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OMB Number: 2900-0629Estimated Burden: 90 min.Expiration Date: 06/30/2021INSTRUCTIONS FOR COMPLETING APPLICATION FOREXTENDED CARE SERVICES (VAF 10-10EC)STEP 1. Before You Start. . . .What is VA Form 10-10EC used for?To determine the estimated amount of your monthly copayment obligations for extended care services provided to you by VA, eitherdirectly by VA or paid for by VA. There is no copayment for the first 21 days of extended care services that VA provides to you inany 12 month period. You must report any changes that might affect the copayment amount to your local VA medical facility within10 calendar days of the change.Where can I get help filling out the form?Contact the Social Work staff at your local VA medical facility for assistance on understanding the information and financial dataneeded to complete VA Form 10-10EC.What will I need to know in order to complete the form?Current income of both veteran and spouse (can report monthly or annual income).Current deductible expenses (can report monthly or annual expenses). For example property taxes may be reported as an annualamount.Value of fixed and liquid assets of both veteran and spouse. See Section IV of these instructions for further information regarding thereporting of assets.All health insurance information covering you even if it is through your spouse (a copy of your insurance card).Medicare information (Part A & Part B) (a copy of your Medicare card).Spousal/Dependent information (including spouse's social security number, dependents date of birth).STEP 2. Completing the application . . . .Section I - General Information. Include your name and full social security number.Section II - Insurance Information. Include information for Medicare and all health insurance companies that cover you. It isimportant that we obtain all health insurance coverage for you (including coverage through a spouse). Please make a copy of yourMedicare card and all health insurance cards and include them with this completed application.Section III - Spouse/Dependent Information. In order to determine if a veteran must pay an extended care copayment amount, it isnecessary to identify spousal and/or dependent information and whether they are residing in the community (not institutionalized). Aspouse or dependent is considered institutionalized if they are residing in a nursing home or hospital setting. A dependent other thanspouse would be son, daughter, stepson, or stepdaughter. Provide address and phone number of spouse or dependent if different fromthe veteran. Report current marital status. Do not include spousal information if you and spouse are legally separated ordivorced. If you are certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by theplace where you and/or your spouse resided at the time of marriage, or where you and/or your spouse reside when you file yourclaim (or at a later date when you become eligible for benefits) (38 U.S.C. 103(c)). Additional guidance on when VA recognizesmarriages is available at http://www.va.gov/opa/marriage/.Section IV - Fixed Assets. Used only in the determination of the extended care copayment amount when a veteran reaches 181 daysor more of institutional (inpatient) extended care services.Report real property minus any outstanding lien or mortgage.Exclude burial plots, veteran's primary residence and veteran's vehicle (if the veteran is receiving institutional (inpatient)extended care services this is the primary residence and vehicle of the spouse or dependents).Section V - Liquid Assets. Used only in the determination of the extended care copayment amount when a veteran reaches 181 daysor more of institutional (inpatient) extended care services.Report cash, stocks, dividends received from IRA, 401K's and other tax deferred annuities, bonds, mutual funds, retirementsaccounts (e.g. IRA, 401Ks, annuities), art, rare coins, stamp collections, and other collectibles.Exclude household and personal items such as furniture, clothing and jewelry if the veteran has a spouse or dependents residingin the community.If the veteran has a spouse residing in the community (not institutionalized), the spousal resource protection amount may beapplied to reduce the value of liquid assets.VA FORMJAN 201710-10ECEXISTING STOCK OF VA FORM 10-10EC, MAY 2005, WILL NOT BE USED.
Section VI - Current Gross Income of Veteran and Spouse. Do not include income from dependents.Report wages, bonuses, tips, severance pay and accrued benefitsReport income from a business (minus business expenses)Report cash gifts, inheritance amounts, intrest income, and the standard dividend income from non tax deferred annunities.Report retirement income and pension income.Report unemployment payments, worker's compensation payments, black lung payments, tort settlement payments, socialsecurity payments, and court mandated payments.Report payments from VA or any other Federal programs, and any other income.Exclude income of the Veteran's dependents.Section VII. Expenses. Not used in the determination of the extended care copayment amount when a veteran reaches 181 days ormore of institutional (inpatient) extended care services and does not a have a spouse or dependents residing in the community (notinstitutionalized).Report basic subsistence (living) expenses.Include any educational expense incurred by the veteran, spouse or dependent.Include any funeral or burial expenses for your spouse or dependent as well as any prepaid funeral or burialarrangements for yourself, spouse, or dependent.Include rent or mortgage payment for primary residence only.Include amount paid for utilities (electricity, gas, water or phone). You can calculate the amount by using the average monthlyexpenses during the past year for your utilities.Include car payment for one vehicle only.Include amount spent for food for veteran, spouse or dependent.Include non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care,medications, eyeglasses, Medicare, medical insurance premiums, medical copayments and other hospital or nursing homeexpense.Include court ordered payments such as alimony or child support.Include insurance premiums such as automobile and homeowners. Exclude life insurance premiums.Include taxes paid on property and average monthly expense for taxes paid on income over the past 12 months.STEP 3. Submitting your applicationWhat do I do when I have finished my application?1. Read Section VIII, Consent for Assignment of Benefits, Section IX, Consent to Agreement to Make Copayments, and SectionX, Privacy Act and Paperwork Reduction Act Information.2. In Section VIII and Section IX, you or an individual to whom you have delegated your Power of Attorney must sign and date.3. Attach any documentation such as copies of Medicare and other health insurance cards, and your Power of Attorney documentsto your application.4. Return the original form and supporting documentation to the Social Work staff at your local VA medical facility.STEP 4. Finding out what my Extended Care Copayment Amount will be.Once the VA Form 10-10EC is completed, the Social Work staff at your local VA medical facility will counsel you, or an individualto whom you have delegated your Power of Attorney, on your estimated monthly copayment obligations for the requested extendedcare services.VA FORMJAN 201710-10EC
OMB Number: 2900-0629Estimated Burden: 90 min.Expiration Date: 06/30/2021APPLICATION FOR EXTENDED CARE SERVICESFederal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulentstatement or representation. (See 18 U.S.C. 287 and 1001)SECTION I - GENERAL INFORMATION1. VETERAN'S NAME (Last, First, MI)2. SOCIAL SECURITY NUMBERSECTION II - INSURANCE INFORMATIONANSWER YES OR NO WHERE APPLICABLE (OTHERWISE PROVIDE THE REQUESTED INFORMATION)3. ARE YOU ELIGIBLE FOR MEDICAID?3B. EFFECTIVE DATE (If "Yes")3A. ARE YOU ENROLLED IN MEDICARE PART A (Hospital Insurance)YESYESNO4. NAME OF INSURANCE COMPANYNO4A. ADDRESS OF INSURANCE COMPANY4C. NAME OF POLICY HOLDER4D. RELATIONSHIP OF POLICY HOLDER4B. PHONE NUMBER OF INSURANCE COMPANY4E. POLICY NUMBER4F. GROUP NAME AND/OR NUMBERSECTION III - SPOUSE/DEPENDENT INFORMATION5. CURRENT MARITAL STATUS (Check one)LEGALLY SEPARATED5A. SPOUSE'S NAME (Last, First, MI)MARRIEDNEVER MARRIEDWIDOWEDDIVORCED5B. SPOUSE RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)YES5C. SPOUSE'S SOCIAL SECURITY NUMBERNO (If "No", explain)6. DEPENDENT'S NAME (Last, First, MI)6A. DEPENDENT'S DATE OF BIRTH6B. DEPENDENT'S SOCIAL SECURITY NUMBER6C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)YESNO (If "No", explain)7. DEPENDENT'S NAME (Last, First, MI)7A. DEPENDENT'S DATE OF BIRTH7B. DEPENDENT'S SOCIAL SECURITY NUMBER7C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide address and phone number if different from veteran)YESNO (If "No", explain)We need to collect information regarding income, assets and expenses for you and your spouse. If you do not wish to provide thisinformation you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services. Seethe top of page 2, read, sign and date.VA FORMJAN 201710-10ECEXISTING STOCK OF VA FORM 10-10EC, MAY 2005, WILL BE USED.Page 1
APPLICATION FOR EXTENDED CARE SERVICES, ContinuedVETERAN'S NAMESOCIAL SECURITY NUMBERI do not wish to provide my detailed financial information. I understand that I will be assessed the maximum copayment amount for extended careservices and agree to pay the applicable VA copayment as required by law.SIGNATURE (Sign in ink)DATESECTION IV - FIXED ASSETS (VETERAN AND SPOUSE)VETERANSPOUSE1. Primary Residence (Market value minus mortgages or liens. Exclude if veteran receiving only noninstitutional extended care services or spouse or dependent residing in the community). If the veteran andspouse maintain separate residences, and the veteran is receiving institutional (inpatient) extended careservices, include value of the veteran's primary residence.) 2. Other Residences/Land/Farm or Ranch (Market value minus mortgages or liens. This would include a secondhome, vacation home, rental property.) 3. Vehicle(s) (Value minus any outstanding lien. Exclude primary vehicle if veteran receiving only noninstitutional extended care services or spouse or dependent residing in community. If the veteran and spousemaintain separate residences and vehicles, and the veteran is receiving institutional (inpatient) extended careservices, include value of the veteran's primary vehicle.) 1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates of deposit, individualretirement accounts, stocks and bonds). 2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus the amount youowe on these items. Exclude household effects, clothing, jewelry, and personal items if veteran receiving onlynon-institutional extended care services or spouse or dependent residing in the community. SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)TOTAL ASSETSSUM OF ALL LINES FIXED AND LIQUID ASSETSSECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSEVETERANCATEGORYHOW MUCHHOW OFTEN1. Gross annual income from employment (e.g., wages, bonuses, tips,severances pay, accrued benefits) 2. Net income from your farm/ranch, property or business. 3. List other income amounts (e.g., social security, Retirement and pension,interest, dividends) Refer to instructions. SECTION VII - DEDUCTIBLE EXPENSESSPOUSEHOW MUCHHOW OFTEN ITEMSAMOUNT1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.) 2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid arrangements) 3. Rent/Mortgage (monthly amount or annual amount) 4. Utilities (calculate by average monthly amounts over the past 12 months) 5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs) 6. Food (for veteran, spouse and dependent) 7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists, medications, Medicare,health insurance, hospital and nursing home expenses) 8. Court-ordered payments (e.g., alimony, child support) 9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude Life Insurance 10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on income over thepast 12 months. TOTALS VA FORMJAN 201710-10ECPage 2
APPLICATION FOR EXTENDED CARE SERVICES, ContinuedSECTION VIII - CONSENT FOR ASSIGNMENT OF BENEFITSI understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized torecover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonserviceconnected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP underwhich I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for mymedical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may haveagainst any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by theVA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of thecost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the AttorneyGeneral of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessaryand appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose,to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical servicesprovided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third partyor administrative agency to disclose to the VA any information regarding my claim.SIGNATURE (Sign in ink)DATEVETERANS NAMESOCIAL SECURITY NUMBERSECTION IX - CONSENT TO AGREEMENT TO MAKE COPAYMENTSCompletion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative hasreceived a copy of the Privacy Act Statement and agrees to make appropriate copayments.l declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge and I agree to make theapplicable copayment for extended care services as required by law. I understand that any materially false, fictitious, or fraudulentstatement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant to title 18, United States Code,Sections 287 and 1001.SIGNATURE (Sign in ink)DATESECTION X - PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATIONThe VA is asking you to provide the information on this form under Title 38, United States Code, sections 1710, 1712, 1722 and 1729 for VA todetermine your eligibility for extended care benefits and to establish financial eligibility, if applicable, when placed in extended care services.Obligation to respond is voluntary. The information you supply may be verified through a computer-matching program. VA may disclose theinformation that you put on the form as permitted by law; possible disclosures include those described in the "routine use" identified in the VAsystem of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. You do nothave to provide the information to VA, but if you don't, VA will be unable to process your request and serve your medical needs. Failure to furnishthe information will not have any affect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VAwill use it to administer your VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits andtheir records, and for other purposes authorized or required by law. The Paperwork Reduction Act of 1995 requires us to notify you that thisinformation collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may notconduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that thetime expended by all individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gatherthe necessary facts and fill out the form.ADDITIONAL COMMENTS:VA FORMJAN 201710-10ECPage 3
Jun 30, 2021 · any funeral or burial expenses for your spouse or dependent as well as any prepaid funeral or burial arrangements for yourself, spouse, or dependent. Include amount paid for utilities (electricity, gas, water or phone). You can calculate the amount by using the average monthly expenses during t
