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  • 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)

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  • SECTION II - MILITARY SERVICE INFORMATION

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  • APPLICATION FOR HEALTH BENEFITS

  • SECTION III - INSURANCE INFORMATION (Use a separate sheet for additional information)

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  • SECTION IV - DEPENDENT INFORMATION

    • Spouse Informaton 
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    • Spouse Information End 
    • CHILD NAME ONE 
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    • CHILD NAME ONE END 
    • CHILD NAME TWO 
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    • CHILD NAME TWO END 
    • CHILD NAME THREE 
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    • CHILD NAME THREE END 
    • CHILD NAME FOUR 
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    • CHILD NAME FOUR END 
    • CHILD NAME FIVE 
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    • CHILD NAME FIVE END 
    • SECTION V - EMPLOYMENT INFORMATION

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

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    • SECTION VII - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES

    • 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

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