35719. EPMO Open Source Coordination Office Redaction File Detail Report

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35719.1 Files compared

#	Location	File	Last Modified
1	CareT v1_iter1_build_2.zip\core\portlets\caret-portlet\docroot\form	1010CG_08282014.docx	Thu Apr 12 13:13:10 2018 UTC
2	CareT v1_iter1_build_2.zip\core\portlets\caret-portlet\docroot\form	1010CG_08282014.docx	Thu Apr 12 13:24:38 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 (1) Prim ary Family Caregiver and up to two (2) S econdary F amily Care givers. O n average, it will t ake 15 min utes to co mplete the applicati on includi ng the tim e it will take you t o read ins tructions, gather th e necessar y facts an d fill out the form. Each time a new Car egiver is appointed a new Form 10-10CG i s 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 VA's websi te 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 h ttp:// DNS . UR /. 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 ); meets t he require ments of 3 8 C.F.R. § 71.25; and generally serves as a back-up to the Pr imary Fami ly Caregiv er.
	34
	35	Stipend:
	36	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).
	37
	38
	39
	40
	41	SEP 2014
	42	10-10CG
	43
	44
	45	Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers?
	46	IF THE IND IVIDUAL IS A:
	47	AND
	48	AND
	49	THEN
	50	Veteran
	51	or
	52	Servicemem ber
	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 . UR and use th e Find You r Local Ca regiver Su pport Coor dinator op tion.
	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	Read Paper work Reduc tion and P rivacy Act Informati on.
	70	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.
	71	Attach POA /Represent ation docu ments to t he applica tion, if a pplicable.
	72	For expedi ted proces sing, mail this appl ication to :
	73	Program of Comprehen sive Assis tance for Family Car egivers He alth Eligi bility Cen ter
	74	2957 Clair mont Road NE, Ste 20 0
	75	Atlanta, G A 30329-16 47
	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 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.
	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.
	79	Completion of this f orm is man datory for eligible Veterans w ho wish to participa te in the Caregiver 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, 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--
	82	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.
	83
	84
	85
	86	SEP 2014
	87	10-10CG
	88
	89	Estimated Burden: 15 min. OMB Number 290 0-0768
	90	Expiration Date: XX/ XX/XXXX
	91
	92	Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program
	93	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.
	94	SECTION I - VETERAN/ SERVICEMEM BER
	95	Last Name
	96	First Name
	97	Middle Nam e
	98	Social Sec urity Numb er
	99	Date of Bi rth (mm-dd -yyyy)
	100	Gender
	101
	102	MaleFemale
	103	Current St reet Addre ss
	104	City
	105	State
	106	Zip Code
	107	Telephone Number (In cluding Ar ea Code)
	108	Cell Numbe r (Includi ng Area Co de)
	109	Email Addr ess
	110	Enrolled i n VA Healt h Care?
	111	YesNo
	112	Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces:
	113	Name of fa cility whe re you las t received medical t reatment:H ospitalCli nic
	114	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
	115	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.
	116	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	117
	118
	119
	120	Veteran/Se rvicemembe r/Represen tative/POA Signature
	121
	122
	123	Date
	124	SECTION II - PRIMARY FAMILY CA REGIVER
	125	Last Name
	126	First Name
	127	Middle Nam e
	128	Social Sec urity Numb er
	129	Date of Bi rth (mm-dd -yyyy)
	130	Gender
	131	MaleFemale
	132	Current St reet Addre ss
	133	City
	134	State
	135	Zip Code
	136
	137
	138	SEP 2014
	139	10-10CG
	140	Page 1 of 2
	141
	142
	143	SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued)
	144	Telephone Number (In cluding Ar ea Code)
	145	Cell Numbe r (Includi ng Area Co de)
	146	E-mail Add ress
	147	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	148	Enrolled i n Medicaid or Medica re?
	149	YesNo
	150	Other Heal th Insuran ce?YesNo
	151
	152	Name
	153	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
	154	I certify that I am at least 1 8 years of age.
	155	Check one:
	156
	157	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	158	OR
	159	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.
	160
	161	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.
	162	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.
	163	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.
	164	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	165
	166
	167
	168	Primary Fa mily Careg iver Signa ture
	169
	170
	171	Date
	172	SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver
	173	Last Name
	174	First Name
	175	Middle Nam e
	176	Social Sec urity Numb er
	177	Date of Bi rth (mm-dd -yyyy)
	178	Gender
	179	MaleFemale
	180	Current St reet Addre ss
	181	City
	182	State
	183	Zip Code
	184	Telephone Number (In cluding Ar ea Code)
	185	Cell Numbe r (Includi ng Area Co de)
	186	Email Addr ess
	187	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	188	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
	189
	190
	191	VA FORM
	192	Page 2 of 2
	193
	194
	195	SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d)
	196	I certify that I am at least 1 8 years of age.
	197	Check one:
	198	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	199	OR
	200	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.
	201
	202	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.
	203	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.
	204	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	205
	206
	207
	208	Secondary Caregiver Signature
	209
	210
	211	Date
	212	SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver.
	213	Last Name
	214	First Name
	215	Middle Nam e
	216	Social Sec urity Numb er
	217	Date of Bi rth (mm-dd -yyyy)
	218	Gender
	219	MaleFemale
	220	Current St reet Addre ss
	221	City
	222	State
	223	Zip Code
	224	Telephone Number (In cluding Ar ea Code)
	225	Cell Numbe r (Includi ng Area Co de)
	226	Email Addr ess
	227	Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other)
	228	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
	229	I certify that I am at least 1 8 years of age.
	230	Check one:
	231	I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion.
	232	OR
	233	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.
	234
	235	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.
	236	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.
	237	I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief.
	238
	239
	240
	241	Secondary Caregiver Signature
	242
	243
	244	Date
	245
	246
	247	VA FORM SE P 2014
	248	10-10CG