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| 1 | core.zip\core\portlets\caret-portlet\docroot\jsp\online | information.jsp | Wed Jan 4 14:29:10 2017 UTC |
| 2 | core.zip\core\portlets\caret-portlet\docroot\jsp\online | information.jsp | Mon Jan 9 14:46:35 2017 UTC |
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| 1 | ||
| 2 | <div> | |
| 3 | ||
| 4 | <div> | |
| 5 | <d iv style=" background :black; co lor: white ; padding: 12px; fon t-size:20p x; float:l eft">Depar tment of V eterans Af fairs | |
| 6 | </ div> | |
| 7 | <h 3 style="t ext-align: center;"> &nbs p;Instruct ions for C ompleting Applicatio n for the Program of Comprehen sive Assis tance for Family Car egivers | |
| 8 | </ h3> | |
| 9 | </div> | |
| 10 | ||
| 11 | <hr> | |
| 12 | <h3> | |
| 13 | Please Rea d Before Y ou Start . . . | |
| 14 | </h3> | |
| 15 | ||
| 16 | <h3> | |
| 17 | What is VA Form 10-1 0CG used f or? | |
| 18 | </h3> | |
| 19 | <p> | |
| 20 | 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 | |
| 21 | assist in determinin g your eli gibility; a clinical assessmen t will als o be requi red. An el igible Vet eran may a ppoint one (1) | |
| 22 | Primary Fa mily Careg iver and u p to two ( 2) Seconda ry Family Caregivers . On avera ge, it wil l take 15 minutes to complete | |
| 23 | the applic ation incl uding the time it wi ll take yo u to read instructio ns, gather the neces sary facts and fill out the fo rm. Each | |
| 24 | time a new Caregiver is appoin ted a new Form 10-10 CG is requ ired. | |
| 25 | </p> | |
| 26 | <h3> | |
| 27 | Where can I get help filling o ut the for m and answ ers to que stions? | |
| 28 | </h3> | |
| 29 | <p> | |
| 30 | 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 1-877-222- | |
| 31 | VETS (8387 ). Access VA's websi te at http ://www. DNS and select "Contact the VA". L ocate and contact th e Caregive r | |
| 32 | Support Co ordinator at your ne arest VA h ealth care facility. A Caregiv er Support Coordinat or locator is availa ble at | |
| 33 | <a href="$ {VA_CG_HRE F}" target ="_blank" >${VA_CG_H REF}</a>. Contact th e National Caregiver Support L ine by cal ling 1-855 -260-3274 or a Veter ans Servic e | |
| 34 | Organizati on. | |
| 35 | </p> | |
| 36 | <hr> | |
| 37 | <h2> | |
| 38 | Definition s of terms used in t his form | |
| 39 | </h2> | |
| 40 | <h3> | |
| 41 | Caregiver Support Co ordinator (CSC): | |
| 42 | </h3> | |
| 43 | ||
| 44 | <p> | |
| 45 | A VA clini cal profes sional who connects Caregivers of Vetera ns with VA and commu nity resou rces offer ing suppor tive | |
| 46 | programs a nd service s. Caregiv er Support Coordinat ors are lo cated at e very VA me dical cent er and are designate d | |
| 47 | specialist s in Careg iving issu es</p><h3> | |
| 48 | Family Mem ber:</h3>< p> | |
| 49 | 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 | |
| 50 | member, an d an exten ded family member), or an indi vidual who lives ful l-time wit h the Vete ran or Ser vicemember , or will | |
| 51 | do so if a pproved as a Primary or Second ary Family Caregiver .</p><h3> | |
| 52 | Injured in the Line of Duty (L OD):</h3>< p> | |
| 53 | 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 | |
| 54 | Servicemem ber's will ful miscon duct or ab use of alc ohol or dr ugs, or it occurred while that individua l was avoi ding duty by | |
| 55 | desertion, or absent without l eave which materiall y interfer ed with th e performa nce of mil itary duty .</p><h3> | |
| 56 | Power of A ttorney (P OA):</h3>< p> | |
| 57 | 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 | |
| 58 | this form. </p><h3> | |
| 59 | Primary Fa mily Careg iver:</h3> <p> | |
| 60 | 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. | |
| 61 | 1720G(a)(7 )(A); and who meets the requir ements of 38 C.F.R. 71.25.</p> <h3> | |
| 62 | Representa tive:</h3> <p> | |
| 63 | 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 | |
| 64 | Care, or o ther desig nated heal th care ag ent. Copie s of docum entation r egarding r epresentat ives are r equested o n this | |
| 65 | applicatio n.</p><h3> | |
| 66 | Secondary Family Car egiver:</h 3><p> | |
| 67 | 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. 1720 G(a)(7)(A) ; | |
| 68 | meets the requiremen ts of 38 C .F.R. 71.2 5; and gen erally ser ves as a b ack-up to the Primar y Family C aregiver.< /p><h3> | |
| 69 | Stipend:</ h3><p> | |
| 70 | 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 | |
| 71 | seriously injured el igible Vet eran (as d efined in 38 C.F.R 7 1.15). | |
| 72 | </p> | |
| 73 | <hr> | |
| 74 | <h3> | |
| 75 | Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers? | |
| 76 | </h3> | |
| 77 | <table> | |
| 78 | <tr><th st yle="width : 20%;"> | |
| 79 | IF THE IND IVIDUAL IS A: | |
| 80 | </th><th s tyle="widt h: 32%;"> | |
| 81 | AND</th><t h style="w idth: 20%; "> | |
| 82 | AND</th><t h style="w idth: 28%; "> | |
| 83 | THEN</th> | |
| 84 | ||
| 85 | </tr><tr>< td> | |
| 86 | <b> | |
| 87 | Veteran | |
| 88 | or | |
| 89 | Servicemem ber</b> | |
| 90 | who has be en issued a | |
| 91 | date of me dical disc harge | |
| 92 | from the m ilitary | |
| 93 | </td><td> | |
| 94 | ||
| 95 | Requires o n-going su pervision or assista nce | |
| 96 | with perfo rming basi c function s of every day | |
| 97 | life due t o a seriou s injury o r mental d isorder | |
| 98 | (including traumatic brain inj ury, | |
| 99 | psychologi cal trauma or other mental | |
| 100 | disorder) incurred o r aggravat ed in <b>t he line | |
| 101 | of duty on or after September 11, 2001</ b></td><td > | |
| 102 | Requires a t least 6 months | |
| 103 | of continu ous Caregi ver | |
| 104 | support</t d><td> | |
| 105 | The Vetera n or Servi cemember | |
| 106 | may meet t he criteri a for VA's | |
| 107 | Program of Comprehen sive | |
| 108 | Assistance for Famil y Caregive rs. | |
| 109 | Complete t his form t o apply | |
| 110 | </td></tr> </table> | |
| 111 | <p> | |
| 112 | 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 | |
| 113 | may be eli gible for VA health benefits a nd other c aregiver s upport ser vices. To find out a bout other caregiver support s ervices, | |
| 114 | contact th e Caregive r Support Coordinato r (CSC) at your loca l VA healt h care fac ility. To obtain the name of y our local CSC, conta ct | |
| 115 | the Caregi ver Suppor t Line at 1-855-260- 3274 or go to www. DNS . DNS and use th e Find You r Local Ca regiver Su pport | |
| 116 | Coordinato r option. | |
| 117 | </p> | |
| 118 | <hr> | |
| 119 | <h3>Gettin g Started: </h3> | |
| 120 | <p> | |
| 121 | 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 | |
| 122 | medical di scharge, s ubmit VA F orm 10-10E Z "Applica tion for H ealth Bene fits" with this form . Enrolled Veterans may submit VA | |
| 123 | Form 10-10 EZR "Healt h Benefits Renewal F orm" with their comp leted VA F orm 10-10C G to provi de informa tion updat es. Do NOT | |
| 124 | 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 | |
| 125 | representa tive or PO A may comp lete this applicatio n; however the POA/R epresentat ion docume nts must b e provided with this | |
| 126 | applicatio n.<p> | |
| 127 | ||
| 128 | <h3>SECTIO N I --VETE RAN AND SE RVICEMEMBE R GENERAL INFORMATIO N</h3><p> | |
| 129 | Directions for Secti on I --Vet eran/Servi cemember, representa tive or PO A, please answer all questions , sign and date.</p> | |
| 130 | <h3>SECTIO N II --PRI MARY FAMIL Y CAREGIVE R GENERAL INFORMATIO N</h3><p> | |
| 131 | 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, | |
| 132 | sign and d ate.</p> | |
| 133 | <h3>SECTIO N III --SE CONDARY FA MILY CAREG IVER(S) GE NERAL INFO RMATION</h 3><p> | |
| 134 | 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 Vete ran/ | |
| 135 | Servicemem ber may ap point up t o two Seco ndary Fami ly Caregiv ers but th is is not required. If a Veter an/Service menber ele cts to | |
| 136 | appoint a Secondary Family Car egiver at a later ti me, Sectio ns I and I II in a ne w 10-10CG must be co mpleted. | |
| 137 | </p><h3> | |
| 138 | Submitting your appl ication. | |
| 139 | </h3><ol> | |
| 140 | <li>Read P aperwork R eduction a nd Privacy Act Infor mation. | |
| 141 | </li><li> | |
| 142 | The Vetera n or an in dividual d elegated a s the Vete ran's repr esentative /POA must sign and d ate the fo rm. | |
| 143 | </li><li> | |
| 144 | Attach POA /Represent ation docu ments to t he applica tion, if a pplicable. | |
| 145 | </li><li> | |
| 146 | For expedi ted proces sing, mail this appl ication to : | |
| 147 | </li></ol> <b> | |
| 148 | Program of Comprehen sive Assis tance for Family Car egivers | |
| 149 | Health Eli gibility C enter | |
| 150 | 2957 Clair mont Road NE, Ste 20 0 | |
| 151 | Atlanta, G A 30329-16 47 | |
| 152 | </b> | |
| 153 | <p> | |
| 154 | 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 | |
| 155 | Medical Ce nter Careg iver Suppo rt Coordin ator (CSC) . To obtai n the name of your l ocal CSC, contact th e Caregive r Support Line | |
| 156 | at 1-855-2 60-3274 or go to htt p://www. DNS . DNS and use th e Find You r Local Ca regiver Su pport Coor dinator op tion. | |
| 157 | <p> | |
| 158 | <hr> | |
| 159 | ||
| 160 | <div style ="backgrou nd:black; color: whi te; paddin g: 12px; f ont-size:2 4px; text- align: cen ter;"> | |
| 161 | THE PAPERW ORK REDUCT ION ACT | |
| 162 | </div> | |
| 163 | <p> | |
| 164 | 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 | |
| 165 | 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 , | |
| 166 | gather nec essary dat a, and fil l out the form. Resp ondents sh ould be aw are that n otwithstan ding any o ther provi sion of la w, no pers on shall b e | |
| 167 | subject to any penal ty for fai ling to co mply with a collecti on of info rmation if it does n ot display a current ly valid O MB control number. | |
| 168 | Completion of this f orm is man datory for eligible Veterans w ho wish to participa te in the Caregiver Program. | |
| 169 | <p> | |
| 170 | <hr> | |
| 171 | <div style ="backgrou nd:black; color: whi te; paddin g: 12px; f ont-size:2 4px; text- align: cen ter;"> | |
| 172 | PRIVACY AC T INFORMAT ION | |
| 173 | </div> | |
| 174 | <p> | |
| 175 | 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, | |
| 176 | 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 | |
| 177 | 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 | |
| 178 | "routine u se" disclo sure of th e informat ion as out lined in t he Privacy Act syste ms of reco rds, €œPat ient Medic al Records --VA€ (2 4VA19), | |
| 179 | Enrollment and Eligi bility Rec ords --VA€ (147VA16 ), and “ Health Adm inistratio n Center C ivilian He alth and M edical pro gram Recor ds-- | |
| 180 | VA€ (54VA 17) and in accordanc e with the VHA Notic e of Priva cy Practic es. Provid ing the re quested in formation, including Social Se curity | |
| 181 | Number, is voluntary , but if a ny or all of the req uested inf ormation i s not prov ided, it m ay delay o r result i n denial o f your req uest for h ealth | |
| 182 | care benef its. Failu re to furn ish the in formation will not h ave any ef fect on an y other be nefits to which you may be ent itled. If you provid e VA | |
| 183 | your Socia l Security Number, V A will use it to adm inister yo ur VA bene fits. VA m ay also us e this inf ormation t o identify Veterans and person s | |
| 184 | claiming o r receivin g VA benef its, and t heir recor ds, and fo r other pu rposes aut horized or required by law. | |
| 185 | <p> | |
| 186 | ||
| 187 | </div> |
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