Va Form 10-10ez - Application For Health Benefits - Department Of Veterans Affairs (Page 5 of 5) in pdf

VETERAN'S NAME

(Last, First, Middle)

SOCIAL SECURITY NUMBER

APPLICATION FOR HEALTH BENEFITS, Continued

SECTION VI - FINANCIAL DISCLOSURE

Failure to disclose your previous year's financial information may affect your eligibility for health care benefits. Your financial information is used by VA to accurately

determine if you should be responsible for copayments for office visits, pharmacy, inpatient, nursing home and long term care, and for some veterans, priority for

enrollment. You are not required to provide this information. However, completing the financial disclosure section results in a more accurate determination of your

eligibility for health care services/benefits.

NO , I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VII THROUGH X.

I understand that VA is currently not enrolling veterans

who decline to provide financial information unless other special eligibility factors exist.

However, if I am enrolled, I agree to pay the

applicable VA copayments. Sign and date the application in Section XII.

YES , I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO ESTABLISH MY ELIGIBILITY FOR CARE. Complete all sections

below that apply to you with last calendar year's information. Sign and date the application in Section XII.

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

1. SPOUSE'S NAME

(Last, First, Middle Name)

2. CHILD'S NAME

(Last, First, Middle Name)

(Check one)

1A. SPOUSE'S MAIDEN NAME

2A. CHILD'S RELATIONSHIP TO YOU

Son

Daughter

Stepson

Stepdaughter

1B. SPOUSE'S SOCIAL SECURITY NUMBER

2B. CHILD'S SOCIAL SECURITY NUMBER

2C. DATE CHILD BECAME YOUR DEPENDENT

(mm/dd/yyyy)

1C. SPOUSE'S DATE OF BIRTH

(mm/dd/yyyy)

1D. DATE OF MARRIAGE

(mm/dd/yyyy)

2D. CHILD'S DATE OF BIRTH

(mm/dd/yyyy)

1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER

(Street, City, State, ZIP )

2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?

YES

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

CALENDAR YEAR?

YES

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

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

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

THE AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT.

REHABILITATION OR TRAINING

SPOUSE

CHILD

SECTION VIII - 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 IX - 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.

(Also enter

2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD

spouse or child's information in Section VII.)

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

VETERAN

SPOUSE

CHILD 1

(e.g., checking and savings accounts, certificates of deposit,

1. CASH, AMOUNT IN BANK ACCOUNTS

individual retirement accounts, stocks and bonds)

(e.g., second homes and

2. MARKET VALUE OF LAND AND BUILDINGS MINUS MORTGAGES AND LIENS.

non-income producing property. Do not count your primary home.)

(e.g., art, rare coins, collectables)

3. VALUE OF OTHER PROPERTY OR ASSETS

MINUS THE AMOUNT

Exclude

YOU OWE ON THESE ITEMS. INCLUDE VALUE OF FARM, RANCH OR BUSINESS ASSETS.

household effects and family vehicles.

SECTION XI - CONSENT TO COPAYMENTS

If you are a 0% service-connected veteran and do not receive VA monetary benefits or a nonservice-connected veteran (and you are not an Ex-POW, Purple Hear

Recipient, WWI veteran or VA pensioner) and your household income (or combined income and net worth) exceeds the established threshold, this application will be

considered for enrollment, but only if you agree to pay VA copayments for treatment of your nonservice-connected conditions. If you are such a veteran by signing this

application you are agreeing to pay the applicable VA copayment as required by law.

SECTION XII - ASSIGNMENT OF BENEFITS

I understand that pursuant to 38 U.S.C. Section 1729, VA is authorized to recover or collect from my health plan (HP) 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.

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

VA FORM

10-10EZ

PAGE 3

FEB 2005