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| 1 | Caregivers_Tool_CareT_v1_Build 4.zip\core\portlets\caret-portlet\docroot\WEB-INF\src | seed1010.pdf | Thu Aug 9 14:03:21 2018 UTC |
| 2 | Caregivers_Tool_CareT_v1_Build 4.zip\core\portlets\caret-portlet\docroot\WEB-INF\src | seed1010.pdf | Thu Aug 16 01:24:49 2018 UTC |
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| 1 | Instructio ns for Com pleting Ap plication for the Pr ogram of C omprehensi ve Assista nce | |
| 2 | for Family Caregiver s | |
| 3 | ||
| 4 | Please Rea d Before Y ou Start . . . | |
| 5 | Caregiver Support Co ordinator (CSC): | |
| 6 | A VA clini cal profes sional who connects Caregivers of Vetera ns with VA and commu nity resou rces offer ing suppor tive | |
| 7 | 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 | |
| 8 | specialist s in Careg iving issu es. | |
| 9 | ||
| 10 | Family Mem ber: | |
| 11 | 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 | |
| 12 | 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 | |
| 13 | do so if a pproved as a Primary or Second ary Family Caregiver . | |
| 14 | ||
| 15 | Injured in the Line of Duty (L OD): | |
| 16 | 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 | |
| 17 | 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 | |
| 18 | desertion, or absent without l eave which materiall y interfer ed with th e performa nce of mil itary duty . | |
| 19 | ||
| 20 | Power of A ttorney (P OA): | |
| 21 | 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 | |
| 22 | this form. | |
| 23 | ||
| 24 | Primary Fa mily Careg iver: | |
| 25 | 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. | |
| 26 | §1720G(a)( 7)(A); and who meets the requi rements of 38 C.F.R. §71.25. | |
| 27 | ||
| 28 | Representa tive: | |
| 29 | 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 | |
| 30 | 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 | |
| 31 | applicatio n. | |
| 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) | |
| 35 | (A); meets the requi rements of 38 C.F.R. §71.25; a nd general ly serves as a back- up to the Primary Fa mily Careg iver. | |
| 36 | ||
| 37 | Stipend: | |
| 38 | 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 | |
| 39 | seriously injured el igible Vet eran (as d efined in 38 C.F.R § 71.15). | |
| 40 | Definition s of terms used in t his form | |
| 41 | What is VA Form 10-1 0CG used f or? | |
| 42 | 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 | |
| 43 | to assist in determi ning your eligibilit y; a clini cal assess ment will also be re quired. A n eligible Veteran m ay appoint one | |
| 44 | (1) Primar y Family C aregiver a nd up to t wo (2) Sec ondary Fam ily Caregi vers. On average, i t will tak e 15 minut es to | |
| 45 | complete t he applica tion inclu ding the t ime it wil l take you to read i nstruction s, gather the necess ary facts and fill o ut the | |
| 46 | form. Eac h time a n ew Caregiv er is appo inted a ne w Form 10- 10CG is re quired. | |
| 47 | ||
| 48 | Where can I get help filling o ut the for m and answ ers to que stions? | |
| 49 | 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- | |
| 50 | 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 | |
| 51 | Support Co ordinator at your ne arest VA h ealth care facility. A Caregiv er Support Coordinat or locator is availa ble at | |
| 52 | http://www .caregiver .va.gov/. Contact t he Nationa l Caregive r Support Line by ca lling 1-85 5-260-3274 or a Vete rans | |
| 53 | Service Or ganization . | |
| 54 | 10-10CGVA FORM APR 2 016 | |
| 55 | Who should apply for VA's Prog ram of Com prehensive Assistanc e for Fami ly Caregiv ers? | |
| 56 | IF THE IND IVIDUAL IS A: | |
| 57 | Veteran | |
| 58 | or | |
| 59 | Servicemem ber | |
| 60 | who has be en issued a | |
| 61 | date of me dical disc harge | |
| 62 | from the m ilitary | |
| 63 | AND AND TH EN | |
| 64 | Requires o n-going su pervision or assista nce | |
| 65 | with perfo rming basi c function s of every day | |
| 66 | life due t o a seriou s injury o r mental d isorder | |
| 67 | (including traumatic brain inj ury, | |
| 68 | psychologi cal trauma or other mental | |
| 69 | disorder) incurred o r aggravat ed in the line | |
| 70 | of duty on or after September 11, 2001 | |
| 71 | Requires a t least 6 months | |
| 72 | of continu ous Caregi ver | |
| 73 | support | |
| 74 | The Vetera n or Servi cemember | |
| 75 | may meet t he criteri a for VA's | |
| 76 | Program of Comprehen sive | |
| 77 | Assistance for Famil y Caregive rs. | |
| 78 | Complete t his form t o apply | |
| 79 | ||
| 80 | 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 | |
| 81 | 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, | |
| 82 | 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, | |
| 83 | contact th e Caregive r Support Line at 1- 855-260-32 74 or go t o http://w ww.caregiv er.va.gov/ . and use the Find Y our Local | |
| 84 | Caregiver Support Co ordinator option. | |
| 85 | THE PAPERW ORK REDUCT ION ACT | |
| 86 | 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 | |
| 87 | 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 , | |
| 88 | 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 | |
| 89 | 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. | |
| 90 | Completion of this f orm is man datory for eligible Veterans w ho wish to participa te in the Caregiver Program. | |
| 91 | PRIVACY AC T INFORMAT ION | |
| 92 | 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, | |
| 93 | 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 | |
| 94 | 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 | |
| 95 | "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), | |
| 96 | “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 -- | |
| 97 | 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 | |
| 98 | 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 | |
| 99 | 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 | |
| 100 | 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 | |
| 101 | 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. | |
| 102 | 1. Read Pa perwork Re duction an d Privacy Act Inform ation. | |
| 103 | 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. | |
| 104 | 3. Attach POA/Repres entation d ocuments t o the appl ication, i f applicab le. | |
| 105 | 4. For exp edited pro cessing, m ail this a pplication to: | |
| 106 | Program of Comprehen sive Assis tance for Family Car egivers | |
| 107 | Health Eli gibility C enter | |
| 108 | 2957 Clair mont Road NE, Ste 20 0 | |
| 109 | Atlanta, G A 30329-16 47 | |
| 110 | Submitting your appl ication. | |
| 111 | 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 | |
| 112 | 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 | |
| 113 | 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 | |
| 114 | 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 | |
| 115 | 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 | |
| 116 | applicatio n. | |
| 117 | Getting St arted: | |
| 118 | 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 | |
| 119 | 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 at | |
| 120 | 1-855-260- 3274 or go to http:/ /www.careg iver.va.go v and use the Find Y our Local Caregiver Support Co ordinator option. | |
| 121 | SECTION I --VETERAN AND SERVIC EMEMBER GE NERAL INFO RMATION | |
| 122 | Directions for Secti on I --Vet eran/Servi cemember, representa tive or PO A, please answer all questions , sign and date. | |
| 123 | SECTION II --PRIMARY FAMILY CA REGIVER GE NERAL INFO RMATION | |
| 124 | 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, | |
| 125 | sign and d ate. | |
| 126 | SECTION II I --SECOND ARY FAMILY CAREGIVER (S) GENERA L INFORMAT ION | |
| 127 | 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/ | |
| 128 | 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 | |
| 129 | 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. | |
| 130 | 10-10CGVA FORM APR 2 016 | |
| 131 | Applicatio n for Comp rehensive Assistance for Famil y Caregive rs Program | |
| 132 | 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 | |
| 133 | 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 | |
| 134 | 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 | |
| 135 | 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. | |
| 136 | SECTION I - VETERAN/ SERVICEMEM BER | |
| 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 | |
| 138 | or claims | |
| 139 | Last Name First Name Middle Na me | |
| 140 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 141 | Male Femal e | |
| 142 | Gender | |
| 143 | Date | |
| 144 | Current St reet Addre ss | |
| 145 | City State Zip Code | |
| 146 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 147 | Name of VA medical c enter or c linic wher e you rece ive or pla n to recei ve health care servi ces: | |
| 148 | Email Addr ess | |
| 149 | Yes No | |
| 150 | Enrolled i n VA Healt h Care? | |
| 151 | Name of fa cility whe re you las t received medical t reatment: Hospital C linic | |
| 152 | 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 | |
| 153 | Primary an d/or Secon dary Careg iver(s) in the Progr am of Comp rehensive Assistance for Famil y Caregive rs. | |
| 154 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 155 | SECTION II - PRIMARY FAMILY CA REGIVER | |
| 156 | Middle Nam eFirst Nam eLast Name | |
| 157 | Social Sec urity Numb er Date of Birth (mm -dd-yyyy) | |
| 158 | Male Femal e | |
| 159 | Gender | |
| 160 | Current St reet Addre ss | |
| 161 | City State Zip Code | |
| 162 | Estimated Burden: 15 min. | |
| 163 | OMB Number 2900-0768 | |
| 164 | Expiration Date: 04/ 30/2018 | |
| 165 | Page 1 of 310-10CGVA FORM APR 2016 | |
| 166 | Veteran/Se rvicemembe r/Represen tative/POA Signature | |
| 167 | SECTION II I - SECOND ARY FAMILY CAREGIVER - Complet e if appoi nting a Se condary Ca regiver | |
| 168 | Last Name First Name Middle Na me | |
| 169 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 170 | Male Femal e | |
| 171 | Gender | |
| 172 | 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 | |
| 173 | or claims | |
| 174 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 175 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 176 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) Email Addr ess | |
| 177 | Yes No | |
| 178 | Enrolled i n Medicaid or Medica re? | |
| 179 | Name | |
| 180 | Other Heal th Insuran ce? Yes No | |
| 181 | SECTION II - PRIMARY FAMILY CA REGIVER (c ontinued) | |
| 182 | I certify that I am at least 1 8 years of age. | |
| 183 | Check one: | |
| 184 | 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 | |
| 185 | applicatio n. | |
| 186 | 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 | |
| 187 | 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 | |
| 188 | requiremen ts as defi ned by law . | |
| 189 | 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 | |
| 190 | employment relations hip with t he Departm ent of Vet erans Affa irs. | |
| 191 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | |
| 192 | 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. | |
| 193 | OR | |
| 194 | Date | |
| 195 | Current St reet Addre ss | |
| 196 | City State Zip Code | |
| 197 | Cell Numbe r (Includi ng Area Co de)Telepho ne Number (Including Area Code ) | |
| 198 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) Email Addr ess | |
| 199 | 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 | |
| 200 | or claims | |
| 201 | Page 2 of 310-10CGVA FORM APR 2016 | |
| 202 | Primary Fa mily Careg iver Signa ture | |
| 203 | SECONDARY FAMILY CAR EGIVER - C omplete if appointin g more tha n one Seco ndary Care giver. | |
| 204 | Last Name First Name Middle Na me | |
| 205 | Date of Bi rth (mm-dd -yyyy)Soci al Securit y Number | |
| 206 | Male Femal e | |
| 207 | Gender | |
| 208 | Current St reet Addre ss | |
| 209 | City State Zip Code | |
| 210 | Telephone Number (In cluding Ar ea Code) C ell Number (Includin g Area Cod e) | |
| 211 | Relationsh ip to Vete ran (e.g., Spouse, P arent, Chi ld, Other) Email Addr ess | |
| 212 | 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 | |
| 213 | or claims | |
| 214 | I certify that I am at least 1 8 years of age. | |
| 215 | Check one: | |
| 216 | 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 | |
| 217 | applicatio n. | |
| 218 | ||
| 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 | |
| 220 | of the Dep artment of Veterans Affairs (o r designee ) may remo ve me from this posi tion immed iately if I fail to comply wit h the | |
| 221 | Program re quirements as define d by law. | |
| 222 | ||
| 223 | I certify that the i nformation above is correct an d true to the best o f my knowl edge and b elief. | |
| 224 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | |
| 225 | 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. | |
| 226 | OR | |
| 227 | Date | |
| 228 | I certify that I am at least 1 8 years of age. | |
| 229 | Check one: | |
| 230 | 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 | |
| 231 | applicatio n. | |
| 232 | ||
| 233 | 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 | |
| 234 | 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 | |
| 235 | Program re quirements as define d by law. | |
| 236 | ||
| 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 | I certify that I am a family m ember of t he Veteran or Servic emember na med in thi s applicat ion. | |
| 239 | 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. | |
| 240 | OR | |
| 241 | Date | |
| 242 | SECTION II I - SECOND ARY FAMILY CAREGIVER (Continue d) | |
| 243 | Page 3 of 310-10CGVA FORM APR 2016 | |
| 244 | Secondary Caregiver Signature | |
| 245 | Secondary Caregiver Signature |
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