Form 10-1394 Application for Adaptive Equip - Motor Vehicle -

"I certify that the amounts billed hereon do not exceed the usual and customary costs for the items or services furnished " ((Specify)) (1 Enter Veteran's Address ) (1 Enter Veteran's Name This is a mandatory field ) (13 SIGNATURE OF APPLICANT) (14 DATE (mm/dd/yyyy)) (16 SIGNATURE AND TITLE OF ELIGIBILITY CLERK OR DESIGNEE) (17 DATE) (19A NAME AND ADDRESS OF PAYEE) (19B AMOUNT) (19C NAME AND ADDRESS OF PAYEE) (19D AMOUNT) (20 NAME AND ADDRESS OF VA FIELD FACILITY) (21 SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL) (22 DATE (mm/dd/yyyy)) (24 Signature Date Enter MM/DD/YYYY ) (3 Last 4 DIGITS OF SSN (5 YEAR YOU RECEIVED GRANT FOR VEHICLE (6 DATE OF VA CERTIFICATE OF ELIGIBILITY (8A DATE PURCHASED) (8B YEAR) (8C MAKE) (8D MODEL) (8E VEHICLE IDENTIFICATION NUMBER) (9 LAST VEHICLE FOR WHICH ADAPTIVE EQUIPMENT WAS PROVIDED) (9A YEAR) (9B MAKE) (9C MODEL) (9D VEHICLE IDENTIFICATION NUMBER) (9E DATE ADAPTIVE EQUIPMENT PROVIDED (mm/dd/yyyy)) (AMOUNT TO BE PAID) (AMOUNT TO BE PAID) (D FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE) (E FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE) (E OTHER DISABILITIES AFFECTING DRIVING) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (ESTIMATED COST) (If January 11 1971 or after) (If January 11 1971 or after)) (If prior to January 11 1971)) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (ITEMS AUTHORIZED) (MAXIMUM (MAXIMUM (MAXIMUM (MAXIMUM (MAXIMUM COST) (MAXIMUM COST) (MAXIMUM COST) (MAXIMUM COST) (mm/dd/yyyy) (mm/dd/yyyy) (This is a mandatory field ) (This is a mandatory field )) (V JUSTIFICATION (Include full description and estimated cost of item T if applicable)) *NOTE: ALL VAN MODIFICATIONS REQUIRE PRIOR AUTHORIZATION BEFORE PURCHASEAPPLICATION FOR ADAPTIVE EQUIPMENT 1 Contact should be made with the Prosthetics Service at your local VA medical center or outpatient clinic prior to any purchase of equipment 1 This is to inform you that if Part II and III of this form have been completed and signed by VA the individual who is designated in this form as the 1 VETERAN'S NAME AND ADDRESS 10 1394 10 LIST OF ADAPTIVE EQUIPMENT REQUESTED (Check items required) 13 SIGNATURE OF APPLICANTAMOUNT TO BE PAID11 MAKE PAYMENT TO THE FOLLOWING (Check appropriate box(es) and attach a certified invoiced:) 16 SIGNATURE AND TITLE OF ELIGIBILITY CLERK OR DESIGNEE15 APPLICANT IS ELIGIBLE UNDER(Check one)17 DATE(Specify) 18 The following adaptive equipment is approved for inclusion with or installation on the specific vehicle described in item 8 on the front of this form Costs 19 REIMBURSEMENT OR PAYMENT TO THE VENDOR(S) OR INDIVIDUAL(S) NAMED BELOW IN THE TOTAL AMOUNTS SPECIFIED FOR EACH IS AUTHORIZED AS 2 After you and the applicant have entered into an agreement for the repair of items or services listed in item 18 and you have completed those repairs 2 below) 2 Complete all item in Part I of this form in duplicate and sign the form 23 SIGNATURE OF APPLICANTPART II ELIGIBILITY (To be completed by Eligibility Clerk or Designee) 24 DATE(mm/dd/yyyy) 3 If you are requesting adaptive equipment or services VA will determine your eligibility and complete Part II 3 Last 4 DIGITS OF SSN 4 After approval you may give the original of this form to the seller/vendor of your choice who will deliver the equipment or services authorized (see 4 DRIVER'S LICENSE VERIFICATION (Check applicable block)6 DATE OF VA CERTIFICATE OF ELIGIBILITY 4 Ensure that the applicant has signed in items 13 and 23 for receipt of the items or services 5 In the event you must obtain some of the equipment on a mail order basis or cannot use this authorization for any other reason you may pay for 5 VA expressly disavows any intent to enter into a contract with the seller; any agreement as to repairs or other services is between the seller/vendor 5 YEAR YOU RECEIVED GRANT FOR VEHICLE(If prior to January 11 1971) 6 After receipt of the items or services authorized sign and date the receipt in items 23 and 24 and direct the seller/vendor's attention to the 7 DISABILITIES Check applicable box(es)8 DESCRIPTION OF VEHICLE FOR WHICH ADAPTIVE EQUIPMENT IS REQUIREDEXTREMITY 8A DATE PURCHASED8C MAKE8B YEAR8D MODEL8E VEHICLE IDENTIFICATION NUMBERE OTHER DISABILITIES AFFECTING DRIVING9 LAST VEHICLE FOR WHICH A AUTOMOTIVE DEALERB ADAPTIVE EQUIPMENT SUPPLIERC PERSONAL REIMBURSEMENTD FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADEE FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE12 STATUS OF APPLICANT (Check one)14 DATE (mm/dd/yyyy) A PROPER CHARGE FOR ADAPTIVE EQUIPMENT PREVIOUSLY PURCHASED BY THE APPLICANT UNDER AUTHORITY OF CFR 3 808: ADAPTIVE EQUIPMENT WAS also paragraphs 3 and 4 below) an authorized item or service and apply for reimbursement from VA In such cases you must present a paid invoice properly certified (see paragraph AND LEVELANKYLOSISLOSS OF USEAMPUTATlONLEFTRIGHTLEFTRIGHTLEFTRIGHTA ARM AEB ARM BEC LEG AK (hip) and the applicant applicant has been authorized the services or items in Item 18 of this form Note that the applicant is not entitled to services that exceed the maximum certification statement on your own invoice COST) COST) COST) COST) COSTMAXIMUM COSTPART III APPROVAL AND AUTHORIZATION (TO BE COMPLETED BY PROSTHETIC REPRESENTATIVE) costs specified on item 18 of this form or approved on your quote D LEG BK (knee) Department of Veterans Affairs E POWER WINDOWSO *DROP FLOORT MINI VAN CONVERSIONH REAR WINDOW DEFROSTERR *VAN LIFTI FOOT/HAND OPERATED PARKING BRAKES *POWER TRANSFER SEATJ AIR CONDITIONERU *OTHER (Describe) entitled Estimated Burden: 15 minutes FFGraphic2 furnish the information will have no adverse effect on any other benefits to which you may be entitled I CERTIFY THAT I have received the items inability to process your request promptly Failure to furnish this information will have no adverse effect on any other benefits to which you may be including installation unless authorized separately will not exceed the total amount indicated for each item INELIGIBLE instructions below This certification signifies that the adaptive equipment installation or service is satisfactory the servicing information on the INSTRUCTIONS TO SELLER/VENDORINSTRUCTIONS TO VETERAN OR SERVICEPERSONThe information requested on this form is solicited under authority of Title 38 U S C Veterans Benefits and will be used to determine your eligibility for invoice has been verified to the best of your ability and the charges appear to be reasonable item or service provided with the cost of each Identify the make model and year of the automobile or other conveyance and include the following ITEMS AUTHORIZEDITEMS AUTHORIZEDMAXIMUM JAN 2008 MOTOR VEHICLEPART I (To be completed by applicant If more space is needed attach a separate sheet and identify by item number ) OMB Number: 2900 0188 or services authorized in item 18 above or services you may use the following reimbursement procedures For repairs items or services prepare your own invoice itemizing each separate OTHER3 Attach a copy of your certified invoice to the original of this form and mail to the VA Office shown in item 20 outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136 published in the Federal Register Disclosure is PAGE 2 of 2 PART IV CERTIFICATION OF RECEIPT (TO BE COMPLETED BY APPLICANT) prosthetic benefits and provide basic data for your treatment Disclosure is voluntary However failure to furnish the information will result in our PROVIDED9A YEAR9B MAKE9C MODEL9D VEHICLE IDENTIFICATION NUMBER9E DATE ADAPTIVE EQUIPMENT PROVIDED PUB L 91 666 (VAF 4 4502) PUB L 96 466 for vets in Voc Rehab PUB L 97 66 for Ankylosis veterans records Additional information may be solicited during the course of processing your application The information you supply may also be disclosed 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 Signature of Company Official19A NAME AND ADDRESS OF PAYEE19B AMOUNT19C NAME AND ADDRESS OF PAYEE19D AMOUNT20 NAME AND ADDRESS OF VA FIELD FACILITY21 SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL22 DATE (mm/dd/yyyy) The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of This includes the time it will take to read instructions gather the necessary facts and fill out the form unless it displays a valid OMB number We anticipate that the time expended by all individuals who must complete this form will average 15 minutes used to determine your eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment and identify your medical V JUSTIFICATION(Include full description and estimated cost of item T if applicable) VA FORMJAN 2008 VA FORMPAGE 1 OF 2 VALID LICENSE OR PERMIT IN POSSESSIONNOT LICENSEDN *SENSITIZED/LOW EFFORT STEERINGG CRUISE CONTROLF TILT STEERING WHEELP *RAISED ROOFO *POWER DOOR OPENERSM *SENSITIZED/LOW EFFORT BRAKEA AUTOMATIC TRANSMISSIONK TRANSFER OF CONTROLSB POWER BRAKESL HAND CONTROLS ACCELERATOR & BRAKEC POWER STEERINGD POWER SEAT (6 way/2 way) VETERANMEMBER OF ARMED FORCESPRIVACY ACT INFORMATION:The information requested on this form is solicited under authority of Title 38 U S C Veterans Benefits and will be voluntary however failure to furnish the information will result in our inability to process your request promptly and serve your medical needs Failure to XDESCRIPTIONESTIMATED COST$XDESCRIPTIONESTIMATED COST$