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INSTRUCTIONS
FOR COMPLETING
APPLICATIONS FOR HEALTH BENEFITS |
DEFINITIONS
SERVICE-CONNECTED: A veteran with a VA determination that an
illness or injury was incurred or aggravated while on active duty.
SERVICE-CONNECTED COMPENSABLE: A veteran who is paid VA monthly compensation for the
service-connected disability.
SERVICE-CONNECTED NONCOMPENSABLE: A veteran who is rated 0% service-connected and not
paid VA monthly compensation.
NONSERVICE-CONNECTED: A veteran who does not have a VA determined service related
condition. |
SECTIONS TO COMPLETE |
The checks (4
) in the table below indicate which Sections of the Application for Health Benefits should
be completed by the applicant.
The Sections in the shaded blocks should be completed only if Section IIB is checked as
"YES." |
SECTION |
I |
IIA |
IIB |
IIC |
IID |
IIE |
III |
| 0% SERVICE-CONNECTED,
NONCOMPENSABLE |
4 |
4 |
4 |
4 |
4 |
4 |
4 |
| 0 TO 20% SERVICE-CONNECTED,
COMPENSABLE |
4 |
4 |
4 |
4 |
4 |
|
4 |
| 30 TO 40% SERVICE-CONNECTED,
COMPENSABLE |
4 |
4 |
4 |
4 |
4 |
|
4 |
| 50% OR GREATER, SERVICE-CONNECTED,
COMPENSABLE |
4 |
|
|
|
|
|
4 |
| NONSERVICE-CONNECTED |
4 |
4 |
4 |
4 |
4 |
4 |
4 |
| FORMER POW OR WWI VETERAN |
4 |
4 |
4 |
4 |
4 |
|
4 |
| NSC PENSION |
4 |
|
|
|
|
|
4 |
|
SECTION I – GENERAL INFORMATION |
| Complete all questions if applying for Health
Services, Nursing Home, Domicilliary or Dental benefits. Please edit all preprinted
information and provide updated information. Skip all blocks with "N/A" or
"For Future Use" preprinted on them. |
SECTION II – FINANCIAL ASSESSMENT |
| The financial assessment is used to determine
certain veterans’ priority level for enrollment, possible exemption from co-payment
requirements, and eligibility for total benefits. Veterans with a combined VA
service-connected disability rating of 50% or greater and veterans in receipt of VA
pension benefits are exempt from this assessment and should not complete this section. |
SECTION IIA – FINANCIAL DISCLOSURE |
| If you answer YES in Section IIB. Complete
Sections IIA, IIC, IID and IIE that apply to you. For example, if you are completing the
form in June 1998, provide calendar year 1997 information. See table above for sections to
complete. |
SECTION IIB – DEPENDENT INFORMATION |
Complete Section IIA if you answered YES in
Section IIB. Use a separate sheet of paper for additional dependent children.
› You may count
your spouse as your dependent even if you did not live together, as long as you
contributed $600 or more in support.
› Children under
the age of 18 are not required to have attended school in order to be counted as a
dependent.
› A child between
the ages of 18 and 23 can only be counted as a dependent if they attend high school, or
college or vocational school
on a full or part time basis.
› Count child
support contributions even if not paid in regular set amounts. Contributions can include
tuition payments or payments of medical bills.
|
CONSENT TO
RELEASE INFORMATION
I hereby authorize the Department of Veterans
Affairs to disclose any such history, diagnostic and treatment information from my medical
records (including information relating to the diagnosis, treatment of other therapy for
the conditions of substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or
testing for or infection with the human immunodeficiency virus) to the contractor of any
health plan contract under which I am apparently eligible for medical care or payment of
the expense of care or to any other party against whom liability is asserted. I understand
that I may revoke this authorization at any time, except to the extent that action has
already been taken in reliance on it. Without my express revocation, this consent will
automatically expire when all action arising from VA’s claim for reimbursement for my
medical care has been completed. I authorize payment of medical benefits to VA for any
services for which payment is accepted. |
| SOCIAL
SECURITY NUMBER
|
DATE OF
BIRTH
|
| SIGNATURE
OF PATIENTS
|
DATE
|
| SECTION
IIC-PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN |
Complete Section IIC if you answered YES
in Section IIB. Answer all questions. If the question does not apply or is not applicable,
enter N/A. If you answered YES to Question 3, you will be provided additional forms to
report your business expenses if your income (or combined income and net worth) exceeds
the established threshold. |
REPORT: All income BEFORE DEDUCTIONS
for you and your spouse. Include:
› All wages, bonuses and tips, severance
pay, or other accrued benefits (including gross income from your farm, ranch, property or
business)
› Retirement and pension income
› Social Security Retirement income
› Social Security Disability income
› Compensation benefits such as: VA
disability, unemployment, workers and black lung
› Cash gifts
› Interest and dividends, including tax
exempt earnings
› Distributions from Individual
Retirement Accounts (IRAs) or annuities
› Your child’s unearned income
information if it could have been used to pay your household expenses.
|
DO NOT REPORT:
› Work income of dependent children
attending high school, college, vocational rehabilitation or training
› Welfare or Supplemental Security Income
(SSI) payments
› Payments from a government entity that
are based on your financial need
› 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 or proceeds of
casualty insurance
› Loans
› Agent Orange and Alaska Native Claim
› Settlement Acts income
› Payments to foster parents
|
SECTION IID – DEDUCTIBLE EXPENSES |
| Complete Section IID if you answered YES in Section IIB.
Answer all questions. If the question does not apply or is not applicable, enter N/A.
Nonreimbursed medical expenses include medical and dental care, drugs, eyeglasses,
Medicare and medical insurance premiums, and other health care expenses. Do not list
medical expenses if you expect to receive reimbursement from insurance or other sources. |
SECTION IIE – NET WORTH |
Complete Section IIE if you answered YES
in Section IIB and you are a nonservice-connected veteran or a
0% service-connected noncompensable veteran. Do not complete this section if your gross
household income, less deductible expenses, is above the threshold for the current year. |
SECTION III– CONSENTS |
ALL APPLICANTS MUST SIGN
AND DATE THE APPLICATION FOR HEALTH BENEFITS. |
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 20 minutes. This includes the time it will take to read instructions, gather the
necessary facts and fill out the form.
Privacy Act Information: The VA is asking you to provide the
information on this form under Title 38, United States Code, sections 1710, 1712, and 1722
in order for VA to determine your eligibility for medical benefits. The information you
supply may be verified 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 for: civil or criminal law enforcement, congressional communications,
epidemiological or research studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest, the Administration of
VA programs and delivery of VA benefits, verification of identity and status, and
personnel administration. You do not have to provide the information to VA, but
it you don’t, we will be unable to process your request and serve your medical needs.
Failure to furnish the information will not have any affect on any other benefits to which
you may be entitled. If you give VA your Social Security Number, VA will use it to
administer your VA benefits, to identify veterans and persons claiming or receiving VA
benefits and their records, and for other purposes authorized or required by law. |
|
APPLICATIONS
FOR HEALTH BENEFITS |
SECTION I – GENERAL INFORMATION |
| 1A. TYPE OF
BENEFIT(S) APPLIED FOR (You may check more than one) HEALTH
SERVICES NURSING HOME DOMICILIARY DENTAL ENROLLMENT |
| 1B. IF APPLYING FOR
HEALTH SERVICES, WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER
|
| 2.
VETERAN’S NAME (Last, First, MI)
|
3. OTHER
NAMES USED
|
4. GENDER
(Check one)M F |
| 5. SOCIAL
SECURITY NUMBER
|
6. CLAIM
NUMBER
|
7. DATE
OF BIRTH (mm/dd/yyy)
|
8.
RELIGION
|
| 9A.
CURRENT MAILING ADDRESS (Street)
|
9B. CITY
|
9C. STATE
|
9D. ZIP
|
| 9E.
COUNTY
|
10. HOME
TELEPHONE NUMBER () |
11. WORK
TELEPHONE NUMBER () |
12. CURRENT MARITAL
STATUS (Check one)
MARRIED NEVER MARRIED SEPARATED WIDOWED DIVORCED UNKNOWN
|
| 13A. LAST
BRANCH OF SERVICE
|
13B. LAST
ENTRY DATE
|
13C. LAST
DISCHARGE DATE
|
13D.
DISCHARGE TYPE
|
13E.
MILITARY SERVICE NUMBER
|
| 14. CHECK YES
OR NO |
| A.
ARE YOU A FORMER PRISONER OF WAR |
YES |
NO |
H.
DO YOU HAVE A MILITARY DENTAL INJURY |
YES |
NO |
| B.
DO YOU HAVE A VA SERVICE-CONNECTED RATING |
YES |
NO |
I.
DO YOU HAVE A SPINAL CORD INJURY |
YES |
NO |
| B1. IF YES, WHAT IS YOUR RATING PERCENTAGE % |
J.
ARE YOU ELIGIBLE FOR MEDICAID |
YES |
NO |
| C.
ARE YOU RECEIVING A VA PENSION |
YES |
NO |
K.
ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART |
YES |
NO |
| D.
ARE YOU RETIRED FROM THE MILITARY |
YES |
NO |
K1.
EFFECTIVE DATE |
| D1.
WAS YOUR RETIREMENT THE RESULT OF A DISABILITY |
YES |
NO |
L.
ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B |
YES |
NO |
| D2.
WERE YOU REGULARLY RETIRES - (20+yrs.) |
YES |
NO |
L1.
EFFECTIVE DATE |
| E.
WERE YOU EXPOSED TO TOXINS IN THE GULF WAR |
YES |
NO |
M.
MEDICARE CLAIM NUMBER |
| F.
WERE YOU EXPOSED TO AGENT ORANGE |
YES |
NO |
| G.
WERE YOU EXPOSED TO RADIATION |
YES |
NO |
| 15A. VETERAN'S
EMPLOYEMENT STATUS (check one) If employed or retired, complete item 15B |
NOT EMPLOYEDEMPLOYED
RETIRED |
Date of retirement |
15B.
COMPANY NAME, ADDRESS AND TELEPHONE NUMBER ; |
| 15A. SPOUSE'S
EMPLOYEMENT STATUS (check one) If employed or retired, complete item 16B |
NOT EMPLOYED
EMPLOYED
RETIRED |
Date of retirement |
16B.
COMPANY NAME, ADDRESS AND TELEPHONE NUMBER ;
|
| 17A.
VETERAN'S HEALTH INSURANCE COMPANY
|
18A.
SPOUSE'S HEALTH INSURANCE COMPANY |
| 17B.
NAME OF POLICY HOLDER
|
18B. NAME
OF POLICY HOLDER |
| 17C.
POLICY NUMBER
|
17D.
GROUP CODE
|
18C.
POLICY NUMBER |
18D.
GROUP CODE |
| 19B. NEXT OF KIN'S
HOME TELEPHONE NUMBER () |
| 19C. NEXT OF KIN'S
WORK TELEPHONE NUMBER () |
| 20B.
EMERGENCY CONTACT HOME TELEPHONE NUMBER () |
| 19C.
EMERGENCY CONTACT WORK TELEPHONE NUMBER () |
| 21. I DESIGNATE THE FOLLOWING
INDIVIDUAL TO RECEIVE POSSESSION OF ALL MY PERSONAL PROPERTY LEFT ON PREMISES UNDER VA
CONTROL AFTER MY DEPARTURE OR AT THE TIME OF MY DEATH. (Check one) (This does not
constitute a will or transfer of title.) EMERGENCY CONTACE
NEXT OF KIN |
| 22A. IS NEED FOR
CARE DUE TO ON THE JOB INJURY (Check on)
YES NO |
22B. IS NEED FOR CARE
DUE TO ACCIDENT (Check one)YES NO |
APPLICATION FOR HEALTH BENEFITS, Continued |
VETERAN'S
NAME |
SOCIAL SECURITY
NUMBER |
SECTION ll – FINANCIAL ASSESSMENT |
SECTION IlA – DEPENDENT INFORMATION (Use a separate sheet for
additional dependents) |
| 1.
SPOUSE'S NAME (Last, First, MI)
|
2.
CHILD'S NAME (Last, First, MI) |
| 3. SPOUSE'S SOCIAL
SECURITY NUMBER |
4.
SPOUSE'S DATE OF BIRTH (mm/dd/yyy) |
5.
CHILD'S DATE OF BIRTH (mm/dd/yyy) |
| 6.
SPOUSE'S ADDRESS AND TELEPHONE (Street, City, State, Zip) ;
|
7. CHILDS
SOCIAL SECURITY NUMBER |
| 8.
SPOUSE'S MAIDEN NAME
|
9.
CHILD'S RELATIONSHIP TO YOU (Check one)
Son Daughter Stepson Stepdaughter |
| 10. DATE
OF MARRIAGE (mm/dd/yyy) |
11. DATE
CHILD BECAME YOUR DEPENDENT |
12. IF
YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, ENTER THE AMOUNT YOU
CONTRIBUTED TO THEIR SUPPORT
SPOUSE $ CHILD $
|
13.
EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OF
TRAINING (tuition, books, materials, etc.) $ |
14.
WAS CHILD PERMANETLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
YES NO
|
15.
IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR? YES NO |
IIB – FINANCIAL DISCLOSURE |
You are not required to
provide the financial information in this Section. However, current law may require VA to
consider your household financial situation to determine your eligibility for enrollment
and/or cost-free care of your nonservice-connected (NSC) conditions. If you are 0% SC
noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your annual
household income (or combined income and net worth) exceeds the established threshold, you
must agree to pay VA co-payments for care of your NSC conditions to be eligible for
enrollment. See Section III - Consent and Signature. |
YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE
ELIGIBILITY FOR CARE DETERMINED. Complete all sections below that apply to you with
last calendar year's information. Sign and date the application.
|
NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I
understand I will be assigned the appropriate enrollment
priority based on nondisclosure of my financial information. By checking NO and signing
below, I am agreeing to pay the applicable VA
co-payment. Sign and date the application.
|
llC – PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE
AND DEPENDENT CHILDREN |
|
VETERAN |
SPOUSE |
CHILDREN |
| 1. WHAT WAS
YOUR GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tip, etc), AS WELL AS
INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS |
$ |
$ |
$ |
| 2. LIST OTHER
INCOME AMOUNTS (Social Security, compensation, pension, interest, dividends) Exclude
welfare. |
$ |
$ |
$ |
3. WAS
INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS (If yes, refer to page 2, Section
llC of the instructions.)
YES NO
|
|
llD – DEDUCTIBLE EXPENSES |
| 1.
NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (payments for doctors,
dentists, drugs, Medicare, health insurance, hospital and nursing home) |
$ |
| 2. AMOUNT
YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR
DEPENDENT CHILD (Also enter spouse of child's information in Section llA) |
$ |
| 3. AMOUNT
YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES
(tuition, books, fees, materials, etc.) DO NOT LIST YOUR DEPENDENTS EDUCATIONAL EXPENSES. |
$ |
llE – NET WORTH |
|
VETERAN |
SPOUSE |
| 1. CASH,
AMOUNT IN BANK ACCOUNTS (Checking and savings accounts, certificates of deposit,
individual retirement accounts, etc.) |
$ |
$ |
| 2. MARKET
VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS. Do not count your
primary home. Include value of farm, ranch, or business assets. |
$ |
$ |
| 3. STOCKS
AND BONDS AND VALUE OF OTHER PROPERTY OR ASSETS (art, rare coins, etc.) MINUS
THE AMOUNT YOU OWE ON THESE ITEMS. Exclude household effects and family vehicles. |
$ |
$ |
SECTION III – CONSENT AND SIGNATURE |
| CO-PAYMENT NOTICE: If you are a 9%
service-connected noncompensable or a nonservice-connected veteran (and are not an Ex-POW,
WWI veteran or VA pensioner) and your household income (or combined income
and net worth) exceeds the established threshold, you may be eligible for enrollment only
if you agree to pay VA co-payments for treatment of your NSC conditions. By signing this
application you are agreeing to pay the applicable VA co-payment if required by law. |
I CERTIFY THE FOREGOING STATEMENT (S) ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND ABILITY.
SIGN HERE
(Signature of applicant or applicant's representative) |
DATE (mm/dd/yyy) |
THE LAW
PROVIDES SEVER PENALTIES FOR WILLFUL SUBMISSION OF FALSE INFORMATION. |
NOTE: Delete this text after reading. In this FREE TEXT area you can use
tab, if needed. You can insert blank lines by hitting enter/return; typing is
unlimited, and SPELL CHECK is available in this area.
|