Produced by Araxis Merge on 8/16/2018 1:15:35 PM Central Daylight Time. See www.araxis.com for information about Merge. This report uses XHTML and CSS2, and is best viewed with a modern standards-compliant browser. For optimum results when printing this report, use landscape orientation and enable printing of background images and colours in your browser.
| # | Location | File | Last Modified |
|---|---|---|---|
| 1 | Caregivers_Tool_CareT_v1_Build 4.zip\core\portlets\caret-portlet\docroot\form | 1010CG_08282014.pdf | Thu Aug 9 14:02:09 2018 UTC |
| 2 | Caregivers_Tool_CareT_v1_Build 4.zip\core\portlets\caret-portlet\docroot\form | 1010CG_08282014.pdf | Thu Aug 16 01:44:12 2018 UTC |
| Description | Between Files 1 and 2 |
|
|---|---|---|
| Text Blocks | Lines | |
| Unchanged | 1 | 488 |
| Changed | 0 | 0 |
| Inserted | 0 | 0 |
| Removed | 0 | 0 |
| Whitespace | |
|---|---|
| Character case | Differences in character case are significant |
| Line endings | Differences in line endings (CR and LF characters) are ignored |
| CR/LF characters | Not shown in the comparison detail |
No regular expressions were active.
| 1 | 10-10CGSEP 2014VA FO RM | |
| 2 | Instructio ns for Com pleting Ap plication for the Pr ogram of C omprehensi ve Assista nce | |
| 3 | for Family Caregiver s | |
| 4 | Please Rea d Before Y ou Start . . . | |
| 5 | ||
| 6 | What is VA Form 10-1 0CG used f or? | |
| 7 | To apply f or VA's Pr ogram of C omprehensi ve Assista nce for Fa mily Careg ivers. VA will use the inform ation on t his form t o | |
| 8 | assist in determinin g your eli gibility; a clinical assessmen t will als o be requi red. An e ligible Ve teran may appoint on e (1) | |
| 9 | Primary Fa mily Careg iver and u p to two ( 2) Seconda ry Family Caregivers . On aver age, it wi ll take 15 minutes t o complete | |
| 10 | 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 | |
| 11 | time a new Caregiver is appoin ted a new Form 10-10 CG is requ ired. | |
| 12 | ||
| 13 | Where can I get help filling o ut the for m and answ ers to que stions? | |
| 14 | 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- | |
| 15 | VETS (8387 ). Access VA's webs ite at htt p://www.va .gov and s elect "Con tact the V A". Locat e and cont act the Ca regiver | |
| 16 | Support Co ordinator at your ne arest VA h ealth care facility. A Caregiv er Support Coordinat or locator is availa ble at htt p:// | |
| 17 | www.caregi ver.va.gov /. Contac t the Nati onal Careg iver Suppo rt Line by calling 1 -855-260-3 274 or a V eterans Se rvice | |
| 18 | Organizati on. | |
| 19 | ||
| 20 | Definition s of terms used in t his form | |
| 21 | ||
| 22 | Caregiver Support Co ordinator (CSC): | |
| 23 | A VA clini cal profes sional who connects Caregivers of Vetera ns with VA and commu nity resou rces offer ing suppor tive | |
| 24 | programs a nd service s. Caregi ver Suppor t Coordina tors are l ocated at every VA m edical cen ter and ar e designat ed | |
| 25 | specialist s in Careg iving issu es. | |
| 26 | ||
| 27 | Family Mem ber: | |
| 28 | 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 | |
| 29 | 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 | |
| 30 | do so if a pproved as a Primary or Second ary Family Caregiver . | |
| 31 | ||
| 32 | Injured in the Line of Duty (L OD): | |
| 33 | 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 | |
| 34 | 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 | |
| 35 | desertion, or absent without l eave which materiall y interfer ed with th e performa nce of mil itary duty . | |
| 36 | ||
| 37 | Power of A ttorney (P OA): | |
| 38 | 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 | |
| 39 | this form. | |
| 40 | ||
| 41 | Primary Fa mily Careg iver: | |
| 42 | 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. | |
| 43 | §1720G(a)( 7)(A); and who meets the requi rements of 38 C.F.R. §71.25. | |
| 44 | ||
| 45 | Representa tive: | |
| 46 | 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 | |
| 47 | 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 | |
| 48 | applicatio n. | |
| 49 | ||
| 50 | Secondary Family Car egiver: | |
| 51 | 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 ); | |
| 52 | 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. | |
| 53 | ||
| 54 | Stipend: | |
| 55 | 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 | |
| 56 | seriously injured el igible Vet eran (as d efined in 38 C.F.R § 71.15). | |
| 57 | 10-10CGSEP 2014VA FO RM | |
| 58 | Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers? | |
| 59 | IF THE IND IVIDUAL IS A: | |
| 60 | Veteran | |
| 61 | or | |
| 62 | Servicemem ber | |
| 63 | who has be en issued a | |
| 64 | date of me dical disc harge | |
| 65 | from the m ilitary | |
| 66 | AND AND TH EN | |
| 67 | Requires o n-going su pervision or assista nce | |
| 68 | with perfo rming basi c function s of every day | |
| 69 | life due t o a seriou s injury o r mental d isorder | |
| 70 | (including traumatic brain inj ury, | |
| 71 | psychologi cal trauma or other mental | |
| 72 | disorder) incurred o r aggravat ed in the line | |
| 73 | of duty on or after September 11, 2001 | |
| 74 | Requires a t least 6 months | |
| 75 | of continu ous caregi ver | |
| 76 | support | |
| 77 | The Vetera n or Servi cemember | |
| 78 | may meet t he criteri a for VA's | |
| 79 | Program of Comprehen sive | |
| 80 | Assistance for Famil y Caregive rs. | |
| 81 | Complete t his form t o apply | |
| 82 | 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 | |
| 83 | 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, | |
| 84 | 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 | |
| 85 | the Caregi ver Suppor t Line at 1-855-260- 3274 or go to www.ca regiver.va .gov and u se the Fin d Your Loc al Caregiv er Support | |
| 86 | Coordinato r option. | |
| 87 | ||
| 88 | Getting St arted: | |
| 89 | 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 | |
| 90 | 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 | |
| 91 | 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 | |
| 92 | 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 | |
| 93 | 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 | |
| 94 | applicatio n. | |
| 95 | SECTION I --VETERAN AND SERVIC EMEMBER GE NERAL INFO RMATION | |
| 96 | Directions for Secti on I --Vet eran/Servi cemember, representa tive or PO A, please answer all questions , sign and date. | |
| 97 | SECTION II --PRIMARY FAMILY CA REGIVER GE NERAL INFO RMATION | |
| 98 | 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, | |
| 99 | sign and d ate. | |
| 100 | SECTION II I --SECOND ARY FAMILY CAREGIVER (S) GENERA L INFORMAT ION | |
| 101 | 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/ | |
| 102 | Servicemem ber may ap point up t o two seco ndary fami ly caregiv ers but th is is not required. If a Vete ran/Servic emenber el ects to | |
| 103 | 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. | |
| 104 | ||
| 105 | Submitting your appl ication. | |
| 106 | 1. Read Pa perwork Re duction an d Privacy Act Inform ation. | |
| 107 | 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. | |
| 108 | 3. Attach POA/Repres entation d ocuments t o the appl ication, i f applicab le. | |
| 109 | 4. For exp edited pro cessing, m ail this a pplication to: | |
| 110 | Program of Comprehen sive Assis tance for Family Car egivers | |
| 111 | Health Eli gibility C enter | |
| 112 | 2957 Clair mont Road NE, Ste 20 0 | |
| 113 | Atlanta, G A 30329-16 47 | |
| 114 | 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 | |
| 115 | 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 | |
| 116 | at 1-855-2 60-3274 or go to htt p://www.ca regiver.va .gov and u se the Fin d Your Loc al Caregiv er Support Coordinat or option. | |
| 117 | THE PAPERW ORK REDUCT ION ACT | |
| 118 | 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 | |
| 119 | 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 , | |
| 120 | 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 | |
| 121 | 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. | |
| 122 | Completion of this f orm is man datory for eligible Veterans w ho wish to participa te in the Caregiver Program. | |
| 123 | PRIVACY AC T INFORMAT ION | |
| 124 | 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, | |
| 125 | 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 | |
| 126 | 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 | |
| 127 | "routine u se" disclo sure of th e informat ion as out lined in t he Privacy Act syste ms of reco rds, “Pati ent Medica l Records --VA” (24V A19), | |
| 128 | “Enrollmen t and Elig ibility Re cords --VA ” (147VA16 ), and “He alth Admin istration Center Civ ilian Heal th and Med ical progr am Records -- | |
| 129 | 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 | |
| 130 | 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 | |
| 131 | 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 | |
| 132 | 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 | |
| 133 | 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. | |
| 134 | 10-10CGSEP 2014VA FO RM | |
| 135 | Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program | |
| 136 | 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 | |
| 137 | Center, 29 57 Clairmo nt Road NE , Ste 200, Atlanta, GA 30329-1 647, for e xpedited p rocessing; or, hand carry it t o your loc al VA Medi cal Center Caregiver | |
| 138 | Support Co ordinator (CSC). The date the applicatio n is recei ved by VA is the dat e the appl ication pr ocess begi ns. At thi s time VA does not p rovide the Program | |
| 139 | of Compreh ensive Ass istance fo r Family C aregivers to Veteran s/Servicem embers and Family Ca regivers l iving in a foreign c ountry. | |
| 140 | SECTION I - VETERAN/ SERVICEMEM BER | |
| 141 | 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 | |
| 142 | or claims | |
| 143 | Last Name First Name Middle Na me | |
| 144 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 145 | Male Femal e | |
| 146 | Gender | |
| 147 | Hospital C linic | |
| 148 | Date | |
| 149 | Page 1 of 2 | |
| 150 | Current St reet Addre ss | |
| 151 | City State Zip Code | |
| 152 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 153 | Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces: | |
| 154 | Email Addr ess | |
| 155 | Yes No | |
| 156 | Enrolled i n VA Healt h Care? | |
| 157 | Name of fa cility whe re you las t received medical t reatment: | |
| 158 | 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 | |
| 159 | Primary an d/or Secon dary Careg iver(s) in the Progr am of Comp rehensive Assistance for Famil y Caregive rs. | |
| 160 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 161 | SECTION II - PRIMARY FAMILY CA REGIVER | |
| 162 | Middle Nam eFirst Nam eLast Name | |
| 163 | Social Sec urity Numb er Date of Birth (mm -dd-yyyy) | |
| 164 | Male Femal e | |
| 165 | Gender | |
| 166 | Veteran/Se rvicemembe r/Represen tative/POA Signature | |
| 167 | Current St reet Addre ss | |
| 168 | City State Zip Code | |
| 169 | Estimated Burden: 15 min. | |
| 170 | OMB Number 2900-0768 | |
| 171 | Expiration Date: XX/ XX/XXXX | |
| 172 | 10-10CGSEP 2014VA FO RM | |
| 173 | SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver | |
| 174 | Last Name First Name Middle Na me | |
| 175 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 176 | Male Femal e | |
| 177 | Gender | |
| 178 | Page 2 of 2 | |
| 179 | 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 | |
| 180 | or claims | |
| 181 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 182 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 183 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) E-mail Add ress | |
| 184 | Yes No | |
| 185 | Enrolled i n Medicaid or Medica re? | |
| 186 | Name | |
| 187 | Other Heal th Insuran ce? Yes No | |
| 188 | SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued) | |
| 189 | I certify that I am at least 1 8 years of age. | |
| 190 | Check one: | |
| 191 | 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 | |
| 192 | applicatio n. | |
| 193 | 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 | |
| 194 | Department of Vetera ns Affairs (or desig nee) may r emove me f rom this p osition im mediately if I fail to comply with the P rogram | |
| 195 | requiremen ts as defi ned by law . | |
| 196 | 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 | |
| 197 | employment relations hip with t he Departm ent of Vet erans Affa irs. | |
| 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 | 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. | |
| 200 | OR | |
| 201 | DatePrimar y Family C aregiver S ignature | |
| 202 | Current St reet Addre ss | |
| 203 | City State Zip Code | |
| 204 | Cell Numbe r (Includi ng Area Co de)Telepho ne Number (Including Area Code ) | |
| 205 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) Email Addr ess | |
| 206 | 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 | |
| 207 | or claims | |
| 208 | 10-10CGSEP 2014VA FO RM | |
| 209 | SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver. | |
| 210 | Last Name First Name Middle Na me | |
| 211 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 212 | Male Femal e | |
| 213 | Gender | |
| 214 | Current St reet Addre ss | |
| 215 | City State Zip Code | |
| 216 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 217 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) Email Addr ess | |
| 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 | I certify that I am at least 1 8 years of age. | |
| 220 | Check one: | |
| 221 | 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 | |
| 222 | applicatio n. | |
| 223 | 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 | |
| 224 | the Depart ment of Ve terans Aff airs (or d esignee) m ay remove me from th is positio n immediat ely if I f ail to com ply with t he | |
| 225 | Program re quirements as define d by law. | |
| 226 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | |
| 227 | 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. | |
| 228 | OR | |
| 229 | DateSecond ary Caregi ver Signat ure | |
| 230 | SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d) | |
| 231 | 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 | |
| 232 | or claims | |
| 233 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 234 | I certify that I am at least 1 8 years of age. | |
| 235 | Check one: | |
| 236 | 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 | |
| 237 | applicatio n. | |
| 238 | 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 | |
| 239 | the Depart ment of Ve terans Aff airs (or d esignee) m ay remove me from th is positio n immediat ely if I f ail to com ply with t he | |
| 240 | Program re quirements as define d by law. | |
| 241 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | |
| 242 | 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. | |
| 243 | OR | |
| 244 | DateSecond ary Caregi ver Signat ure |
Araxis Merge (but not the data content of this report) is Copyright © 1993-2016 Araxis Ltd (www.araxis.com). All rights reserved.