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| 1 | core.zip\core\dist\caret-portlet-6.2.10.47..war\form | 1010CG_08282014.docx | Mon Jan 9 17:01:50 2017 UTC |
| 2 | core.zip\core\dist\caret-portlet-6.2.10.47..war\form | 1010CG_08282014.docx | Tue Jan 10 21:14:17 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 PII 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 | PII | ||
| 76 | 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. | ||
| 77 | THE PAPERW ORK REDUCT ION ACT | ||
| 78 | 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 . | ||
| 79 | PRIVACY AC T INFORMAT ION | ||
| 80 | 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, | ||
| 81 | 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 | ||
| 82 | 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-- | ||
| 83 | 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. | ||
| 84 | |||
| 85 | |||
| 86 | |||
| 87 | SEP 2014 | ||
| 88 | |||
| 89 | 10-10CG | ||
| 90 | |||
| 91 | Estimated Burden: 15 min. OMB Number 290 0-0768 | ||
| 92 | Expiration Date: XX/ XX/XXXX | ||
| 93 | |||
| 94 | |||
| 95 | |||
| 96 | Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program | ||
| 97 | 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. | ||
| 98 | SECTION I - VETERAN/ SERVICEMEM BER | ||
| 99 | Last Name | ||
| 100 | First Name | ||
| 101 | Middle Nam e | ||
| 102 | Social Sec urity Numb er | ||
| 103 | Date of Bi rth (mm-dd -yyyy) | ||
| 104 | Gender | ||
| 105 | |||
| 106 | MaleFemale | ||
| 107 | Current St reet Addre ss | ||
| 108 | City | ||
| 109 | State | ||
| 110 | Zip Code | ||
| 111 | Telephone Number (In cluding Ar ea Code) | ||
| 112 | Cell Numbe r (Includi ng Area Co de) | ||
| 113 | Email Addr ess | ||
| 114 | Enrolled i n VA Healt h Care? | ||
| 115 | |||
| 116 | YesNo | ||
| 117 | Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces: | ||
| 118 | Name of fa cility whe re you las t received medical t reatment:H ospitalCli nic | ||
| 119 | 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 | ||
| 120 | 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 | ||
| 121 | 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. | ||
| 122 | |||
| 123 | |||
| 124 | |||
| 125 | Veteran/Se rvicemembe r/Represen tative/POA Signature | ||
| 126 | |||
| 127 | |||
| 128 | |||
| 129 | Date | ||
| 130 | SECTION II - PRIMARY FAMILY CA REGIVER | ||
| 131 | Last Name | ||
| 132 | First Name | ||
| 133 | Middle Nam e | ||
| 134 | Social Sec urity Numb er | ||
| 135 | Date of Bi rth (mm-dd -yyyy) | ||
| 136 | Gender | ||
| 137 | |||
| 138 | MaleFemale | ||
| 139 | Current St reet Addre ss | ||
| 140 | City | ||
| 141 | State | ||
| 142 | Zip Code | ||
| 143 | |||
| 144 | |||
| 145 | SEP 2014 | ||
| 146 | 10-10CG | ||
| 147 | Page 1 of 2 | ||
| 148 | |||
| 149 | |||
| 150 | SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued) | ||
| 151 | Telephone Number (In cluding Ar ea Code) | ||
| 152 | Cell Numbe r (Includi ng Area Co de) | ||
| 153 | E-mail Add ress | ||
| 154 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) | ||
| 155 | Enrolled i n Medicaid or Medica re? | ||
| 156 | |||
| 157 | YesNo | ||
| 158 | Other Heal th Insuran ce?YesNo | ||
| 159 | |||
| 160 | Name | ||
| 161 | 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 | ||
| 162 | I certify that I am at least 1 8 years of age. | ||
| 163 | |||
| 164 | Check one: | ||
| 165 | |||
| 166 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | ||
| 167 | OR | ||
| 168 | 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. | ||
| 169 | |||
| 170 | 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. | ||
| 171 | |||
| 172 | 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. | ||
| 173 | |||
| 174 | 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. | ||
| 175 | |||
| 176 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | ||
| 177 | |||
| 178 | |||
| 179 | |||
| 180 | Primary Fa mily Careg iver Signa ture | ||
| 181 | |||
| 182 | |||
| 183 | |||
| 184 | Date | ||
| 185 | SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver | ||
| 186 | Last Name | ||
| 187 | First Name | ||
| 188 | Middle Nam e | ||
| 189 | Social Sec urity Numb er | ||
| 190 | Date of Bi rth (mm-dd -yyyy) | ||
| 191 | Gender | ||
| 192 | |||
| 193 | MaleFemale | ||
| 194 | Current St reet Addre ss | ||
| 195 | City | ||
| 196 | State | ||
| 197 | Zip Code | ||
| 198 | Telephone Number (In cluding Ar ea Code) | ||
| 199 | Cell Numbe r (Includi ng Area Co de) | ||
| 200 | Email Addr ess | ||
| 201 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) | ||
| 202 | 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 | ||
| 203 | |||
| 204 | |||
| 205 | |||
| 206 | VA FORM | ||
| 207 | Page 2 of 2 | ||
| 208 | |||
| 209 | |||
| 210 | SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d) | ||
| 211 | I certify that I am at least 1 8 years of age. | ||
| 212 | |||
| 213 | Check one: | ||
| 214 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | ||
| 215 | OR | ||
| 216 | 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. | ||
| 217 | |||
| 218 | 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. | ||
| 219 | 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. | ||
| 220 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | ||
| 221 | |||
| 222 | |||
| 223 | |||
| 224 | Secondary Caregiver Signature | ||
| 225 | |||
| 226 | |||
| 227 | |||
| 228 | Date | ||
| 229 | SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver. | ||
| 230 | Last Name | ||
| 231 | First Name | ||
| 232 | Middle Nam e | ||
| 233 | Social Sec urity Numb er | ||
| 234 | Date of Bi rth (mm-dd -yyyy) | ||
| 235 | Gender | ||
| 236 | |||
| 237 | MaleFemale | ||
| 238 | Current St reet Addre ss | ||
| 239 | City | ||
| 240 | State | ||
| 241 | Zip Code | ||
| 242 | Telephone Number (In cluding Ar ea Code) | ||
| 243 | Cell Numbe r (Includi ng Area Co de) | ||
| 244 | Email Addr ess | ||
| 245 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) | ||
| 246 | 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 | ||
| 247 | I certify that I am at least 1 8 years of age. | ||
| 248 | |||
| 249 | Check one: | ||
| 250 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | ||
| 251 | OR | ||
| 252 | 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. | ||
| 253 | |||
| 254 | 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. | ||
| 255 | 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. | ||
| 256 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | ||
| 257 | |||
| 258 | |||
| 259 | |||
| 260 | Secondary Caregiver Signature | ||
| 261 | |||
| 262 | |||
| 263 | |||
| 264 | Date | ||
| 265 | |||
| 266 | |||
| 267 | VA FORM SE P 2014 | ||
| 268 | |||
| 269 | 10-10CG |
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