender value of life insurance; lump-sum proceeds of life insurance policy on a

Veteran; and payments received under the Medicare transitional assistance program.

Section VII - Previous Calendar Year Deductible Expenses

Section VIII - Consent to Copays and to Receive Communications

Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs, eyeglasses,

Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom you have a legal

or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other sources. Report last

illness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).

By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as

required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile

number. However, providing your email, home phone number, or mobile number is voluntary.

Submitting Your Application

Where do I send my application?

Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section

3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it

displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 30 minutes. This includes the

time it will take to read instructions, gather the necessary facts and fill out the form.

VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705,1710, 1712, and 1722 in order for VA to

determine your eligibility for medical benefits. Information you supply may be verified from initial submission forward through a computer-matching program.

VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the

Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any

or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will

not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA

benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposes

authorized or required by law.

1. You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an "X", 2

people you know must witness you as you sign. They must sign the form and print their names. If the form is not signed and dated

appropriately, VA will return it for you to complete.

2. Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.

Section V - Employment Information:

VA FORM 10-10EZ, JUL 2021 PAGE 2 OF 5

• Veterans Employment Status

• Date of Retirement

• Company Name

• Company Address

• Company Phone Number

Privacy Act Information:

HEC

SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

(Use a separate sheet for additional dependents)

SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

SECTION V - EMPLOYMENT INFORMATION

SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)

SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)

APPLICATION FOR HEALTH BENEFITS

Continued

VETERAN'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER

2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND

SCHOOL LAST CALENDAR YEAR?

2B. CHILD'S SOCIAL SECURITY NO.

2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)

2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE

AGE OF 18?

3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST

YEAR, DID YOU PROVIDE SUPPORT?

1B. SPOUSE'S DATE OF

BIRTH (mm/dd/yyyy)

1D. DATE OF MARRIAGE (mm/dd/yyyy)

2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)

2D. CHILD'S RELATIONSHIP TO YOU (Check one)

1. SPOUSE'S NAME (Last, First, Middle Name) 2. CHILD'S NAME (Last, First, Middle Name)

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP

if different from Veteran's)

2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE,

VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

1A. SPOUSE'S SOCIAL SECURITY NUMBER

1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips, VETERAN SPOUSE CHILD 1

etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR

BUSINESS

2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

3. LIST OTHER INCOME AMOUNTS (e.g., Social Security, compensation,

pension, interest, dividends) EXCLUDING WELFARE.

1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications,

Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES)

FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section VI.)

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books,

fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

YES NO

YES NO

YES NO

SON DAUGHTER STEPSON STEPDAUGHTER

1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)

2. NAME OF POLICY HOLDER 3. POLICY NUMBER 4. GROUP CODE

5. ARE YOU ELIGIBLE FOR MEDICAID?

(Federal health insurance for low income adults)

6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?

YES NO

YES NO

6B. EFFECTIVE DATE (mm/dd/yyyy)

FULL TIME PART TIME NOT EMPLOYED RETIRED

1A. VETERAN'S EMPLOYMENT STATUS (Check one). 1B. DATE OF RETIREMENT (mm/dd/yyyy)

1C. COMPANY NAME.

(Complete if employed or retired)

1D. COMPANY ADDRESS

(Complete if employed or retired - Street, City, State, ZIP )

1E. COMPANY PHONE NUMBER

(Complete if employed or retired)

(Include area code)

VA FORM 10-10EZ, JUL 2021 PAGE 4 OF 5

MALE FEMALE

TRANSMALE/TRANSMAN/FEMALE-TO-MALE

CHOOSE NOT TO ANSWER

TRANSFEMALE/TRANSWOMAN/MALE-TO-FEMALE

1C. SELF-IDENTIFIED GENDER IDENTITY

HEC

ASSIGNMENT OF BENEFITS

SECTION VIII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan

(HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby

authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the

charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or

entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or

prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be

entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary

and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party

or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify

my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.

ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.

DATE (mm/dd/yyyy)

By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also

agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number,

or mobile number is voluntary.

APPLICATION FOR HEALTH BENEFITS

Continued

VETERAN'S NAME (Last, First, Middle) SOCIAL SECURITY NUMBER

SIGNATURE OF APPLICANT

(Sign in ink)

VA FORM 10-10EZ, JUL 2021 HEC PAGE 5 OF 5