Free VA Form 10-10EC - Application For Extended Care Services - Federal

OMB Number: 2900-0629 Estimated Burden: 90 min.

INSTRUCTIONS FOR COMPLETING APPLICATION FOR EXTENDED CARE SERVICES (VAF 10-10EC) STEP 1. Before You Start. . . .
What is VA Form 10-10EC used for? To apply for extended care services provided by VA or paid for by VA and to determine the amount of your Extended Care Copayment obligation if applicable. Who should complete a VA Form 10-10EC? A veteran applying for extended care services may be required to complete VA Form 10-10EC. The following veterans will NOT BE REQUIRED to complete VA Form 10-10EC or pay Extended Care Copayments. A veteran compensable with a service-connected disability. A veteran whose annual income is less than the Single Veteran Pension Rate in effect under 38 U.S.C. 1521(b). A veteran receiving care for a service-connected disability as determined by a VA health care provider and documented in the medical records. A veteran receiving extended care services that began on or before November 30,1999. A veteran receiving extended care services related to Vietnam-era herbicide-exposure, radiation/exposure, Persian Gulf War and post-Persian Gulf War combat-exposure. A veteran receiving extended care services related to treatment for military sexual trauma as authorized under 38 U.S.C. 1720D. A veteran receiving extended care services related to certain care or services for cancer of the head or neck as authorized under 38 U.S.C. 1720E. A veteran receiving Hospice Care as a part of extended care services. An eligible combat veteran receiving extended care services related to treatment authorized under 38 U.S.C. 1710(e)(1)(D). Where can I get help filling out the form? The Social Work personnel at the VA health care facility can help you understand the application and what information and financial data needs to be collected in order to fully complete VA Form 10-10EC. Health Administration personnel at the VA health care facility can help you fill out the form. Gather necessary financial information and complete as much of the form as you can before you call or go to the VA health care facility. 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 annual amount. Value of fixed and liquid assets of both veteran and spouse. See Section IV of these instructions for further information regarding the reporting 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 is important that we obtain all health insurance coverage for you (including coverage through a spouse). Please make a copy of your Medicare 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 is necessary to identify spousal and/or dependent information and whether they are residing in the community (not institutionalized). A spouse or dependent is considered institutionalized if they are residing in a nursing home or hospital setting. A dependent other than spouse would be son, daughter, stepson, or stepdaughter. Provide address and phone number of spouse or dependent if different from the veteran. Report current marital status. Do not include spousal information if you and spouse are legally separated or divorced. Section IV - Fixed and Liquid Assets. Do not report fixed assets if the veteran is receiving only non-institutional extended care services. Fixed assets means real property. Exclude burial plots. Do not report the value of the primary residence and one vehicle if the spouse or dependent is residing in the community and maintaining the residence. If the veteran and spouse maintain separate residences include the value of the veteran's residence and vehicle minus any outstanding liens or mortgages. Include the value of all other fixed assets such as other residences (vacation home), land, farm or ranch minus any outstanding liens or mortgages. Fixed assets are only included in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services.
VA FORM MAY 2005

10-10EC

EXISTING STOCK OF VA FORM 10-1OEC, DEC 2002, WILL BE USED.

Instructions - Page 1 of 2

Section V - Liquid Assets. Do not report liquid assets if the veteran is receiving only non-institutional extended care services. Liquid assets include, but are not limited to, cash, interest, dividends, stocks, bonds, mutual funds, retirements accounts, stamp or coin collections, art work, and other collectibles. Liquid assets are only included in the determination of the extended care copayment amount when a veteran reaches 181 days or more of institutional (inpatient) extended care services. Section VI - Current Gross Income of Veteran and Spouse. Do not include income from dependents. Do not include VA pension (including A&A or HB) as income. Report gross annual income from employment including information about your wages, bonuses, tips, severance pay and other accrued benefits. Report net income from farm, ranch, property or business. Report other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income, Compensation benefits such a VA disability, unemployment, Workers and black lung, cash gifts, court mandated payments, inheritance amounts, tort settlement payments, interest and dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities. Section VII. Expenses. Expenses means basic subsistence expenses. Expenses are NOT included in the determination of the extended care copyayment amount if the veteran is single and has been receiving inpatient extended care services for 181 days or more. 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 burial arrangements 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 monthly expenses 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 home expense. 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 application
What do I do when I have finished my application? Read, sign, and date Section VIII, Consent for Assignment of Benefits, Section IX, Consent to Agreement to Make Copayments, and Section X, Paperwork and Privacy Act Information. Attach any documentation such as copies of Medicare or Insurance cards to the application. Return the completed documentation to the Social Worker assisting you with the Extended Care Services placement.

STEP 4. Finding out what my Extended Care Copayment Amount will be.
Once the the VA Form 10-10EC is completed, the Social Worker or other designee will meet with you to review your extended care copayment amounts.

VA FORM MAY 2005

10-10EC

Instructions - Page2 of 2

OMB Number: 2900-0629 Estimated Burden: 90 min.

APPLICATION FOR EXTENDED CARE SERVICES
SECTION I - GENERAL INFORMATION
1. VETERAN'S NAME (Last,

First, MI)

2. SOCIAL SECURITY NUMBER

SECTION II - INSURANCE INFORMATION ANSWER YES OR NO WHERE APPLICABLE (OTHERWISE PROVIDE THE REQUESTED INFORMATION)
3. ARE YOU ELIGIBLE FOR MEDICAID? 3A. ARE YOU ENROLLED IN MEDICARE PART A (Hospital YES NO

Insurance)

3B. EFFECTIVE DATE (If

"Yes")

YES

NO

4. ARE YOU ENROLLED IN MEDICARE PART B (Medical YES NO

Insurance) 4A. EFFECTIVE DATE

(If "Yes")

4B. MEDICARE CLAIM NUMBER (If

applicable)

5. ARE YOU COVERED BY HEALTH INSURANCE

coverage to you.)
YES

(including coverage through a spouse)? (If "YES", provide the following information for all insurance company(s) providing

NO 6A. ADDRESS OF INSURANCE COMPANY 6B. PHONE NUMBER OF INSURANCE COMPANY

6. NAME OF INSURANCE COMPANY

6C. NAME OF POLICY HOLDER

6D. RELATIONSHIP OF POLICY HOLDER

6E. POLICY NUMBER

6F. GROUP NAME AND/OR NUMBER

7. NAME OF INSURANCE COMPANY

7A. ADDRESS OF INSURANCE COMPANY

7B. PHONE NUMBER OF INSURANCE COMPANY

7C. NAME OF POLICY HOLDER

7D. RELATIONSHIP OF POLICY HOLDER

7E. POLICY NUMBER

7F. GROUP NAME AND/OR NUMBER

8. NAME OF INSURANCE COMPANY

8A. ADDRESS OF INSURANCE COMPANY

8B. PHONE NUMBER OF INSURANCE COMPANY

8C. NAME OF POLICY HOLDER

8D. RELATIONSHIP OF POLICY HOLDER

8E. POLICY NUMBER

8F. GROUP NAME AND/OR NUMBER

SECTION III - SPOUSE/DEPENDENT INFORMATION
9. CURRENT MARITAL STATUS (Check LEGALLY SEPARATED

one)

MARRIED WIDOWED

NEVER MARRIED DIVORCED

9A. SPOUSE'S NAME (Last,

First, MI)

9B. SPOUSE RESIDING IN THE COMMUNITY? (Provide

address and phone number if different from veteran)

9C. SPOUSE'S SOCIAL SECURITY NUMBER

YES

NO (If

"No", explain) First, MI)
10A. DEPENDENT'S DATE OF BIRTH 10B. DEPENDENT'S SOCIAL SECURITY

10. DEPENDENT'S NAME (Last,

10C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide

address and phone number if different from veteran)

YES

NO (If

"No", explain) First, MI)
11A. DEPENDENT'S DATE OF BIRTH 11B. DEPENDENT'S SOCIAL SECURITY

11. DEPENDENT'S NAME (Last,

11C. DEPENDENT RESIDING IN THE COMMUNITY? (Provide

address and phone number if different from veteran)

YES

NO (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 this information you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services. See the top of page 2, read, sign and date.
VA FORM MAY 2005

10-10EC

EXISTING STOCK OF VA FORM 10-1OEC, DEC 2002, WILL BE USED.

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SOCIAL SECURITY NUMBER APPLICATION FOR EXTENDED VETERAN'S NAME CARE SERVICES, Continued I do not wish to provide my detailed financial information. I understand that I will be assessed the maximum copayment amount for extended care services and agree to pay the applicable VA copayment as required by law. SIGNATURE DATE

1. Primary Residence (Market value minus mortgages or liens. Exclude if veteran receiving only non-institutional extended care services or spouse or dependent residing in the community). If the veteran and spouse maintain separate residences, and the veteran is receiving institutional (inpatient) extended care services, 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 second home, vacation home, rental property.) 3. Vehicle(s) (Value minus any outstanding lien. Exclude primary vehicle if veteran receiving only non-institutional extended care services or spouse or dependent residing in community. If the veteran and spouse maintain separate residences and vehicles, and the veteran is receiving institutional (inpatient) extended care services, include value of the veteran's primary vehicle.) 1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates of deposit, individual retirement accounts, stocks and bonds). 2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal items if veteran receiving only non-institutional extended care services or spouse or dependent residing in the community.
SECTION V - LIQUID ASSETS (VETERAN AND SPOUSE)

SECTION IV - FIXED ASSETS (VETERAN AND SPOUSE))

VETERAN

SPOUSE

$ $ $

$ $ $

$ $ $

$ $ $

SUM OF ALL LINES FIXED AND LIQUID ASSETS
CATEGORY

TOTAL ASSETS

SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE VETERAN SPOUSE HOW MUCH HOW OFTEN HOW MUCH HOW OFTEN

1. 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.
ITEMS

$ $ $ $ $ $ $ $ $ $ $ $ $ $
AMOUNT

$ $

SECTION VII - DEDUCTIBLE EXPENSES

1. 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 the past 12 months. TOTALS
SECTION VIII - CONSENT FOR ASSIGNMENT OF BENEFITS

I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been completed. I authorize payment of medical benefits to VA for any services for which payment is accepted.
SIGNATURE DATE

VA FORM MAY 2005

10-10EC

Page 2 of 3

APPLICATION FOR EXTENDED CARE SERVICES, Continued

VETERANS NAME

SOCIAL SECURITY NUMBER

SECTION IX - CONSENT TO AGREEMENT TO MAKE COPAYMENTS

Completion of this form with signature of the Veteran or veteran's representative is certification that the veteran/representative has received a copy of the Privacy Act Statement and agrees to make appropriate copayments. I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable copayment for extended care services as required by law.
SIGNATURE DATE

SECTION X - PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION

The 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 to determine your eligibility for extended care benefits and to establish financial eligibility, if applicable, when placed in extended care services. The 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; possible disclosures include those described in the "routine use" identified in the VA system of records 24VA136, Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. You do not have 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 furnish the information will not have any affect 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. 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 90 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
ADDITIONAL COMMENTS:

VA FORM MAY 2005

10-10EC

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