Fillable Form 10-10CG Application for Comprehensive Assistance Family Caregivers

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Form 10-10CG Application for Comprehensive Assistance Family Caregivers

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10-10CG
VA 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.
10-10CG
VA 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
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Form 10-10CG Application for Comprehensive Assistance Family Caregivers

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Completed 21 February 2020

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