VA Form 10-3542 Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

What Is VA Form 10-3542?

VA Form 10-3542, Veteran/Beneficiary Claim for Reimbursement of Travel Expenses is a document submitted to the Department of Veterans Affairs (VA) by the veteran or beneficiary to cover trip expenses for getting professional medical help in another state or country.

The latest version of the form was released by the VA in November 2013 with all previous editions obsolete. An up-to-date VA Form 10-3542 fillable version is available for download below and can be found through the VA website.

If you are a veteran or beneficiary receiving a VA pension or if your income is lower than the pension, you are entitled to a travel compensation. The purpose of the travel eligible for reimbursement must be linked to your condition, treatment or service. Costs are reimbursed within thirty days after the travel.

To be considered eligible, the claimant has to belong to one of the following categories:

  • Veterans with a disability rating of 30% or more may be reimbursed for travel related to any healthcare condition;
  • Veterans with a disability rating of 30% or less may be reimbursed for travel related to their service-connected condition;
  • Veterans receiving VA pension benefits may be reimbursed for travel related to any condition;
  • Veterans with an annual income below the maximum allowed annual rate of pension may be reimbursed for travel related to any condition;
  • Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations);
  • Veterans traveling in relation to a Compensation and Pension (C&P) examination;
  • Beneficiaries of other Federal Agencies authorized by that agency;
  • Allied beneficiaries when authorized by the appropriate foreign government agency;
  • Certain non-veterans (caregivers to veterans under the National Caregivers Program, medically required attendants, VA transplant care donor and support person, or other claimants subject to current regulatory guidelines).

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OMB Number: 2900-0798
Estimated Burden: 15 minutes
VETERAN/BENEFICIARY CLAIM FOR
REIMBURSEMENT OF TRAVEL EXPENSES
Section A. Traveler's Information
1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)
1.b Claimant's SSN
1.c Claimant's Date of Birth (mm/dd/yyyy)
2.a Claimant's status: (check one) Complete 3.a, 3.b, 3.c and 3.d if Caregiver, Attendant or Donor is checked.
Caregiver
Attendant
Donor
Veteran
Other
(National Caregiver Program)
(Medically authorized by VA)
(VA Transplant Care)
3.a Name of Veteran (Last, First, Middle)
3.b Veteran's SSN
3.c Veteran's Date of Birth (mm/dd/yyyy)
Section B. Trip Information
1.a I am claiming travel reimbursement from address:
(Street, City, State, Zip)
1.b Date Trip Began
1.c Travel by:
(mm/dd/yyyy)
(e.g., car, train, bus,
taxi)
2.a I am claiming return travel reimbursement to the address in B.1.a above
2.b Date Trip Ended
2.c Travel by:
(mm/dd/yyyy)
(e.g., car, train, bus,
YES
NO (if no, provide the Street, City, State, Zip below)
taxi)
YES
NO
3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.
(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)
a.
b.
c.
d.
e.
f.
g.
h.
4. Treating Facility Name (VA or Non-VA location)
5. Treating Facility Address (Optional)
Section C. Statements and Certifications
Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent
claim
Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of Government
owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no-cost to me. I am the only person claiming for the
travel listed. I have not previously received payment for the transportation claimed. I certify that the above information is correct.
Signature of Claimant
Date (mm/dd/yyyy)
10-3542
VA FORM
NOV 2013
OMB Number: 2900-0798
Estimated Burden: 15 minutes
VETERAN/BENEFICIARY CLAIM FOR
REIMBURSEMENT OF TRAVEL EXPENSES
Section A. Traveler's Information
1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)
1.b Claimant's SSN
1.c Claimant's Date of Birth (mm/dd/yyyy)
2.a Claimant's status: (check one) Complete 3.a, 3.b, 3.c and 3.d if Caregiver, Attendant or Donor is checked.
Caregiver
Attendant
Donor
Veteran
Other
(National Caregiver Program)
(Medically authorized by VA)
(VA Transplant Care)
3.a Name of Veteran (Last, First, Middle)
3.b Veteran's SSN
3.c Veteran's Date of Birth (mm/dd/yyyy)
Section B. Trip Information
1.a I am claiming travel reimbursement from address:
(Street, City, State, Zip)
1.b Date Trip Began
1.c Travel by:
(mm/dd/yyyy)
(e.g., car, train, bus,
taxi)
2.a I am claiming return travel reimbursement to the address in B.1.a above
2.b Date Trip Ended
2.c Travel by:
(mm/dd/yyyy)
(e.g., car, train, bus,
YES
NO (if no, provide the Street, City, State, Zip below)
taxi)
YES
NO
3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.
(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)
a.
b.
c.
d.
e.
f.
g.
h.
4. Treating Facility Name (VA or Non-VA location)
5. Treating Facility Address (Optional)
Section C. Statements and Certifications
Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent
claim
Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of Government
owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no-cost to me. I am the only person claiming for the
travel listed. I have not previously received payment for the transportation claimed. I certify that the above information is correct.
Signature of Claimant
Date (mm/dd/yyyy)
10-3542
VA FORM
NOV 2013
INSTRUCTIONS FOR COMPLETING
VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES
Who is Eligible for Reimbursement of Travel Expenses
1. Veterans rated by VA 30% or more service-connected for travel relating to any condition
2. Veterans rated by VA less than 30% for travel relating to their service-connected condition
3. Veterans receiving VA pension benefits for travel relating to any condition
4. Veterans with annual income below the maximum applicable annual rate of pension for any condition
5. Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations)
6. Veterans traveling in relation to a Compensation and Pension (C&P) examination
7. Certain Veterans in certain emergency situations
8. Beneficiaries of other Federal Agencies when authorized by that agency
9. Allied beneficiaries when authorized by appropriate foreign government agency
10. Certain non-Veterans when related to care of a Veteran (Caregivers under the National Caregivers
Program, medically required attendants, VA transplant care donor and support person, or other claimants
subject to current regulatory guidelines)
Instructions
1. The claimant or legal representative of claimant may complete this form.
2. Allied beneficiaries and beneficiaries of other federal agencies are not required to complete Section A,
Question 3a-c.
3. The form may be presented in person or mailed to VA health care facility where care was provided.
Addresses of VA health care facilities can be found at:
http://www.va.gov/directory
Note: The claim for
travel benefits may also be done in person at a VA health care facility.
4. Application for travel reimbursement must be done within 30 days of travel. Exception: application
beyond 30 days may occur when claim is a result of change in Beneficiary Travel eligibility.
5. Receipts are required for allowable non-mileage expenses, e.g., bridge, road and tunnel tolls; parking;
ferry fares; meals; lodging; and transport by bus, train, taxi or other public transportation. Prior approval
is required for meals and lodging.
6. Application will be evaluated to determine eligibility for travel benefits and services received. If eligible, the
claim will be processed for payment at currently authorized rate subject to any required deductibles.
7. Payment will be by electronic funds transfer (EFT) unless other arrangements have been made.
8. For assistance in completing the form, call 1-877-222-VETS (8387)
The Paperwork Reduction Act of 1995 requires VA to notify you that this information collection is in
accordance with the clearance requirements of Section 3507 of this Act. We anticipate the time expended by
individuals who must complete this form will average 3 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. No person will be penalized for failing to furnish
this information if it does not display a currently valid OMB control number. This information is collected under
38 CFR 70 and is intended to fulfill the need for Veterans and beneficiaries to claim Beneficiary Travel benefits
and for VA to determine the individual's eligibility for the benefit.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections
111 to determine your eligibility for Beneficiary Travel benefits and will be used for that purpose. 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 systems of records 24VA19 Patient Medical Record-VA, published in the Federal Register in accordance
with the Privacy Act of 1974. 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 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.
10-3542
VA FORM
NOV 2013

Download VA Form 10-3542 Veteran/Beneficiary Claim for Reimbursement of Travel Expenses

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VA Form 10-3542 Instructions

The form is completed by a veteran-claimant or their representative. Allied beneficiaries and beneficiaries of other federal agencies do not have to complete Section A, Question 3a-c regarding the veteran's full name, social security number, and date of birth.

Receipts are required for the following expenses: non-mileage expenses, including bridge, road and tunnel tolls, as well as parking, ferry fares, meals and lodging, transport by bus, train, taxi or other public transportation. Meals and lodging require prior approval.

The claim will be evaluated to determine eligibility for travel benefits and services. If it is determined eligible, it will be processed for payment at a currently authorized rate subject to any required deductibles.

The VA Form 10-3542 is distributed with filling guidelines provided in the second page of the form. Step-by-step instructions can be found below.

How to Fill Out VA Form 10-3542?

The VA 10-3542 must be completed with the following details:

  1. Section A requires information about the traveler. The claimant's full name, date of birth, social security number, and status must be provided. It is recommended to use a passport or ID card to enter correct details, as given in official documents. The form requires the veteran's name, social security number, and date of birth;
  2. Section B is for providing data about the travel. The date, time of the trip with the departure and arrival addresses should be submitted. To avoid making mistakes, a claimant should prepare the tickets and other documents containing this information;
  3. If an individual is going to apply for additional reimbursement, they have to enlist all the items they want to receive compensation for, such as tolls, parking, lodging, meals, etc. A claimant must be ready to provide the receipt for each item they want to be reimbursed for. The name of treating facility and its address must be provided, which may be a VA- or non-VA treating clinic;
  4. Section C is for the certification. The claimant states that they have provided true-to-life and up-to-date information and have incurred a cost in relation to the travel claimed; has not obtained transportation at government expense, through the use of government-owned conveyance, or government purchased tickets or tokens or received other transportation resources at no cost to them. Also, the claimant has to certify that they have never received any veteran trip compensation before, and they are the only person claiming for the travel listed. When signing the form the claimant must be aware of their full responsibility for the provided data. Providing false, fictitious, or fraudulent details leads to severe criminal and civil penalties including fine or imprisonment, or both.

Where Do I Send My VA Form 10-3542?

The form may be presented in person or mailed to the VA health care facility where this care was provided. An up-to-date VA facility locator tool allows an individual to search for the nearest VA medical center, as well as other health facilities, benefits offices, cemeteries, and Vet Centers within 1925 VA facilities. This storehouse of facility and key staff information within VA facilities is maintained on a regular basis throughout the VA network, is designed for ease-of-use and categorizes information for browsing by state and administration. The addresses of all VA health care facilities can be found on the VA website.

Where to Fax VA Form 10-3542?

One of the methods to apply for travel reimbursement is to send the VA travel form 10-3542 via secure fax or mail to the local Beneficiary Travel Office. Contact information, including phone numbers and fax numbers of VA health care facilities, can be found at the VA website.

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