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: 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. Submit the completed form to the Health Eligibility Center using the address below or submit the form to your local VA Medical Center
Caregiver Support Coordinator. If you do not know the name and address of your local Caregiver Support Coordinator(s) you can go
and use the Find Your Local Caregiver Support Coordinator feature. You may also contact the Caregiver
Support Line at 1-855-260-3274.
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.
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
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.
VA FORM 10-10CG, JAN 2020
VA MISSION Act of 2018 expands eligibility to Family Caregivers of eligible Veterans of all eras and VA will announce when applications are
able to be considered under the expanded eligibility. Until such announcement is made, eligibility is limited to Veterans and Servicemembers
who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001.
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 http://www.caregiver.va.gov/
. and use the Find Your Local Caregiver Support Coordinator option.
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Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Ste 200
Atlanta, GA 30329-1647