VA APPLICATION FOR HEALTH BENEFITS

APPLICATION FOR HEALTH BENEFITS
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)
Contact Email Address*
example@example.com
1A. VETERAN'S NAME (Last, First, Middle Name)*
1B. PREFERRED NAME
2. MOTHER'S MAIDEN NAME*
3.A BIRTH SEX*

MALEFEMALE
3.B SELF-IDENTIFIED GENDER IDENTITY*

MALEFEMALE
4. ARE YOU SPANISH, HISPANIC, OR LATINO?*

YESNO
5. WHAT IS YOUR RACE? (You may check more than one. Information is required for statistical purposes only)*

ASIANAMERICAN INDIAN OR ALASKA NATIVEBLACK OF AFRICAN AMERICANWHITENATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
6. SOCIAL SECURITY NO.*
7. VA CLAIM NUMBER
8A. DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
8B. PLACE OF BIRTH (City and State)*
9. RELIGION
10A. PERMANENT ADDRESS(street)*
10B. CITY*
10C. STATE*
10D. ZIP CODE*
10E. COUNTY*
10F. HOME TELEPHONE NO. (optional)
10G. MOBILE TELEPHONE NO. (optional)
10H. E MAIL ADDRESS (optional)
example@example.com
11A. RESIDENTIAL ADDRESS (Street)*
11B. CITY*
11C. STATE*
11D. ZIP CODE*
11E. COUNTY*
12. TYPE OF BENEFIT(S) APPLYING FOR*

ENROLLMENT/HEALTH SERVICESDENTAL
13. CURRENT MARTIAL STATUS*

MARRIEDNEVER MARRIEDSEPARATEDWIDOWEDDIVORCED
14A. NEXT OF KIN NAME*
14B. NEXT OF KIN ADDRESS*
14C. NEXT OF KIN RELATIONSHIP*
14D. NEXT OF KIN TELEPHONE NO. (Include Area Code)*
14E. NEXT OF KIN WORK TELEPHONE NO. (Include Area Code)*
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)*
16. I AM ENROLLING TO OBTAIN MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT*

YESNO
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?*

YESNO
SECTION II - MILITARY SERVICE INFORMATION
1A. LAST BRANCH OF SERVICE*
1B. LAST ENTRY DATE*

MonthDayYear
Date
1C. FUTURE DISCHARGE DATE

MonthDayYear
Date
1D. LAST DISCHARGE DATE*

MonthDayYear
Date
1E. DISCHARGE TYPE*
1F. MILITARY SERVICE NUMBER
A. ARE YOU A PURPLE HEART AWARD RECIPIENT?*

YESNO
B. ARE YOU A FORMER PRISONER OF WAR?*

YESNO
C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER 11/11/1998?*

YESNO
D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A DISABILITY INCURRED IN THE LINE OF DUTY?*

YESNO
E. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF VA COMPENSATION?*

YESNO
F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEEN AUGUST 2, 1990 AND NOVEMBER 11, 1998?*

YESNO
G. DO YOU HAVE A VA SERVICE-CONNECTED RATING?*

NOYES (IF "YES", WHAT IS YOUR RATED PERCENTAGE)
H. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND MAY 7, 1975?*

YESNO
I. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?*

YESNO
J. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS WHILE IN THE MILITARY?*

YESNO
K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT CAMP LEJEUNE FROM AUGUST 1, 1953 THROUGH DECEMBER 31, 1987?*

YESNO
APPLICATION FOR HEALTH BENEFITS
VETERAN'S NAME (Last, First, Middle)*
SOCIAL SECURITY NUMBER*
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)*
2. NAME OF POLICY HOLDER*
3. POLICY NUMBER*
4. GROUP CODE*
5. ARE YOU ELIGIBLE FOR MEDICAID OR MEDI-CAL?*

YESNO
6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?*

YESNO
6B. EFFECTIVE DATE*

MonthDayYear
(mm/dd/yyyy)
SECTION IV - DEPENDENT INFORMATION

Spouse Informaton
1. SPOUSE'S NAME (Last, First, Middle Name)*
1A. SPOUSE'S SOCIAL SECURITY NUMBER*
1B. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
1C. SPOUSE SELF-IDENTIFIED GENDER IDENTITY*

MALEFEMALE
1D. DATE OF MARRIAGE (mm/dd/yyyy)*

MonthDayYear
Date
1E. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran's)*

Spouse Information End
If you have dependent Children please specify how many?

CHILD NAME ONE
2.1 CHILD'S NAME (Last, First, Middle Name)*
2.1.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
2.1.B. CHILD'S SOCIAL SECURITY NO.*
2.1.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
Date
2.1.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.1.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.1.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.1.G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

CHILD NAME ONE END

CHILD NAME TWO
2.2 CHILD'S NAME (Last, First, Middle Name)*
2.2.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
2.2.B. CHILD'S SOCIAL SECURITY NO.*
2.2.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
Date
2.2.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.2.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.2.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.2.G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

CHILD NAME TWO END

CHILD NAME THREE
2.3 CHILD'S NAME (Last, First, Middle Name)*
2.3.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
2.3.B. CHILD'S SOCIAL SECURITY NO.*
2.3.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
Date
2.3.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.3.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.3.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.3.G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

CHILD NAME THREE END

CHILD NAME FOUR
2.4 CHILD'S NAME (Last, First, Middle Name)*
2.4.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
2.4.B. CHILD'S SOCIAL SECURITY NO.*
2.4.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
Date
2.4.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.4.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.4.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.4.G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

CHILD NAME FOUR END

CHILD NAME FIVE
2.5 CHILD'S NAME (Last, First, Middle Name)*
2.5.A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)*

MonthDayYear
Date
2.5.B. CHILD'S SOCIAL SECURITY NO.*
2.5.C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)*

MonthDayYear
Date
2.5.D. CHILD'S RELATIONSHIP TO YOU (Check one)*

SONDAUGHTERSTEPSONSTEPDAUGHTER
2.5.E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?*

YESNO
2.5.F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND SCHOOL LAST CALENDAR YEAR?

YESNO
2.5.G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE, VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)

CHILD NAME FIVE END
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT

YESNO
SECTION V - EMPLOYMENT INFORMATION
1A. VETERAN'S EMPLOYMENT STATUS (Check one).

FULL TIMEPART TIMENOT EMPLOYEDRETIRED
1B. DATE OF RETIREMENT*

MonthDayYear
Date
1D. COMPANY ADDRESS*
(Complete if employed or retired - Street, City, State, ZIP )
1C. COMPANY NAME. (Complete if employed or retired)*
(Complete if employed or retired) (Include area code)
1E. COMPANY PHONE NUMBER (Complete if employed or retired) (Include area code)*
SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

	Veteran	Spouse	Child1	Child2	Child3	Child4	Child5
1. Gross Annual Income from employment(wages, bonuses, tips, etc) excluding income from your farm, ranch, property of business
2. Net income from your farm, ranch, property of 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.
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
SECTION VIII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS
By submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) as required by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobile number. However, providing your email, home phone number, or mobile number is voluntary.
ASSIGNMENT OF BENEFITS
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.
SIGNATURE OF APPLICANT
SIGNATURE OF APPLICANT (Sign in ink)

Clear
DATE

MonthDayYear
Date
Should be Empty:

APPLICATION FOR HEALTH BENEFITS

SECTION I - GENERAL INFORMATION

SECTION II - MILITARY SERVICE INFORMATION

APPLICATION FOR HEALTH BENEFITS

SECTION V - EMPLOYMENT INFORMATION

SECTION VI - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN

SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

SECTION VIII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONS

ASSIGNMENT OF BENEFITS

SIGNATURE OF APPLICANT