VA Form 10-10EC Application for Extended Care Services

VA Form 10-10EC or the "Application For Extended Care Services" is a form issued by the U.S. Department of Veterans Affairs.

Download a PDF version of the VA Form 10-10EC down below or find it on the U.S. Department of Veterans Affairs Forms website.

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OMB Number: 2900-0629
Estimated Burden: 90 min.
Expiration Date: 01/31/2017
INSTRUCTIONS FOR COMPLETING APPLICATION
FOR EXTENDED CARE SERVICES (VAF 10-10EC)
STEP 1. Before You Start. . . .
What is VA Form 10-10EC used for?
To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, either
directly by VA or paid for by VA.
Who should complete a VA Form 10-10EC?
A
veteran
applying
for
extended
care
services
may
be
required
to
complete
VA
Form
10-10EC.
The following veterans will NOT BE REQUIRED to complete VA Form 10-10EC or pay Extended Care Copayments.
A
veteran
compensable
with
a
service-connected
disability.
A veteran whose annual income is less than the Single Veteran Pension Rate in effect under 38 U.S.C. 1521(b).
A veteran receiving care for a service-connected disability as determined by a VA health care provider and documented in the
medical records.
A
veteran
receiving
extended
care
services
that
began
on
or
before
November
30,1999.
A veteran receiving extended care services related to Vietnam-era herbicide-exposure, radiation/exposure, Persian Gulf War and
post-Persian Gulf War combat-exposure.
A veteran receiving extended care services related to treatment for military sexual trauma as authorized under
38
U.S.C.
1720D.
A veteran receiving extended care services related to certain care or services for cancer of the head or neck as authorized under 38 U.
S.C. 1720E.
A veteran receiving Hospice Care as a part of extended care services.
An eligible combat veteran receiving extended care services related to treatment authorized under 38 U.S.C. 1710(e)(1)(D).
A veteran who VA determines to be catastrophically disabled, as defined in 38 CFR 17.36(e), is exempt from copayments for adult
day health care, non-institutional respite care, and non-institutional geriatric care.
A veteran receiving care for psychosis or a mental illness other than psychosis pursuant to 38 CFR 17.109.
Where can I get help filling out the form?
Contact the Social Work staff at your local VA medical facility for assistance on understanding the information and financial data
needed to complete VA Form 10-10EC.
What will I need to know in order to complete the form?
Current
income
of
both
veteran
and
spouse
(can
report
monthly
or
annual
income).
Current deductible expenses (can report monthly or annual expenses). For example property taxes may be reported as an annual
amount.
Value of fixed and liquid assets of both veteran and spouse. See Section IV of these instructions for further information regarding the
reporting of assets.
All health insurance information covering you even if it is through your spouse (a copy of your insurance card).
Medicare information (Part A & Part B) (a copy of your Medicare card).
Spousal/Dependent information (including spouse's social security number, dependents date of birth).
STEP 2. Completing the application . . . .
Section I - General Information. Include your name and full social security number.
Section II - Insurance Information. Include information for Medicare and all health insurance companies that cover you. It is
important that we obtain all health insurance coverage for you (including coverage through a spouse). Please make a copy of your
Medicare card and all health insurance cards and include them with this completed application.
Section III - Spouse/Dependent Information. In order to determine if a veteran must pay an extended care copayment amount, it is
necessary to identify spousal and/or dependent information and whether they are residing in the community (not institutionalized). A spouse
or dependent is considered institutionalized if they are residing in a nursing home or hospital setting. A dependent other than spouse would
be son, daughter, stepson, or stepdaughter. Provide address and phone number of spouse or dependent if different from the veteran. Report
current marital status. Do not include spousal information if you and spouse are legally separated or divorced. If you are certifying that
a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse
resided at the time of marriage, or where you and/or your spouse reside when you file your claim (or at a later date when you become
eligible for benefits) (38 U.S.C. 103(c)).
Additional guidance on when VA recognizes marriages is available at
http://www.va.gov/opa/marriage/.
Section IV
Do not report fixed assets if the veteran is receiving only non-institutional extended care services. Fixed
- Fixed Assets.
assets means real property. Exclude burial plots. Do not report the value of the primary residence and one vehicle if the spouse or dependent
is residing in the community and maintaining the residence. If the veteran and spouse maintain separate residences include the value of the
veteran's residence and vehicle minus any outstanding liens or mortgages. Include the value of all other fixed assets such as other residences
(vacation home), land, farm or ranch minus any outstanding liens or mortgages. Fixed assets are only included in the determination of the
extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.
10-10EC
VA FORM
Instructions - Page 1 of 2
EXISTING STOCK OF VA FORM 10-10EC, MAY 2005, WILL NOT BE USED.
JUL 2014
OMB Number: 2900-0629
Estimated Burden: 90 min.
Expiration Date: 01/31/2017
INSTRUCTIONS FOR COMPLETING APPLICATION
FOR EXTENDED CARE SERVICES (VAF 10-10EC)
STEP 1. Before You Start. . . .
What is VA Form 10-10EC used for?
To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, either
directly by VA or paid for by VA.
Who should complete a VA Form 10-10EC?
A
veteran
applying
for
extended
care
services
may
be
required
to
complete
VA
Form
10-10EC.
The following veterans will NOT BE REQUIRED to complete VA Form 10-10EC or pay Extended Care Copayments.
A
veteran
compensable
with
a
service-connected
disability.
A veteran whose annual income is less than the Single Veteran Pension Rate in effect under 38 U.S.C. 1521(b).
A veteran receiving care for a service-connected disability as determined by a VA health care provider and documented in the
medical records.
A
veteran
receiving
extended
care
services
that
began
on
or
before
November
30,1999.
A veteran receiving extended care services related to Vietnam-era herbicide-exposure, radiation/exposure, Persian Gulf War and
post-Persian Gulf War combat-exposure.
A veteran receiving extended care services related to treatment for military sexual trauma as authorized under
38
U.S.C.
1720D.
A veteran receiving extended care services related to certain care or services for cancer of the head or neck as authorized under 38 U.
S.C. 1720E.
A veteran receiving Hospice Care as a part of extended care services.
An eligible combat veteran receiving extended care services related to treatment authorized under 38 U.S.C. 1710(e)(1)(D).
A veteran who VA determines to be catastrophically disabled, as defined in 38 CFR 17.36(e), is exempt from copayments for adult
day health care, non-institutional respite care, and non-institutional geriatric care.
A veteran receiving care for psychosis or a mental illness other than psychosis pursuant to 38 CFR 17.109.
Where can I get help filling out the form?
Contact the Social Work staff at your local VA medical facility for assistance on understanding the information and financial data
needed to complete VA Form 10-10EC.
What will I need to know in order to complete the form?
Current
income
of
both
veteran
and
spouse
(can
report
monthly
or
annual
income).
Current deductible expenses (can report monthly or annual expenses). For example property taxes may be reported as an annual
amount.
Value of fixed and liquid assets of both veteran and spouse. See Section IV of these instructions for further information regarding the
reporting of assets.
All health insurance information covering you even if it is through your spouse (a copy of your insurance card).
Medicare information (Part A & Part B) (a copy of your Medicare card).
Spousal/Dependent information (including spouse's social security number, dependents date of birth).
STEP 2. Completing the application . . . .
Section I - General Information. Include your name and full social security number.
Section II - Insurance Information. Include information for Medicare and all health insurance companies that cover you. It is
important that we obtain all health insurance coverage for you (including coverage through a spouse). Please make a copy of your
Medicare card and all health insurance cards and include them with this completed application.
Section III - Spouse/Dependent Information. In order to determine if a veteran must pay an extended care copayment amount, it is
necessary to identify spousal and/or dependent information and whether they are residing in the community (not institutionalized). A spouse
or dependent is considered institutionalized if they are residing in a nursing home or hospital setting. A dependent other than spouse would
be son, daughter, stepson, or stepdaughter. Provide address and phone number of spouse or dependent if different from the veteran. Report
current marital status. Do not include spousal information if you and spouse are legally separated or divorced. If you are certifying that
a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the place where you and/or your spouse
resided at the time of marriage, or where you and/or your spouse reside when you file your claim (or at a later date when you become
eligible for benefits) (38 U.S.C. 103(c)).
Additional guidance on when VA recognizes marriages is available at
http://www.va.gov/opa/marriage/.
Section IV
Do not report fixed assets if the veteran is receiving only non-institutional extended care services. Fixed
- Fixed Assets.
assets means real property. Exclude burial plots. Do not report the value of the primary residence and one vehicle if the spouse or dependent
is residing in the community and maintaining the residence. If the veteran and spouse maintain separate residences include the value of the
veteran's residence and vehicle minus any outstanding liens or mortgages. Include the value of all other fixed assets such as other residences
(vacation home), land, farm or ranch minus any outstanding liens or mortgages. Fixed assets are only included in the determination of the
extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.
10-10EC
VA FORM
Instructions - Page 1 of 2
EXISTING STOCK OF VA FORM 10-10EC, MAY 2005, WILL NOT BE USED.
JUL 2014
Section V - Liquid Assets. Do not report liquid assets if the veteran is receiving only non-institutional extended care services.
Liquid assets include, but are not limited to, cash, interest, dividends, stocks, bonds, mutual funds, retirements accounts, stamp or
coin collections, art work, and other collectibles.
Liquid assets are only included in the determination of the extended care copayment amount when a veteran reaches 181 days or
more of institutional (inpatient) extended care services.
Section VI - Current Gross Income of Veteran and Spouse. Do not include income from dependents.
Report gross annual income from employment including information about your wages, bonuses, tips, severance pay
and other ccrued benefits.
Report net income from farm, ranch, property or business.
Report other income amounts, including retirement and pension income, Social Security Retirement and Social Security
Disability income, Compensation benefits such a VA disability, unemployment, Workers and black lung, cash gifts, court
mandated payments, inheritance amounts, tort settlement payments, interest and dividends, including tax exempt earnings and
distributions from Individual Retirement Accounts (IRAs) or annuities.
Section VII. Expenses. Expenses means basic subsistence expenses. Expenses are NOT included in the determination of the
extended care copyayment amount if the veteran is single and has been receiving inpatient extended care services for 181 days or
more.
Include any educational expense incurred by the veteran, spouse or dependent.
Include any funeral or burial expenses for your spouse or dependent as well as any prepaid funeral or burial
arrangements for yourself, spouse, or dependent.
Include rent or mortgage payment for primary residence only.
Include amount paid for utilities (electricity, gas, water or phone). You can calculate the amount by using the average
monthly expenses during the past year for your utilities.
Include car payment for one vehicle only.
Include amount spent for food for veteran, spouse or dependent.
Include non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, medications,
eyeglasses, Medicare, medical insurance premiums, medical copayments and other hospital or nursing home expense.
Include
court ordered payments such as alimony or child support.
Include insurance premiums such as automobile and homeowners. Exclude life insurance premiums.
Include taxes paid on property and average monthly expense for taxes paid on income over the past 12 months.
STEP 3. Submitting your application
What do I do when I have finished my application?
1. Read Section VIII, Consent for Assignment of Benefits, Section IX, Consent to Agreement to Make Copayments, and Section X,
Privacy Act and Paperwork Reduction Act Information.
2. In Section VIII and Section IX, you or an individual to whom you have delegated your Power of Attorney must sign and date.
3. Attach any documentation such as copies of Medicare and other health insurance cards, and your Power of Attorney documents
to your application.
4. Return the original form and supporting documentation to the Social Work staff at your local VA medical facility.
STEP 4. Finding out what my Extended Care Copayment Amount will be.
Once the VA Form 10-10EC is completed, the Social Work staff at your local VA medical facility will counsel you, or an
individual to whom you have delegated your Power of Attorney, on your estimated monthly copayment obligations for the
requested extended care services.
10-10EC
VA FORM
Instructions - Page2 of 2
JUL 2014
OMB Number: 2900-0629
Estimated Burden: 90 min.
Expiration Date:01/31/2017
APPLICATION FOR EXTENDED CARE SERVICES
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement
or
representation.
(See 18 U.S.C. 287 and 1001)
SECTION I - GENERAL INFORMATION
1. VETERAN'S NAME (Last, First, MI)
2. SOCIAL SECURITY NUMBER
SECTION II - INSURANCE INFORMATION
ANSWER YES OR NO WHERE APPLICABLE (OTHERWISE PROVIDE THE REQUESTED INFORMATION)
3. ARE YOU ELIGIBLE FOR MEDICAID?
3A. ARE YOU ENROLLED IN MEDICARE PART A (Hospital Insurance)
3B. EFFECTIVE DATE (If "Yes")
YES
NO
YES
NO
4. NAME OF INSURANCE COMPANY
4A. ADDRESS OF INSURANCE COMPANY
4B. PHONE NUMBER OF INSURANCE COMPANY
4C. NAME OF POLICY HOLDER
4D. RELATIONSHIP OF POLICY HOLDER
4F. GROUP NAME AND/OR NUMBER
4E. POLICY NUMBER
SECTION III - SPOUSE/DEPENDENT INFORMATION
5. CURRENT MARITAL STATUS (Check one)
5A. SPOUSE'S NAME (Last, First, MI)
MARRIED
NEVER MARRIED
LEGALLY SEPARATED
WIDOWED
DIVORCED
5B. SPOUSE RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)
5C. SPOUSE'S SOCIAL SECURITY NUMBER
YES
NO (If "No", explain)
6. DEPENDENT'S NAME (Last, First, MI)
6A. DEPENDENT'S DATE OF BIRTH
6B. DEPENDENT'S SOCIAL SECURITY
6C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)
NO (If "No", explain)
YES
7. DEPENDENT'S NAME (Last, First, MI)
7A. DEPENDENT'S DATE OF BIRTH
7B. DEPENDENT'S SOCIAL SECURITY
7C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)
YES
NO (If "No", explain)
We need to collect information regarding income, assets and expenses for you and your spouse. If you do not wish to provide this
information you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services. See the
top of page 2, read, sign and date.
Page 1 of 3
10-10EC
EXISTING STOCK OF VA FORM 10-10EC, MAY 2005, WILL BE USED.
VA FORM
JUL 2014
APPLICATION FOR EXTENDED CARE SERVICES, Continued
SOCIAL SECURITY NUMBER
VETERAN'S NAME
I do not wish to provide my detailed financial information. I understand that I will be assessed the maximum copayment amount for extended care
services and agree to pay the applicable VA copayment as required by law.
SIGNATURE
DATE
SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)
VETERAN
SPOUSE
1. Primary Residence (Market value minus mortgages or liens. Exclude if veteran receiving only non-institutional
$
$
extended care services or spouse or dependent residing in the community). If the veteran and spouse maintain
separate residences, and the veteran is receiving institutional (inpatient) extended care services, include value of
the veteran's primary residence.)
2. Other Residences/Land/Farm or Ranch (Market value minus mortgages or liens. This would include a second
$
$
home, vacation home, rental property.)
3. Vehicle(s) (Value minus any outstanding lien. Exclude primary vehicle if veteran receiving only non-
$
$
institutional extended care services or spouse or dependent residing in community. If the veteran and spouse
maintain separate residences and vehicles, and the veteran is receiving institutional (inpatient) extended care
services, include value of the veteran's primary vehicle.)
SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)
$
$
1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates of deposit, individual
retirement accounts, stocks and bonds).
$
2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus the amount you owe
$
on these items. Exclude household effects, clothing, jewelry, and personal items if veteran receiving only non-
institutional extended care services or spouse or dependent residing in the community.
$
$
TOTAL ASSETS
SUM OF ALL LINES FIXED AND LIQUID ASSETS
SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE
VETERAN
SPOUSE
CATEGORY
HOW MUCH
HOW OFTEN
HOW MUCH
HOW OFTEN
1. Gross annual income from employment (e.g., wages, bonuses, tips, severances
$
$
pay, accrued benefits)
$
2. Net income from your farm/ranch, property or business.
$
3. List other income amounts (e.g., social security, Retirement and pension,
$
$
interest, dividends) Refer to instructions.
SECTION VII - DEDUCTIBLE EXPENSES
ITEMS
AMOUNT
1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)
$
2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid
$
arrangements)
3. Rent/Mortgage (monthly amount or annual amount)
$
4. Utilities (calculate by average monthly amounts over the past 12 months)
$
5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)
$
6. Food (for veteran, spouse and dependent)
$
$
7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians,
dentists, medications, Medicare, health insurance, hospital and nursing home expenses)
8. Court-ordered payments (e.g., alimony, child support)
$
$
9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude Life Insurance
10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on
$
income over the past 12 months.
$
TOTALS
10-10EC
VA FORM
Page 2 of 3
JUL 2014
APPLICATION FOR EXTENDED CARE SERVICES, Continued
SECTION VIII - CONSENT FOR 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.
SIGNATURE
DATE
VETERANS NAME
SOCIAL SECURITY NUMBER
SECTION IX - CONSENT TO AGREEMENT TO MAKE COPAYMENTS
Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative has
received a copy of the Privacy Act Statement and agrees to make appropriate copayments.
l declare under penalty of perjury that the foregoing
is true and accurate to the best of my knowledge and I agree to make the
applicable copayment for extended care services as required by law.
I understand that any
materially false, fictitious, or fraudulent
statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code,
Sections 287 and 1001.
SIGNATURE
DATE
SECTION X - PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION
The VA is asking you to provide the information on this form under Title 38, United States Code, sections 1710, 1712, 1722 and 1729
for VA to determine your eligibility for extended care benefits and to establish financial eligibility, if applicable, when placed in
extended care services. Obligation to respond is voluntary. 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; possible disclosures include
those described in the "routine use" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the
Federal Register in accordance with the Privacy Act of 1974. You do not have to provide the information to VA, but if you don't,
VA 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 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. 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 90 minutes. This
includes the time it will take to read instructions, gather the necessary facts and fill out the form.
ADDITIONAL COMMENTS:
10-10EC
VA FORM
Page 3 of 3
JUL 2014

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