Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs (Page 6 of 6) in pdf

(Last, First, Middle)

SOCIAL SECURITY NUMBER

VETERAN'S NAME

APPLICATION FOR HEALTH BENEFITS, Continued

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

(Use a separate sheet for additional dependents)

VETERAN

SPOUSE

CHILD 1

(wages, bonuses, tips, etc.)

1. GROSS ANNUAL INCOME FROM EMPLOYMENT

EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS

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

(eg., Social Security, compensation, pension

3. LIST OTHER INCOME AMOUNTS

interest, dividends).

EXCLUDING WELFARE.

SECTION VIII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

(e.g., payments for doctors, dentists, medications, Medicare, health

1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE

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

(Also enter spouse or child's information in Section VI.)

SPOUSE OR DEPENDENT CHILD

(e.g., tuition, books, fees, materials) DO

3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES

NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.

SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH (Use a separate sheet for additional dependents)

VETERAN

SPOUSE

CHILD 1

1. CASH AMOUNT IN BANK ACCOUNTS (e.g., checking, savings accounts, certificates of

deposit, individual retirement accounts, stocks and bonds)

2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS. (e.g.,

second home and non-incoming producing property. Do not count your primary home.)

3. VALUE OF OTHER PROPERTY OR ASSETS (e.g., art, rare coins, collectables) MINUS

THE AMOUNT YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH OR

BUSINESS ASSETS. Exclude household effects and family vehicles.

SECTION X - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION

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 45 minutes. This includes the time it will

take to read instructions, gather the necessary facts and fill out the form

Privacy Act Information: 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 beverified 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.

SECTION XI - CONSENT TO COPAYS

By signing this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as

required by law.

SECTION XII - ASSIGNMENT OF BENEFITS

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.

SIGNATURE OF APPLICANT

DATE

10-10EZ

VA FORM

PAGE 3

FEB 2011

Va Form 10-10ez - Application For Health Benefits - Department Of Veteran Affairs Page 6

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