16875. EPMO Open Source Coordination Office Redaction File Detail Report

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16875.1 Files compared

#	Location	File	Last Modified
1	core.zip\core\portlets\caret-portlet\docroot\form	1010CG_08282014.docx	Mon Jan 9 17:01:50 2017 UTC
2	core.zip\core\portlets\caret-portlet\docroot\form	1010CG_08282014.docx	Mon Jan 9 17:34:08 2017 UTC

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	1	Instructio ns for Com pleting Ap plication for the Pr ogram of C omprehensi ve Assista nce for Fa mily Careg ivers
	2
	3	Please Rea d Before Y ou Start . . .
	4
	5	What is VA Form 10-1 0CG used f or?
	6	To apply f or VA's Pr ogram of C omprehensi ve Assista nce for Fa mily Careg ivers. VA will use t he informa tion on th is form to assist in determini ng your el igibility; a clinica l assessme nt will al so be requ ired. An e ligible Ve teran may appoint on e (1) Prim ary Family Caregiver and up to two (2) S econdary F amily Care givers. On average, it will ta ke 15 minu tes to com plete the applicatio n includin g the time it will t ake you to read inst ructions, gather the necessary facts and fill out the form. Each time a new Care giver is a ppointed a new Form 10-10CG is required.
	7
	8	Where can I get help filling o ut the for m and answ ers to que stions?
	9	You may us e ANY of t he followi ng to requ est assist ance: Ask VA to help you fill out the fo rm by call ing us at PII . Access V A's websit e at http: //www. DNS and selec t "Contact the VA". Locate and contact t he Caregiv er Support Coordinat or at your nearest V A health c are facili ty. A Care giver Supp ort Coordi nator loca tor is ava ilable at http:// DNS www. DNS /. Contact the Natio nal Caregi ver Suppor t Line by calling 1- 855-260-32 74 or a Ve terans Ser vice Organ ization.
	10
	11	Definition s of terms used in t his form
	12
	13	Caregiver Support Co ordinator (CSC):
	14	A VA clini cal profes sional who connects Caregivers of Vetera ns with VA and commu nity resou rces offer ing suppor tive progr ams and se rvices. Ca regiver Su pport Coor dinators a re located at every VA medical center an d are desi gnated spe cialists i n Caregivi ng issues.
	15
	16	Family Mem ber:
	17	A member o f the Vete ran's or S ervicememb er's famil y (includi ng a paren t, a spous e, a son o r daughter , a step-f amily memb er, and an extended family mem ber), or a n individu al who liv es full-ti me with th e Veteran or Service member, or will do s o if appro ved as a P rimary or Secondary Family Car egiver.
	18
	19	Injured in the Line of Duty (L OD):
	20	An injury incurred o r aggravat ed during active mil itary serv ice, unles s the inju ry resulte d from the Veteran's or Servic emember's willful mi sconduct o r abuse of alcohol o r drugs, o r it occur red while that indiv idual was avoiding d uty by des ertion, or absent wi thout leav e which ma terially i nterfered with the p erformance of milita ry duty.
	21
	22	Power of A ttorney (P OA):
	23	A Power of Attorney is an auth orization for someon e to act o n the Vete ran's or S ervicememb er's behal f when com pleting th is form.
	24
	25	Primary Fa mily Careg iver:
	26	A Family M ember (def ined herei n), who is designate d as a "pr imary prov ider of pe rsonal car e services " under 38 U.S.C.
	27	§1720G(a)( 7)(A); and who meets the requi rements of 38 C.F.R. §71.25.
	28
	29	Representa tive:
	30	Refers to a Veteran' s or Servi cemember's court-app ointed leg al guardia n or speci al guardia n, Durable POA for H ealth Care , or other designate d health c are agent. Copies of documenta tion regar ding repre sentatives are reque sted on th is applica tion.
	31
	32	Secondary Family Car egiver:
	33	An individ ual approv ed as a "p rovider of personal care servi ces" for t he eligibl e Veteran under 38 U .S.C. §172 0G(a)(7)(A );
	34	meets the requiremen ts of 38 C .F.R. §71. 25; and ge nerally se rves as a back-up to the Prima ry Family Caregiver.
	35
	36	Stipend:
	37	An allowan ce given t o a Primar y Family C aregiver i n acknowle dgement of the sacri fices they are makin g to care for a seri ously inju red eligib le Veteran (as defin ed in 38 C .F.R §71.1 5).
	38
	39
	40
	41
	42
	43	SEP 2014
	44	10-10CG
	45
	46
	47	Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers?
	48	IF THE IND IVIDUAL IS A:
	49	AND
	50	AND
	51	THEN
	52	Veteran or Serviceme mber
	53	who has be en issued a date of medical di scharge fr om the mil itary
	54	Requires o n-going su pervision or assista nce with p erforming basic func tions of e veryday li fe due to a serious injury or mental dis order (inc luding tra umatic bra in injury, psycholog ical traum a or other mental di sorder) in curred or aggravated in the li ne of duty on or aft er Septemb er 11, 200 1
	55	Requires a t least 6 months of continuous caregiver support
	56	The Vetera n or Servi cemember m ay meet th e criteria for VA's Program of Comprehen sive Assis tance for Family Car egivers. C omplete th is form to apply
	57	Veterans a nd Service members wh o do not m eet the cr iteria for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers may be eligible for VA hea lth benefi ts and oth er caregiv er support services. To find o ut about o ther careg iver suppo rt service s, contact the Careg iver Suppo rt Coordin ator (CSC) at your l ocal VA he alth care facility. To obtain the name o f your loc al CSC, co ntact the Caregiver Support Li ne at 1-85 5-260-3274 or go to DNS www. DNS and use t he Find Yo ur Local C aregiver S upport Coo rdinator o ption.
	58
	59	Getting St arted:
	60	Answer all questions on the fo rm. If you are not e nrolled in VA's heal th care sy stem or ar e currentl y Active D uty underg oing medic al dischar ge, submit VA Form 1 0-10EZ "Ap plication for Health Benefits" with this form. Enr olled Vete rans may s ubmit VA F orm 10-10E ZR "Health Benefits Renewal Fo rm" with t heir compl eted VA Fo rm 10-10CG to provid e informat ion update s. Do NOT exceed the designate d spaces ( e.g., do N OT extend Last Name into First Name area ). The Vet eran's or Servicemem ber's repr esentative or POA ma y complete this appl ication; h owever the POA/Repre sentation documents must be pr ovided wit h this app lication.
	61	SECTION I --VETERAN AND SERVIC EMEMBER GE NERAL INFO RMATION
	62	Directions for Secti on I --Vet eran/Servi cemember, representa tive or PO A, please answer all questions , sign and date. SEC TION II -- PRIMARY FA MILY CAREG IVER GENER AL INFORMA TION
	63	Directions for Secti on II --pr imary fami ly caregiv er applica nt, please answer al l question s, includi ng health insurance informatio n,
	64	sign and d ate.
	65	SECTION II I --SECOND ARY FAMILY CAREGIVER (S) GENERA L INFORMAT ION
	66	Directions for Secti on III --s econdary f amily care giver appl icant(s) p lease answ er all que stions, si gn, and da te. . A V eteran/ Se rvicemembe r may appo int up to two second ary family caregiver s but this is not re quired. I f a Vetera n/Servicem enber elec ts to appo int a seco ndary fami ly caregiv er at a la ter time, Sections I and III i n a new 10 -10CG must be comple ted.
	67
	68	Submitting your appl ication.
	69	1. Read Pa perwork Re duction an d Privacy Act Inform ation.
	70	2. The Vet eran or an individua l delegate d as the V eteran's r epresentat ive/POA mu st sign an d date the form.
	71	3. Attach POA/Repres entation d ocuments t o the appl ication, i f applicab le.
	72	4. For exp edited pro cessing, m ail this a pplication to:
	73	Program of Comprehen sive Assis tance for Family Car egivers
	74	Health Eli gibility C enter
	75	2957 Clair mont Road NE, Ste 20 0
	76	Atlanta, G A 30329-16 47
	77	If you pre fer to pre sent or ta ke this ap plication in person, you may h and carry the printe d and sign ed applica tion to yo ur local V A Medical Center Car egiver Sup port Coord inator (CS C). To obt ain the na me of your local CSC , contact the Caregi ver Suppor t Line at PII or go to http://www . DNS and use t he Find Yo ur Local C aregiver S upport Coo rdinator o ption.
	78	THE PAPERW ORK REDUCT ION ACT
	79	This infor mation col lection is in accord ance with the cleara nce requir ements of section 35 07 of the Paperwork Reduction Act of 199 5. Public reporting burden for this coll ection of informatio n is estim ated to av erage 15 m inutes per response, including the time to read in structions , gather n ecessary d ata, and f ill out th e form. Re spondents should be aware that notwithst anding any other pro vision of law, no pe rson shall be subjec t to any p enalty for failing t o comply w ith a coll ection of informatio n if it do es not dis play a cur rently val id OMB con trol numbe r. Complet ion of thi s form is mandatory for eligib le Veteran s who wish to partic ipate in t he Caregiv er Program .
	80	PRIVACY AC T INFORMAT ION
	81	Privacy Ac t Informat ion: Priva cy Act Inf ormation: VA is aski ng you to provide th e informat ion on thi s form und er 38 U.S. C. Section s 101,
	82	5303A, 170 5, 1710, 1 720B, and 1720G, in order for VA to dete rmine your eligibili ty for med ical benef its. Infor mation you supply ma y be
	83	verified t hrough a c omputer-ma tching pro gram. VA m ay disclos e the info rmation th at you put on the fo rm as perm itted by l aw. VA may make a "r outine use " disclosu re of the informatio n as outli ned in the Privacy A ct systems of record s, “Patien t Medical Records -- VA” (24VA1 9), “Enrol lment and Eligibilit y Records --VA” (147 VA16), and “Health A dministrat ion Center Civilian Health and Medical p rogram Rec ords--
	84	VA” (54VA1 7) and in accordance with the VHA Notice of Privac y Practice s. Providi ng the req uested inf ormation, including Social Sec urity Numb er, is vol untary, bu t if any o r all of t he request ed informa tion is no t provided , it may d elay or re sult in de nial of yo ur request for healt h care ben efits. Fai lure to fu rnish the informatio n will not have any effect on any other benefits t o which yo u may be e ntitled. I f you prov ide VA you r Social S ecurity Nu mber, VA w ill use it to admini ster your VA benefit s. VA may also use t his inform ation to i dentify Ve terans and persons c laiming or receiving VA benefi ts, and th eir record s, and for other pur poses auth orized or required b y law.
	85
	86
	87
	88	SEP 2014
	89
	90	10-10CG
	91
	92	Estimated Burden: 15 min. OMB Number 290 0-0768
	93	Expiration Date: XX/ XX/XXXX
	94
	95
	96
	97	Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program
	98	Attention: Complete the applic ation (pri nt or type written on ly) and ma il it to: Program of Comprehen sive Assis tance for Family Car egivers, H ealth Elig ibility Ce nter, 2957 Clairmont Road NE, Ste 200, A tlanta, GA 30329-164 7, for exp edited pro cessing; o r, hand ca rry it to your local VA Medica l Center C aregiver S upport Coo rdinator ( CSC). The date the a pplication is receiv ed by VA i s the date the appli cation pro cess begin s. At this time VA d oes not pr ovide the Program of Comprehen sive Assis tance for Family Car egivers to Veterans/ Servicemem bers and F amily Care givers liv ing in a f oreign cou ntry.
	99	SECTION I - VETERAN/ SERVICEMEM BER
	100	Last Name
	101	First Name
	102	Middle Nam e
	103	Social Sec urity Numb er
	104	Date of Bi rth (mm-dd -yyyy)
	105	Gender
	106
	107	MaleFemale
	108	Current St reet Addre ss
	109	City
	110	State
	111	Zip Code
	112	Telephone Number (In cluding Ar ea Code)
	113	Cell Numbe r (Includi ng Area Co de)
	114	Email Addr ess
	115	Enrolled i n VA Healt h Care?
	116
	117	YesNo
	118	Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces:
	119	Name of fa cility whe re you las t received medical t reatment:H ospitalCli nic
	120	Federal La ws (18 USC 287 and 1 001) provi de for cri minal pena lties for knowingly submitting false, fi ctitious o r fraudule nt stateme nts or cla ims
	121	I certify that I giv e consent to the ind ividual(s) named in this appli cation to perform pe rsonal car e services for me up on being a pproved as
	122	Primary an d/or Secon dary Careg iver(s) in the Progr am of Comp rehensive Assistance for Famil y Caregive rs. I cert ify that t he informa tion above is correc t and true to the be st of my k nowledge a nd belief.
	123
	124
	125
	126	Veteran/Se rvicemembe r/Represen tative/POA Signature
	127
	128
	129
	130	Date
	131	SECTION II - PRIMARY FAMILY CA REGIVER
	132	Last Name
	133	First Name
	134	Middle Nam e
	135	Social Sec urity Numb er
	136	Date of Bi rth (mm-dd -yyyy)
	137	Gender
	138
	139	MaleFemale
	140	Current St reet Addre ss
	141	City
	142	State
	143	Zip Code
	144
	145
	146	SEP 2014
	147	10-10CG
	148	Page 1 of 2
	149
	150
	151	SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued)
	152	Telephone Number (In cluding Ar ea Code)
	153	Cell Numbe r (Includi ng Area Co de)
	154	E-mail Add ress
	155	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	156	Enrolled i n Medicaid or Medica re?
	157
	158	YesNo
	159	Other Heal th Insuran ce?YesNo
	160
	161	Name
	162	Federal La ws (18 USC 287 and 1 001) provi de for cri minal pena lties for knowingly submitting false, fi ctitious o r fraudule nt stateme nts or cla ims
	163	I certify that I am at least 1 8 years of age.
	164
	165	Check one:
	166
	167	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	168	OR
	169	I certify am not a f amily memb er and I r eside with the Veter an or Serv icemember or will do so upon a pproval.
	170
	171	I agree to perform p ersonal ca re service s as the P rimary Fam ily Caregi ver for th e Veteran or Service member nam ed on this applicati on.
	172
	173	I understa nd that th e Veteran may revoke my design ation as P rimary Fam ily Caregi ver at any time and that the S ecretary o f the Depa rtment of Veterans A ffairs (or designee) may remov e me from this posit ion immedi ately if I fail to c omply with the Progr am require ments as d efined by law.
	174
	175	I understa nd that pa rticipatio n in the P rogram of Comprehens ive Assist ance for F amily Care givers doe s not crea te an empl oyment rel ationship with the D epartment of Veteran s Affairs.
	176
	177	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	178
	179
	180
	181	Primary Fa mily Careg iver Signa ture
	182
	183
	184
	185	Date
	186	SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver
	187	Last Name
	188	First Name
	189	Middle Nam e
	190	Social Sec urity Numb er
	191	Date of Bi rth (mm-dd -yyyy)
	192	Gender
	193
	194	MaleFemale
	195	Current St reet Addre ss
	196	City
	197	State
	198	Zip Code
	199	Telephone Number (In cluding Ar ea Code)
	200	Cell Numbe r (Includi ng Area Co de)
	201	Email Addr ess
	202	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	203	Federal La ws (18 USC 287 and 1 001) provi de for cri minal pena lties for knowingly submitting false, fi ctitious o r fraudule nt stateme nts or cla ims
	204
	205
	206
	207	VA FORM
	208	Page 2 of 2
	209
	210
	211	SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d)
	212	I certify that I am at least 1 8 years of age.
	213
	214	Check one:
	215	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	216	OR
	217	I certify am not a f amily memb er and I r eside with the Veter an or Serv icemember or will do so upon a pproval.
	218
	219	I agree to perform p ersonal ca re service s as the S econdary F amily Care giver for the Vetera n or Servi cemember n amed on th is applica tion.
	220	I understa nd that th e Veteran may revoke my design ation as S econdary F amily Care giver at a ny time an d that the Secretary of the De partment o f Veterans Affairs ( or designe e) may rem ove me fro m this pos ition imme diately if I fail to comply wi th the Pro gram requi rements as defined b y law.
	221	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	222
	223
	224
	225	Secondary Caregiver Signature
	226
	227
	228
	229	Date
	230	SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver.
	231	Last Name
	232	First Name
	233	Middle Nam e
	234	Social Sec urity Numb er
	235	Date of Bi rth (mm-dd -yyyy)
	236	Gender
	237
	238	MaleFemale
	239	Current St reet Addre ss
	240	City
	241	State
	242	Zip Code
	243	Telephone Number (In cluding Ar ea Code)
	244	Cell Numbe r (Includi ng Area Co de)
	245	Email Addr ess
	246	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	247	Federal La ws (18 USC 287 and 1 001) provi de for cri minal pena lties for knowingly submitting false, fi ctitious o r fraudule nt stateme nts or cla ims
	248	I certify that I am at least 1 8 years of age.
	249
	250	Check one:
	251	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	252	OR
	253	I certify am not a f amily memb er and I r eside with the Veter an or Serv icemember or will do so upon a pproval.
	254
	255	I agree to perform p ersonal ca re service s as the S econdary F amily Care giver for the Vetera n or Servi cemember n amed on th is applica tion.
	256	I understa nd that th e Veteran may revoke my design ation as S econdary F amily Care giver at a ny time an d that the Secretary of the De partment o f Veterans Affairs ( or designe e) may rem ove me fro m this pos ition imme diately if I fail to comply wi th the Pro gram requi rements as defined b y law.
	257	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	258
	259
	260
	261	Secondary Caregiver Signature
	262
	263
	264
	265	Date
	266
	267
	268	VA FORM SE P 2014
	269
	270	10-10CG