Fillable INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS (College of DuPage)

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INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS (College of DuPage)

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Financial Disclosure: ONLY NSC AND 0% NONCOMPENSABLE SC VETERANS MUST COMPLETE THIS
SECTION TO DETERMINE ELIGIBILITY AND COPAY RESPONSIBILITY FOR VA HEALTH CARE ENROLLMENT
AND/OR CARE OR SERVICES.
Financial Disclosure Requirements Do Not Apply To:
• a former Prisoner of War; or
• those in receipt of a Purple Heart; or
• a recently discharged Combat Veteran; or
• those discharged for a disability incurred or aggravated in the line of duty; or
• those receiving VA SC disability compensation; or
• those receiving VA pension; or
• those in receipt of Medicaid benefits; or
• those who served in Vietnam between January 9, 1962 and May 7, 1975; or
• those who served in SW Asia during the Gulf War between August 2, 1990 and November 11, 1998; or
• those who served at least 30 days at Camp Lejeune between August 1, 1953 and December 31, 1987.
INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS
Getting Started:
Definitions of terms used on this form:
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."
• Contact the Enrollment Coordinator at your local VA health care facility.
• Contact a National or State Veterans Service Organization.
For Veterans to apply for enrollment in the VA health care system. The information provided on this form will be used by VA
to determine your eligibility for medical benefits and on average will take 30 minutes to complete. This includes the time it
will take to read instructions, gather the necessary facts and fill out the form.
Please Read Before You Start . . . What is VA Form 10-10EZ used for?
SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the
active military, naval or air service.
COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
Complete only the sections that apply to you; sign and date the form.
VA FORM
APR 2017
10-10EZ
ALL VETERANS MUST COMPLETE SECTIONS I - III.
Directions for Sections I - III:
Section I - General Information:
Answer all questions.
Section II - Military Service Information: If you are not currently receiving benefits from VA, you may attach a copy of
your discharge or separation papers from the military (such as DD-214 or, for WWII Veterans, a "WD" Form), with your
signed application to expedite processing of your application. If you are currently receiving benefits from VA, we will cross-
reference your information with VA data.
Section III - Insurance Information: Include information for all health insurance companies that cover you, this includes
coverage provided through a spouse or significant other. Bring your insurance cards, Medicare and/or Medicaid card with you
to each health care appointment.
Directions for Sections IV-VI:
You are not required to disclose your financial information; however, VA is not currently enrolling new applicants who decline to
provide their financial information unless they have other qualifying eligibility factors. If a financial assessment is not used to
determine your priority for enrollment you may choose not to disclose your information. However, if a financial assessment is used
to determine your eligibility for cost-free medication, travel assistance or waiver of the travel deductible, and you do not disclose
your financial information, you will not be eligible for these benefits.
PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
VA FORM
APR 2017
10-10EZ
Continued ...
Report:
• Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages,
bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay
your household expenses.
• Net income from your farm, ranch, property, or business.
• Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability
income, compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends,
including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.
Section V - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.
Do Not Report:
Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI)and need-based
payments from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on
Individual Retirement Accounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement for
casualty loss; loans; Radiation Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims
Settlement Acts Income, payments to foster parent; amounts in joint accounts in banks and similar institutions acquired by reason
of death of the other joint owner; Japanese ancestry restitution under Public Law 100-383; cash surrender value of life insurance;
lump-sum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional assistance
program.
Section VI - Previous Calendar Year Deductible Expenses.
Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs,
eyeglasses, Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom
you have a legal or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other
sources. Report last illness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).
Section VII - Submitting your application.
Where do I send my application?
Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200
Atlanta, GA 30329.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and
you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that
the time expended by all individuals who must complete this form will average 30 minutes. This includes the time it will
take to read instructions, gather the necessary facts and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1705,1710, 1712, and
1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified from initial submission
forward 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 notices and in accordance with the
VHA Notice of Privacy Practices. Providing the requested information 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.
Section IV - Dependent Information: Include the following:
• Your spouse even if you did not live together, as long as you contributed support last calendar year.
• Your biological children, adopted children, and stepchildren who are unmarried and under the age of 18, or at least 18 but under
23 and attending high school, college or vocational school (full or part-time), or became permanently unable to support
themselves before age 18.
• Child support contributions. Contributions can include tuition or clothing payments or payments of medical bills.
1.
You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an
"X", 2 people you know must witness you as you sign. They must sign the form and print their names. If the form is not signed
and dated appropriately, VA will return it for you to complete.
2.
Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.
14E. NEXT OF KIN WORK TELEPHONE NO.
(Include Area Code)
SECTION II - MILITARY SERVICE INFORMATION
SECTION I - GENERAL INFORMATION
Federal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing a material fact or making a materially
false statement. (See 18 U.S.C. 1001)
4. ARE YOU SPANISH,
HISPANIC,OR LATINO?
6. SOCIAL SECURITY NO.
PAGE 1
VA FORM
APR 2017
10-10EZ
APPLICATION FOR HEALTH BENEFITS
1A. VETERAN'S NAME (Last, First, Middle Name)
2. MOTHER'S MAIDEN NAME
5. WHAT IS YOUR RACE?
(You may check more than one.
Information is required for statistical purposes only.)
8A. DATE OF BIRTH (mm/dd/yyyy) 8B. PLACE OF BIRTH (City and State)
OMB Approved No. 2900-0091
Estimated Burden Avg. 30 min.
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
10C. STATE10B. CITY 10D. ZIP CODE
10A. PERMANENT ADDRESS
(Street)
10E.COUNTY
17. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
(for listing of facilities visit www.va.gov/directory)
18. WOULD YOU LIKE FOR VA TO
CONTACT YOU TO SCHEDULE
YOUR FIRST APPOINTMENT?
1A. LAST BRANCH OF SERVICE 1B. LAST ENTRY DATE 1D. LAST DISCHARGE DATE
1E. DISCHARGE TYPE
2. MILITARY HISTORY (Check yes or no)
YES NO
A. ARE YOU A PURPLE HEART AWARD RECIPIENT?
F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN
AUGUST 2, 1990 AND NOVEMBER 11, 1998?
C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER
11/11/1998?
D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A
DISABILITY INCURRED IN THE LINE OF DUTY?
H. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962
AND MAY 7, 1975?
I. WERE YOU EXPOSED TO RADIATION WHILE IN THE
MILITARY?
J. DID YOU RECEIVE NOSE AND THROAT RADIUM
TREATMENTS WHILE IN THE MILITARY?
K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT
CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH
DECEMBER 31, 1987?
YES NO
B. ARE YOU A FORMER PRISONER OF WAR?
13. CURRENT MARTIAL STATUS
16. I AM ENROLLING TO OBTAIN MINIMUM
ESSENTIAL COVERAGE UNDER THE
AFFORDABLE CARE ACT
YES
NO
MALE
FEMALE
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
WHITE BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
ENROLLMENT/HEALTH SERVICES DENTAL
YES
NO
MARRIED NEVER MARRIED SEPARATED WIDOWED DIVORCED
1B. PREFERRED NAME
3A. BIRTH SEX
3B. SELF-IDENTIFIED
GENDER IDENTITY
FEMALE
MALE
7. VA CLAIM NUMBER
9. RELIGION
11C. STATE11B. CITY 11D. ZIP CODE
11A. RESIDENTIAL ADDRESS
(Street)
11E.COUNTY
10G. MOBILE TELEPHONE NO. (Include area code)
10H. E-MAIL ADDRESS
10F. HOME TELEPHONE NO.
(Include area code)
12. TYPE OF BENEFIT(S) APPLYING FOR
(You may check more than one)
NOYES
14A. NEXT OF KIN NAME 14B. NEXT OF KIN ADDRESS 14C. NEXT OF KIN RELATIONSHIP
14D. NEXT OF KIN TELEPHONE NO.
(Include Area Code)
1C. FUTURE DISCHARGE DATE
1F. MILITARY SERVICE NUMBER
E. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF
VA COMPENSATION?
G. DO YOU HAVE A VA SERVICE-CONNECTED RATING?
IF "YES", WHAT IS YOUR RATED PERCENTAGE %
15. DESIGNEE - INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONAL
PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR
DEPARTURE OR AT THE TIME OF DEATH
(Note: This does not constitute a
will or transfer of title)
APPLICATION FOR HEALTH BENEFITS
Continued
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
PAGE 2
10-10EZ
VA FORM
APR 2017
2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL
LAST CALENDAR YEAR?
2B. CHILD'S SOCIAL SECURITY NO.
2C. DATE CHILD BECAME YOUR DEPENDENT
(mm/dd/yyyy)
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE
AGE OF 18?
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST
YEAR, DID YOU PROVIDE SUPPORT?
1B. SPOUSE'S DATE OF BIRTH
(mm/dd/yyyy)
1D. DATE OF MARRIAGE (mm/dd/yyyy)
2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
2D. CHILD'S RELATIONSHIP TO YOU (Check one)
1. SPOUSE'S NAME (Last, First, Middle Name) 2. CHILD'S NAME (Last, First, Middle Name)
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP
if different from Veteran's)
2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL
REHABILITATION OR TRAINING
(e.g., tuition, books, materials)
SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1A. SPOUSE'S SOCIAL SECURITY NUMBER
SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
VETERAN SPOUSE CHILD 1
1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips,
etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR
BUSINESS
2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS
3. LIST OTHER INCOME AMOUNTS
(e.g., Social Security, compensation,
pension interest, dividends) EXCLUDING WELFARE.
$
$
$
$
$
$
$
$
$
SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE (e.g., payments for doctors, dentists, medications,
Medicare, health insurance, hospital and nursing home) VA will calculate a deductible and the net medical expenses you may claim.
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES)
FOR YOUR DECEASED SPOUSE OR DEPENDENT CHILD
(Also enter spouse or child's information in Section VI.)
3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books,
fees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.
$
$
$
STEPDAUGHTER
YES NO
YES NO
YES NO
STEPSONDAUGHTER SON
SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
4. GROUP CODE 2. NAME OF POLICY HOLDER
3. POLICY NUMBER
5. ARE YOU
ELIGIBLE FOR
MEDICAID?
6A. ARE YOU ENROLLED IN MEDICARE
HOSPITAL INSURANCE PART A?
YES NO
YES
NO
6B. EFFECTIVE DATE
(mm/dd/yyyy)
1C. SPOUSE SELF-IDENTIFIED
GENDER IDENTITY
MALE FEMALE
SECTION V - EMPLOYMENT INFORMATION
NOT EMPLOYEDFULL TIME
1A. VETERAN'S EMPLOYMENT STATUS
(Check one).
1B. DATE OF RETIREMENT
1C. COMPANY NAME.
(Complete if employed or retired)
1D. COMPANY ADDRESS
(Complete if employed or retired -Street, City, State, ZIP )
1E. COMPANY PHONE NUMBER
(Complete if employed or retired)
(Include area code)
PART TIME RETIRED
ASSIGNMENT OF BENEFITS
SECTION VII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan
(HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby
authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the
charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or
entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or
prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be
entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary
and 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 services provided to me, information from my medical records as necessary to verify
my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.
ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.
DATE
PAGE 3
10-10EZ
VA FORM
APR 2017
By submitting this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law. You also
agree to receive communications from VA to your supplied email or mobile number.
APPLICATION FOR HEALTH BENEFITS
Continued
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
SIGNATURE OF APPLICANT
(Sign in ink)
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INSTRUCTIONS FOR COMPLETING ENROLLMENT APPLICATION FOR HEALTH BENEFITS (College of DuPage)

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Completed 25 July 2020

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