Assignment Content Complete the Hewlett-Packard Case Study Analysis. Submit your analysis. Prepare a 7- to 10-slide Microsoft® PowerPoint®, Prezi, or Microsoft® Sway®presentation describing your analysis of the Hewlett-Packard Case Study. Describe how you

10-10CGVA FORM April 2016

Instructions for Completing Application for the Program of Comprehensive Assistance for Family Caregivers

Please Read Before You Start . . .

Caregiver Support Coordinator (CSC): A VA clinical professional who connects Caregivers of Veterans with VA and community resources offering supportive programs and services. Caregiver Support Coordinators are located at every VA medical center and are designated specialists in Caregiving issues. Family Member: A member of the Veteran's or Servicemember's family (including a parent, a spouse, a son or daughter, a step-family member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or Secondary Family Caregiver. Injured in the Line of Duty (LOD): An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran's or Servicemember's willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty. Power of Attorney (POA): A Power of Attorney is an authorization for someone to act on the Veteran's or Servicemember's behalf when completing this form. Primary Family Caregiver: A Family Member (defined herein), who is designated as a "primary provider of personal care services" under 38 U.S.C. §1720G(a)(7)(A); and who meets the requirements of 38 C.F.R. §71.25. Representative: Refers to a Veteran's or Servicemember's court-appointed legal guardian or special guardian, Durable POA for Health Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this application. Secondary Family Caregiver: An individual approved as a "provider of personal care services" for the eligible Veteran under 38 U.S.C. §1720G(a)(7)(A); meets the requirements of 38 C.F.R. §71.25; and generally serves as a back-up to the Primary Family Caregiver. Stipend: An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured eligible Veteran (as defined in 38 C.F.R §71.15).

Definitions of terms used in this form

What is VA Form 10-10CG used for? To apply for VA's Program of Comprehensive Assistance for Family Caregivers. VA will use the information on this form to assist in determining your eligibility; a clinical assessment will also be required. An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family Caregivers. On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the necessary facts and fill out the form. Each time a new Caregiver is appointed a new Form 10-10CG is required. Where can I get help filling out the form and answers to questions? You may use ANY of the following to request assistance: Ask VA to help you fill out the form by calling us at 1-877-222- VETS (8387). Access VA's website at http://www.va.gov and select "Contact the VA". Locate and contact the Caregiver Support Coordinator at your nearest VA health care facility. A Caregiver Support Coordinator locator is available at http:// www.caregiver.va.gov/. Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service Organization.

10-10CGVA FORM April 2016

Who should apply for VA's Program of Comprehensive Assistance for Family Caregivers? IF THE INDIVIDUAL IS A: Veteran or Servicemember who has been issued a date of medical discharge from the military

AND AND THEN Requires on-going supervision or assistance with performing basic functions of everyday life due to a serious injury or mental disorder (including traumatic brain injury, psychological trauma or other mental disorder) incurred or aggravated in the line of duty on or after September 11, 2001

Requires at least 6 months of continuous Caregiver support

The Veteran or Servicemember may meet the criteria for VA's Program of Comprehensive Assistance for Family Caregivers. Complete this form to apply

Veterans and Servicemembers who do not meet the criteria for VA's Program of Comprehensive Assistance for Family Caregivers may be eligible for VA health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver Support Coordinator (CSC) at your local VA health care facility. To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.

THE PAPERWORK REDUCTION ACT This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.

PRIVACY ACT INFORMATION Privacy Act Information: Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, and 1720G, in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records --VA” (24VA19), “Enrollment and Eligibility Records --VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records-- VA” (54VA17) and in accordance with the VHA Notice of Privacy Practices. Providing the requested information, including Social Security Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits, and their records, and for other purposes authorized or required by law.

1. Read Paperwork Reduction and Privacy Act Information. 2. The Veteran or an individual delegated as the Veteran's representative/POA must sign and date the form. 3. Attach POA/Representation documents to the application, if applicable. 4. For expedited processing, mail this application to:

Program of Comprehensive Assistance for Family Caregivers Health Eligibility Center 2957 Clairmont Road NE, Ste 200 Atlanta, GA 30329-1647

Submitting your application.

Answer all questions on the form. If you are not enrolled in VA's health care system or are currently Active Duty undergoing medical discharge, submit VA Form 10-10EZ "Application for Health Benefits" with this form. Enrolled Veterans may submit VA Form 10-10EZR "Health Benefits Renewal Form" with their completed VA Form 10-10CG to provide information updates. Do NOT exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran's or Servicemember's representative or POA may complete this application; however the POA/Representation documents must be provided with this application.

Getting Started:

If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local VA Medical Center Caregiver Support Coordinator (CSC). To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.

SECTION I --VETERAN AND SERVICEMEMBER GENERAL INFORMATION Directions for Section I --Veteran/Servicemember, representative or POA, please answer all questions, sign and date.

SECTION II --PRIMARY FAMILY CAREGIVER GENERAL INFORMATION Directions for Section II --Primary Family Caregiver applicant, please answer all questions, including health insurance information, sign and date.

SECTION III --SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION Directions for Section III --Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/ Servicemember may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to appoint a Secondary Family Caregiver at a later time, Sections I and III in a new 10-10CG must be completed.

10-10CG Page of VA FORM April 2016

Application for Comprehensive Assistance for Family Caregivers Program Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA 30329-1647, for expedited processing; or, hand carry it to your local VA Medical Center Caregiver Support Coordinator (CSC). The date the application is received by VA is the date the application process begins. At this time VA does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.

SECTION I - VETERAN/SERVICEMEMBER

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Last Name First Name Middle Name

Date of Birth (mm-dd-yyyy)Social Security Number

Male Female

Gender

Date

Current Street Address

City State Zip Code

Telephone Number (Including Area Code) Cell Number (Including Area Code)

Name of VA medical center or clinic where you receive or plan to receive health care services:

Email Address

Yes No

Enrolled in VA Health Care?

Name of facility where you last received medical treatment: Hospital Clinic

I certify that I give consent to the individual(s) named in this application to perform personal care services for me upon being approved as Primary and/or Secondary Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers. I certify that the information above is correct and true to the best of my knowledge and belief.

SECTION II - PRIMARY FAMILY CAREGIVER Middle NameFirst NameLast Name

Social Security Number Date of Birth (mm-dd-yyyy)

Male Female

Gender

Current Street Address

City State Zip Code

Estimated Burden: 15 min. OMB Number 2900-0768 Expiration Date: 04/30/2018

Veteran/Servicemember/Representative/POA Signature

10-10CG Page of VA FORM April 2016

SECTION III - SECONDARY FAMILY CAREGIVER - Complete if appointing a Secondary Caregiver Last Name First Name Middle Name

Date of Birth (mm-dd-yyyy)Social Security Number

Male Female

Gender

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that the information above is correct and true to the best of my knowledge and belief.

Telephone Number (Including Area Code) Cell Number (Including Area Code)

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)E-mail Address

Yes No

Enrolled in Medicaid or Medicare?

Name

Other Health Insurance? Yes No

SECTION II - PRIMARY FAMILY CAREGIVER (continued)

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Primary Family Caregiver for the Veteran or Servicemember named on this application.

I understand that the Veteran may revoke my designation as Primary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.

I understand that participation in the Program of Comprehensive Assistance for Family Caregivers does not create an employment relationship with the Department of Veterans Affairs.

I certify that I am a family member of the Veteran or Servicemember named in this application.

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval. OR

Date

Current Street Address

City State Zip Code

Cell Number (Including Area Code)Telephone Number (Including Area Code)

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)Email Address

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Primary Family Caregiver Signature

10-10CG Page of VA FORM April 2016

SECONDARY FAMILY CAREGIVER - Complete if appointing more than one Secondary Caregiver. Last Name First Name Middle Name

Date of Birth (mm-dd-yyyy)Social Security Number Male Female

Gender

Current Street Address

City State Zip Code

Telephone Number (Including Area Code) Cell Number (Including Area Code)

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)Email Address

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application. I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law. I certify that the information above is correct and true to the best of my knowledge and belief.

I certify that I am a family member of the Veteran or Servicemember named in this application.

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval. OR

Date

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application. I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law. I certify that the information above is correct and true to the best of my knowledge and belief.

I certify that I am a family member of the Veteran or Servicemember named in this application.

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval. OR

Date

SECTION III - SECONDARY FAMILY CAREGIVER (Continued)

Secondary Family Caregiver Signature

Secondary Family Caregiver Signature

10-10CG

10-10 C G

VA FORM
April 2016

V A FORM

10-10CG

10-10 C G

Page  of 

VA FORM
April 2016

V A FORM

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Logo: Department of Veterans Affairs

Instructions for Completing Application for the Program of Comprehensive Assistance for Family Caregivers

 

Please Read Before You Start . . . 

Caregiver Support Coordinator (CSC): 

A VA clinical professional who connects Caregivers of Veterans with VA and community resources offering supportive programs and services.  Caregiver Support Coordinators are located at every VA medical center and are designated specialists in Caregiving issues. 

 

Family Member: 

A member of the Veteran's or Servicemember's family (including a parent, a spouse, a son or daughter, a step-family member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or Secondary Family Caregiver.

 

Injured in the Line of Duty (LOD): 

An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran's or Servicemember's willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty. 

 

Power of Attorney (POA):

A Power of Attorney is an authorization for someone to act on the Veteran's or Servicemember's behalf when completing this form. 

 

Primary Family Caregiver: 

A Family Member (defined herein), who is designated as a "primary provider of personal care services" under 38 U.S.C. §1720G(a)(7)(A); and who meets the requirements of 38 C.F.R. §71.25. 

 

Representative: 

Refers to a Veteran's or Servicemember's court-appointed legal guardian or special guardian, Durable POA for Health Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this application.

 

Secondary Family Caregiver: 

An individual approved as a "provider of personal care services" for the eligible Veteran under 38 U.S.C. §1720G(a)(7)(A); meets the requirements of 38 C.F.R. §71.25; and generally serves as a back-up to the Primary Family Caregiver. 

 

Stipend: 

An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured eligible Veteran (as defined in 38 C.F.R §71.15).

Caregiver Support Coordinator (C S C): A V A clinical professional who connects Caregivers of Veterans with V A and community resources offering supportive programs and services. Caregiver Support Coordinators are located at every V A medical center and are designated specialists in Caregiving issues. Family Member: A member of the Veteran's or Servicemember's family (including a parent, a spouse, a son or daughter, a step-family member, and an extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or Secondary Family Caregiver. Injured in the Line of Duty (L O D): An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran's or Servicemember's willful misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which materially interfered with the performance of military duty. Power of Attorney (P O A): A Power of Attorney is an authorization for someone to act on the Veteran's or Servicemember's behalf when completing this form. Primary Family Caregiver: A Family Member (defined herein), who is designated as a "primary provider of personal care services" under 38 U S C §1 7 2 0G(a)(7)(A); and who meets the requirements of 38 C F R §71.25. Representative: Refers to a Veteran's or Servicemember's court-appointed legal guardian or special guardian, Durable P O A for Health Care, or other designated health care agent. Copies of documentation regarding representatives are requested on this application. Secondary Family Caregiver: An individual approved as a "provider of personal care services" for the eligible Veteran under 38 U S C §1 7 2 0G(a)(7)(A); meets the requirements of 38 C F R §71.25; and generally serves as a back-up to the Primary Family Caregiver. Stipend: An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured eligible Veteran (as defined in 38 C F R §71.15).

Definitions of terms used in this form 

What is VA Form 10-10CG used for? 

To apply for VA's Program of Comprehensive Assistance for Family Caregivers.  VA will use the information on this form to assist in determining your eligibility; a clinical assessment will also be required.  An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family Caregivers.  On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the necessary facts and fill out the form.  Each time a new Caregiver is appointed a new Form 10-10CG is required.

 

Where can I get help filling out the form and answers to questions? 

You may use ANY of the following to request assistance: Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).  Access VA's website at http://www.va.gov and select "Contact the VA".  Locate and contact the Caregiver Support Coordinator at your nearest VA health care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.va.gov/.  Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service Organization. 

What is V A Form 10-10C G used for? To apply for V A's Program of Comprehensive Assistance for Family Caregivers. V A will use the information on this form to assist in determining your eligibility; a clinical assessment will also be required. An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family Caregivers. On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the necessary facts and fill out the form. Each time a new Caregiver is appointed a new Form 10-10C G is required. Where can I get help filling out the form and answers to questions? You may use ANY of the following to request assistance: Ask V A to help you fill out the form by calling us at 1-8 7 7-2 2 2-VETS (8 3 8 7). Access V A's website at http://www.V A.gov and select "Contact the V A". Locate and contact the Caregiver Support Coordinator at your nearest V A health care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.V A.gov/. Contact the National Caregiver Support Line by calling 1-855-260-3274 or a Veterans Service Organization.

Who should apply for VA's Program of Comprehensive Assistance for Family Caregivers?

IF THE INDIVIDUAL IS A:

Veteran 

or 

Servicemember 

who has been issued a date of medical discharge from the military

AND

AND

THEN

Requires on-going supervision or assistance with performing basic functions of everyday life due to a serious injury or mental disorder (including traumatic brain injury, psychological trauma or other mental disorder) incurred or aggravated in the line of duty on or after September 11, 2001

Requires at least 6 months of continuous Caregiver support

The Veteran or Servicemember may meet the criteria for VA's Program of Comprehensive Assistance for Family Caregivers. Complete this form to apply

The Veteran or Servicemember may meet the criteria for V A's Program of Comprehensive Assistance for Family Caregivers. Complete this form to apply

 

Veterans and Servicemembers who do not meet the criteria for VA's Program of Comprehensive Assistance for Family Caregivers may be eligible for VA health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver Support Coordinator (CSC) at your local VA health care facility. To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option. 

Veterans and Servicemembers who do not meet the criteria for V A's Program of Comprehensive Assistance for Family Caregivers may be eligible for V A health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver Support Coordinator (C S C) at your local V A health care facility. To obtain the name of your local C S C, contact the Caregiver Support Line at 1-855-260-3274 or go to www.caregiver.V A.gov and use the Find Your Local Caregiver Support Coordinator option.

THE PAPERWORK REDUCTION ACT

This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.

This information collection is in accordance with the clearance requirements of section 3 5 0 7 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid O M B control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.

PRIVACY ACT INFORMATION

Privacy Act Information: Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, and 1720G, in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records --VA” (24VA19), “Enrollment and Eligibility Records --VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records--VA” (54VA17) and in accordance with the VHA Notice of Privacy Practices. Providing the requested information, including Social Security Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits, and their records, and for other purposes authorized or required by law.

Privacy Act Information: Privacy Act Information: V A is asking you to provide the information on this form under 38 U S C Sections 101, 5 3 0 3. A, 1 7 0 5, 1 7 1 0, 1 7 2 0B, and 1 7 2 0G, in order for V A to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. V A may disclose the information that you put on the form as permitted by law. V A may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records, “Patient Medical Records --V A” (2 4 V A 1 9), “Enrollment and Eligibility Records --V A” (1 4 7 V A 1 6), and “Health Administration Center Civilian Health and Medical program Records--V A” (5 4 V A 1 7) and in accordance with the V H A Notice of Privacy Practices. Providing the requested information, including Social Security Number, is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide V A your Social Security Number, V A will use it to administer your V A benefits. V A may also use this information to identify Veterans and persons claiming or receiving V A benefits, and their records, and for other purposes authorized or required by law.

1. Read Paperwork Reduction and Privacy Act Information. 

2. The Veteran or an individual delegated as the Veteran's representative/POA must sign and date the form. 

2. The Veteran or an individual delegated as the Veteran's representative/P O A must sign and date the form.

3. Attach POA/Representation documents to the application, if applicable. 

3. Attach P O A/Representation documents to the application, if applicable.

4. For expedited processing, mail this application to: 

Program of Comprehensive Assistance for Family Caregivers 

Health Eligibility Center 

2957 Clairmont Road NE, Ste 200 

Atlanta, GA 30329-1647 

4. For expedited processing, mail this application to: Program of Comprehensive Assistance for Family Caregivers Health Eligibility Center 2 9 5 7 Clairmont Road Northeast, Suite 200 Atlanta, Georgia 3 0 3 2 9-1 6 4 7

Submitting your application. 

Answer all questions on the form. If you are not enrolled in VA's health care system or are currently Active Duty undergoing medical discharge, submit VA Form 10-10EZ "Application for Health Benefits" with this form. Enrolled Veterans may submit VA Form 10-10EZR "Health Benefits Renewal Form" with their completed VA Form 10-10CG to provide information updates. Do NOT exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran's or Servicemember's representative or POA may complete this application; however the POA/Representation documents must be provided with this application.

Answer all questions on the form. If you are not enrolled in V A's health care system or are currently Active Duty undergoing medical discharge, submit V A Form 10-10E Z "Application for Health Benefits" with this form. Enrolled Veterans may submit V A Form 10-10E Z R "Health Benefits Renewal Form" with their completed V A Form 10-10C G to provide information updates. Do NOT exceed the designated spaces (e.g., do NOT extend Last Name into First Name area). The Veteran's or Servicemember's representative or P O A may complete this application; however the P O A/Representation documents must be provided with this application.

Getting Started: 

If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local VA Medical Center Caregiver Support Coordinator (CSC). To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.

If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local V A Medical Center Caregiver Support Coordinator (C S C). To obtain the name of your local C S C, contact the Caregiver Support Line at 1-855-260-3274 or go to http://www.caregiver.V A.gov and use the Find Your Local Caregiver Support Coordinator option.

SECTION I --VETERAN AND SERVICEMEMBER GENERAL INFORMATION 

SECTION 1 --VETERAN AND SERVICEMEMBER GENERAL INFORMATION

Directions for Section I --Veteran/Servicemember, representative or POA, please answer all questions, sign and date. 

Directions for Section 1 --Veteran/Servicemember, representative or P O A, please answer all questions, sign and date.

SECTION II --PRIMARY FAMILY CAREGIVER GENERAL INFORMATION 

SECTION 2 --PRIMARY FAMILY CAREGIVER GENERAL INFORMATION

Directions for Section II --Primary Family Caregiver applicant, please answer all questions, including health insurance information,  sign and date.

Directions for Section 2 --Primary Family Caregiver applicant, please answer all questions, including health insurance information, sign and date.

SECTION III --SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION 

SECTION 3 --SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION

Directions for Section III --Secondary Family Caregiver applicant(s) please answer all questions, sign, and date.  A Veteran/Servicemember may appoint up to two Secondary Family Caregivers but this is not required.  If a Veteran/Servicemenber elects to appoint a Secondary Family Caregiver at a later time, Sections I and III in a new 10-10CG must be completed.

Directions for Section 3 --Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/Servicemember may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to appoint a Secondary Family Caregiver at a later time, Sections 1 and 3 in a new 10-10C G must be completed.

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V A LOGO

Application for Comprehensive Assistance for Family Caregivers Program

Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA 30329-1647, for expedited processing; or, hand carry it to your local VA Medical Center Caregiver Support Coordinator (CSC). The date the application is received by VA is the date the application process begins. At this time VA does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.

Attention: Complete the application (print or typewritten only) and mail it to: Program of Comprehensive Assistance for Family Caregivers, Health Eligibility Center, 2957 Clairmont Road Northeast, Suite 200, Atlanta, Georgia 3 0 3 2 9-1 6 4 7, for expedited processing; or, hand carry it to your local V A Medical Center Caregiver Support Coordinator (C S C). The date the application is received by V A is the date the application process begins. At this time V A does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/Servicemembers and Family Caregivers living in a foreign country.

SECTION I - VETERAN/SERVICEMEMBER

SECTION 1 - VETERAN/SERVICEMEMBER

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Gender

Enrolled in VA Health Care?

Enrolled in V A Health Care?

I certify that I give consent to the individual(s) named in this application to perform personal care services for me upon being approved as Primary and/or Secondary Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers.

I certify that the information above is correct and true to the best of my knowledge and belief. 

SECTION II - PRIMARY FAMILY CAREGIVER

SECTION 2 - PRIMARY FAMILY CAREGIVER

Gender

Estimated Burden: 15 min.

OMB Number 2900-0768

Expiration Date: 04/30/2018

Estimated Burden: 15 minutes O M B Number 2 9 0 0-0 7 6 8 Expiration Date: XX/XX/XXXX

Veteran/Servicemember/Representative/POA Signature

SECTION III - SECONDARY FAMILY CAREGIVER - Complete if appointing a Secondary Caregiver

SECTION 3 - SECONDARY FAMILY CAREGIVER - Complete if appointing a Secondary Caregiver

Gender

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that the information above is correct and true to the best of my knowledge and belief. 

Enrolled in Medicaid or Medicare?

Other Health Insurance?

SECTION II - PRIMARY FAMILY CAREGIVER (continued)

SECTION 2 - PRIMARY FAMILY CAREGIVER (continued)

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Primary Family Caregiver for the Veteran or Servicemember named on this application.

I understand that the Veteran may revoke my designation as Primary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.

I understand that participation in the Program of Comprehensive Assistance for Family Caregivers does not create an employment relationship with the Department of Veterans Affairs.

OR

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Primary Family Caregiver Signature

SECONDARY FAMILY CAREGIVER - Complete if appointing more than one Secondary Caregiver.

Gender

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

Federal Laws (18 U S C 2 8 7 and 1 0 0 1) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.

 

I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.

 

I certify that the information above is correct and true to the best of my knowledge and belief. 

OR

I certify that I am at least 18 years of age.

Check one:

I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.

 

I understand that the Veteran may revoke my designation as Secondary Family Caregiver at any time and that the Secretary of the Department of Veterans Affairs (or designee) may remove me from this position immediately if I fail to comply with the Program requirements as defined by law.

 

I certify that the information above is correct and true to the best of my knowledge and belief. 

OR

SECTION III - SECONDARY FAMILY CAREGIVER (Continued)

SECTION 3 - SECONDARY FAMILY CAREGIVER (Continued)

Secondary Family Caregiver Signature

Secondary Family Caregiver Signature

8.2.1.4029.1.523496.503679

Application for Comprehensive Assistance for Family Caregivers Program

Department of Veterans Affairs

Application for Comprehensive Assistance for Family Caregivers Program