35718. EPMO Open Source Coordination Office Redaction File Detail Report

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35718.1 Files compared

#	Location	File	Last Modified
1	CareT v1_iter1_build_2.zip\core\portlets\caret-portlet\docroot\form	10-10CG.docx	Thu Apr 12 13:13:23 2018 UTC
2	CareT v1_iter1_build_2.zip\core\portlets\caret-portlet\docroot\form	10-10CG.docx	Thu Apr 12 13:22:37 2018 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
	7	(1) Primar y Family C aregiver a nd up to t wo (2) Sec ondary Fam ily Caregi vers. On a verage, it will take 15 minute s to compl ete the ap plication including the time i t will tak e you to r ead instru ctions, ga ther the n ecessary f acts and f ill out th e form. Ea ch time a new Caregi ver is app ointed a n ew Form 10 -10CG is r equired.
	8
	9	Where can I get help filling o ut the for m and answ ers to que stions?
	10	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- VETS (838 7). Access VA's webs ite at and select "Contact the VA". L ocate and contact th e Caregive r Support Coordinato r at your nearest VA health ca re facilit y. A Careg iver Suppo rt Coordin ator locat or is avai lable at http:// DNS . UR . Contact the Nation al Caregiv er Support Line by c alling 1-8 55-260-327 4 or a Vet erans Serv ice Organi zation.
	11
	12	Definition s of terms used in t his form
	13
	14	Caregiver Support Co ordinator (CSC):
	15	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.
	16
	17	Family Mem ber:
	18	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.
	19
	20	Injured in the Line of Duty (L OD):
	21	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.
	22
	23	Power of A ttorney (P OA):
	24	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.
	25
	26	Primary Fa mily Careg iver:
	27	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.
	28	§1720G(a)( 7)(A); and who meets the requi rements of 38 C.F.R. §71.25.
	29
	30	Representa tive:
	31	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.
	32
	33	Secondary Family Car egiver:
	34	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); meets the requir ements of 38 C.F.R. §71.25; an d generall y serves a s a back-u p to the P rimary Fam ily Caregi ver.
	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	Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers?
	41	IF THE IND IVIDUAL IS A:
	42	AND
	43	AND
	44	THEN
	45	Veteran
	46	or
	47	Servicemem ber
	48	who has be en issued a date of medical di scharge fr om the mil itary
	49	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
	50	Requires a t least 6 months of continuous Caregiver support
	51	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
	52	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 http:/ DNS . UR /. and use the Find Your Local Caregiver Support C oordinator option.
	53
	54	Getting St arted:
	55	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.
	56	SECTION I --VETERAN AND SERVIC EMEMBER GE NERAL INFO RMATION
	57	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
	58	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,
	59	sign and d ate.
	60	SECTION II I --SECOND ARY FAMILY CAREGIVER (S) GENERA L INFORMAT ION
	61	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 Vet eran/ Serv icemember may appoin t up to tw o Secondar y Family C aregivers but this i s not requ ired. If a Veteran/ Servicemen ber elects to appoin t a Second ary Family Caregiver at a late r time, Se ctions I a nd III in a new 10-1 0CG must b e complete d.
	62
	63	Submitting your appl ication.
	64	Read Paper work Reduc tion and P rivacy Act Informati on.
	65	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.
	66	Attach POA /Represent ation docu ments to t he applica tion, if a pplicable.
	67	For expedi ted proces sing, mail this appl ication to :
	68	Program of Comprehen sive Assis tance for Family Car egivers He alth Eligi bility Cen ter
	69	2957 Clair mont Road NE, Ste 20 0
	70	Atlanta, G A 30329-16 47
	71	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 1-855-260- 3274 or go to http:/ / DNS . UR and use t he Find Yo ur Local C aregiver S upport Coo rdinator o ption.
	72	THE PAPERW ORK REDUCT ION ACT
	73	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.
	74	Completion of this f orm is man datory for eligible Veterans w ho wish to participa te in the Caregiver Program.
	75	PRIVACY AC T INFORMAT ION
	76	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, 530 3A, 1705, 1710, 1720 B, and 172 0G, in ord er for VA to determi ne your el igibility for medica l benefits . Informat ion you su pply may b e verifie d through a computer -matching program. V A may disc lose the i nformation that you put on the form as p ermitted b y law. VA may make a "routine use" discl osure of t he informa tion as ou tlined in the Privac y Act syst ems of rec ords, “Pat ient Medic al Records --VA” (24 VA19), “En rollment a nd Eligibi lity Recor ds --VA” ( 147VA16), and “Healt h Administ ration Cen ter Civili an Health and Medica l program Records--
	77	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.
	78
	79	Estimated Burden: 15 min. OMB Number 290 0-0768
	80	Expiration Date: 04/ 30/2018
	81
	82	Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program
	83	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.
	84	SECTION I - VETERAN/ SERVICEMEM BER
	85	Last Name
	86	First Name
	87	Middle Nam e
	88	Social Sec urity Numb er
	89	Date of Bi rth (mm-dd -yyyy)
	90	Gender
	91
	92	MaleFemale
	93	Current St reet Addre ss
	94	City
	95	State
	96	Zip Code
	97	Telephone Number (In cluding Ar ea Code)
	98	Cell Numbe r (Includi ng Area Co de)
	99	Email Addr ess
	100	Enrolled i n VA Healt h Care?
	101	YesNo
	102	Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces:
	103	Name of fa cility whe re you las t received medical t reatment:H ospitalCli nic
	104	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
	105	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 Primary a nd/or Seco ndary Care giver(s) i n the Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers.
	106	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	107
	108
	109	Veteran/Se rvicemembe r/Represen tative/POA Signature
	110
	111
	112	Date
	113	SECTION II - PRIMARY FAMILY CA REGIVER
	114	Last Name
	115	First Name
	116	Middle Nam e
	117	Social Sec urity Numb er
	118	Date of Bi rth (mm-dd -yyyy)
	119	Gender
	120	MaleFemale
	121	Current St reet Addre ss
	122	City
	123	State
	124	Zip Code
	125
	126
	127	SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued)
	128	Telephone Number (In cluding Ar ea Code)
	129	Cell Numbe r (Includi ng Area Co de)
	130	Email Addr ess
	131	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	132	Enrolled i n Medicaid or Medica re?
	133	YesNo
	134	Other Heal th Insuran ce?YesNo
	135
	136	Name
	137	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
	138	I certify that I am at least 1 8 years of age.
	139	Check one:
	140
	141	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	142	OR
	143	I certify I am not a family me mber and I reside wi th the Vet eran or Se rvicemembe r or will do so upon approval.
	144
	145	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.
	146	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.
	147	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.
	148	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	149
	150
	151	Primary Fa mily Careg iver Signa ture
	152
	153
	154	Date
	155	SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver
	156	Last Name
	157	First Name
	158	Middle Nam e
	159	Social Sec urity Numb er
	160	Date of Bi rth (mm-dd -yyyy)
	161	Gender
	162	MaleFemale
	163	Current St reet Addre ss
	164	City
	165	State
	166	Zip Code
	167	Telephone Number (In cluding Ar ea Code)
	168	Cell Numbe r (Includi ng Area Co de)
	169	Email Addr ess
	170	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	171	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
	172
	173
	174	SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d)
	175	I certify that I am at least 1 8 years of age.
	176	Check one:
	177	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	178	OR
	179	I certify I am not a family me mber and I reside wi th the Vet eran or Se rvicemembe r or will do so upon approval.
	180	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.
	181
	182	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.
	183
	184	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	185
	186
	187	Secondary Caregiver Signature
	188
	189
	190	Date
	191	SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver.
	192	Last Name
	193	First Name
	194	Middle Nam e
	195	Social Sec urity Numb er
	196	Date of Bi rth (mm-dd -yyyy)
	197	Gender
	198	MaleFemale
	199	Current St reet Addre ss
	200	City
	201	State
	202	Zip Code
	203	Telephone Number (In cluding Ar ea Code)
	204	Cell Numbe r (Includi ng Area Co de)
	205	Email Addr ess
	206	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	207	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
	208	I certify that I am at least 1 8 years of age.
	209	Check one:
	210
	211	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	212	OR
	213	I certify I am not a family me mber and I reside wi th the Vet eran or Se rvicemembe r or will do so upon approval.
	214	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.
	215
	216	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.
	217
	218	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	219
	220
	221	Secondary Caregiver Signature
	222
	223
	224	Date