Form 10-10EC Application For Extended Care Services

You can calculate the amount by using the average monthly "routine "YES" (a copy of your insurance card) (calculate by average monthly amounts over the past 12 months) (can report monthly or annual income) (Check one) (e g alimony child support) (e g automobile insurance homeowners insurance) Exclude Life Insurance (e g personal property for home automobile) Include average monthly expense for taxes paid on (e g tuition books fees material etc ) (electricity gas water or phone) (exclude gas automobile insurance parking fees repairs) (for veteran spouse and dependent) (Hospital Insurance) (If "No" explain) (If "No" explain) (If "Yes") (If applicable) (including (including A&A or HB) (including spouse's social security number dependents date of birth) (inpatient) (inpatient) (Last First MI) (Last First MI) (Market (Medical Insurance) (monthly amount or annual amount) (OTHERWISE PROVIDE THE REQUESTED INFORMATION) (Part A & Part B) (a copy of your Medicare card) (Provide address and phone number if different from veteran) (Provide address and phone number if different from veteran) (spouse (vacation (VAF 10 10EC) (Value (VETERAN AND SPOUSE) (VETERAN AND SPOUSE)) 1 Educational expenses of veteran spouse or dependent 1 VETERAN'S NAME 10 10EC 10 10EC 10 10EC 10 10EC 10 DEPENDENT'S NAME 10 Taxes 10A DEPENDENT'S DATE OF BIRTH 10B DEPENDENT'S SOCIAL SECURITY 10C DEPENDENT RESIDING IN THE COMMUNITY? 11 DEPENDENT'S NAME 11A DEPENDENT'S DATE OF BIRTH 11B DEPENDENT'S SOCIAL SECURITY 11C DEPENDENT RESIDING IN THE COMMUNITY? 2 Net income from your farm/ranch property or business 2 SOCIAL SECURITY NUMBER 24VA136 3 ARE YOU ELIGIBLE FOR MEDICAID? 3 Rent/Mortgage 3A ARE YOU ENROLLED IN MEDICARE PART A 3B EFFECTIVE DATE 4 ARE YOU ENROLLED IN MEDICARE PART B 4 Utilities 4A EFFECTIVE DATE 4B MEDICARE CLAIM NUMBER 5 Car Payment for one vehicle only 6 Food 6 NAME OF INSURANCE COMPANY 6A ADDRESS OF INSURANCE COMPANY 6B PHONE NUMBER 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 Court ordered payments 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 9 CURRENT MARITAL STATUS 9 Insurance 9A SPOUSE'S NAME 9B SPOUSE RESIDING IN THE COMMUNITY? 9C SPOUSE'S SOCIAL SECURITY NUMBER A veteran applying for extended care services may be required to complete VA Form 10 10EC A veteran compensable with a service connected disability 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 that began on or before November 30 1999 A veteran receiving Hospice Care as a part of extended care services A veteran whose annual income is less than the Single Veteran Pension Rate in effect under 38 U S C 1521(b) accordance accounts Accounts accrued benefits action ADDITIONAL COMMENTS: address administer Administration Affairs affect against agree agreeing Agreement All health insurance information covering you even if it is through your spouse already AMOUNT amount amount amount amount amount amount paid for utilities amount spent for food for veteran spouse or dependent amounts An eligible combat veteran receiving extended care services related to treatment authorized under 38 U S C 1710(e)(1)(D) and fill out the form and Section X Paperwork and Privacy Act Information and/or annual annual ANSWER YES OR NO WHERE APPLICABLE anticipate any educational expense incurred by the veteran spouse or dependent any funeral or burial expenses for your spouse or dependent as well as any prepaid funeral or burial arrangements for apparently applicable application APPLICATION FOR EXTENDED APPLICATION FOR EXTENDED CARE SERVICES apply arising arrangements) as income asking asserted assessed assets assets assets assets assets Assets Assignment Attach any documentation such as copies of Medicare or Insurance cards to the application authorization authorize authorized automatically average basic before you call or go to the VA health care facility belief benefits benefits benefits black bonds bonuses burial Burial cancer car payment for one vehicle only CARE SERVICES Continued care services include value of the veteran's primary vehicle ) CATEGORY certain certificates certification certify charged checking child claim claiming clearance clothing coin collections art work and other collectibles coins collect collected collectibles) collection collections community community community) companies company(s) Compensation complete complete completed Completion computer matching conduct consent Consent considered contract contractor copayment copayment copayment copayment amounts copayment for extended care services as required by law Copayment obligation if applicable copayments Copayments copyayment correct court court ordered payments such as alimony or child support cover coverage coverage coverage to you ) COVERED current Current Current income of both veteran and spouse daughter deductible dentists Department Department of Veterans Affairs dependent dependent dependent dependent dependents deposit described designee detailed determination determination determine determine determined diagnostic different disability Disability disclose disclosures displays distributions dividends DIVORCED documented don't earnings effects eligibility eligible employment entitled establish Estimated Burden: 90 min example except Exclude Exclude exempt EXISTING STOCK OF VA FORM 10 1OEC DEC 2002 WILL BE USED expended expense expenses expenses expenses Expenses expenses during the past year for your utilities expenses) expire express extended extended extended extended extended extended extended extended extended extended care services EXTENDED CARE SERVICES extended care services and agree to pay the applicable VA copayment as required by law extent eyeglasses Medicare medical insurance premiums medical copayments and other hospital or nursing home expense facility facts Failure Federal financial financial Fixed fixed Fixed following foregoing from Individual Retirement Accounts (IRAs) or annuities fully funds funeral furnish further gather gifts Gross gross annual income from employment including information about your wages bonuses tips severance pay and other health health health Health herbicide exposure hereby history home vacation home rental property ) home) hospital household HOW MUCH HOW OFTEN identified identify important Include Include Include Include Include include include include include Include Include your name and full social security number included included includes including income income income income over the past 12 months individual individuals information information information information information information information information information information Information inheritance inpatient institutional institutional institutionalized institutionalized) instructions INSTRUCTIONS FOR COMPLETING APPLICATION FOR Instructions Page 1 of 2 Instructions Page2 of 2 insurance insurance INSURANCE insurance premiums such as automobile and homeowners Exclude life insurance premiums interest interest dividends) ITEMS items jewelry knowledge legally LEGALLY SEPARATED liability liens liens limited liquid Liquid Liquid Liquid maintain maintain maintaining mandated marital MARRIED maximum MAY 2005 MAY 2005 MAY 2005 means medical medical medical medical benefits to VA for any services for which payment is accepted medical records Medicare Medicare card and all health insurance cards and include them with this completed application Medicare information medications Medicare health insurance hospital and nursing home expenses) minus minus minus minutes monthly more of institutional mortgages mortgages mutual necessary necessary needs net income from farm ranch property or business NEVER MARRIED non institutional non institutional non institutional extended care services or spouse or dependent residing in the community Non reimbursed non reimbursed medical expenses paid by you or your spouse Include expenses for medical and dental care medications notify number Number nursing obtain OMB Number: 2900 0629 order other other other other Other other income amounts including retirement and pension income Social Security Retirement and Social Security outstanding outstanding Page 1 of 3 Page 2 of 3 Page 3 of 3 Paperwork party Patient pay accrued benefits) payment payments pension permitted Persian personal personnel persons phone physicians placed Please plots possible post Persian Gulf War combat exposure prepaid primary Primary Privacy process program property provide provide provide Provide provided provider providing published purposes radiation/exposure ranch reaches received a copy of the Privacy Act Statement and agrees to make appropriate copayments receiving receiving receiving receiving receiving receiving Record VA records records Reduction Refer to instructions regarding Register reimbursement related reliance rent or mortgage payment for primary residence only Report Report report report reported representative request required requirements requires residence residence residences residences Residences/Land/Farm residing residing residing respond Retirement retirement accounts stocks and bonds) retirements Return the completed documentation to the Social Worker assisting you with the Extended Care Services placement review revocation revoke savings second section Section Section Section Section SECTION I GENERAL INFORMATION SECTION II INSURANCE INFORMATION SECTION III SPOUSE/DEPENDENT INFORMATION SECTION IV FIXED ASSETS SECTION IX CONSENT TO AGREEMENT TO MAKE COPAYMENTS SECTION V LIQUID ASSETS SECTION VI CURRENT GROSS INCOME OF VETERAN AND SPOUSE SECTION VII DEDUCTIBLE EXPENSES SECTION VIII CONSENT FOR ASSIGNMENT OF BENEFITS SECTION X PRIVACY ACT AND PAPERWORK REDUCTION ACT INFORMATION sections security separate separate separated serve service connected services services services services services services services include value of the veteran's primary residence ) setting settlement severances SIGNATURE SIGNATURE single social Social SOCIAL SECURITY NUMBER sponsor spousal Spousal/Dependent information SPOUSE spouse spouse spouse spouse spouse spouse spouse spouse) spouse)? Spouse/Dependent stamp statement(s) States status STEP 1 Before You Start STEP 2 Completing the application STEP 3 Submitting your application STEP 4 Finding out what my Extended Care Copayment Amount will be stepdaughter stepson stocks subsistence SUM OF ALL LINES FIXED AND LIQUID ASSETS supply system taken taxes taxes paid on property and average monthly expense for taxes paid on income over the past 12 months The following veterans will NOT BE REQUIRED to complete VA Form 10 10EC or pay Extended Care Copayments the reporting of assets their these those through through Title top of page 2 read sign and date TOTAL ASSETS TOTALS treatment U S C 1720E unable under under understand understand unemployment United unless valid value value value Value vehicle vehicle Vehicle(s) vehicles verified VETERAN veteran veteran veteran veteran veteran veteran veteran veteran veteran veteran Veteran veteran/representative veterans veteran's Veterans VETERANS NAME VETERAN'S NAME Vietnam era wages What do I do when I have finished my application? What is VA Form 10 10EC used for? What will I need to know in order to complete the form? Where can I get help filling out the form? whether which Who should complete a VA Form 10 10EC? WIDOWED Without Worker Workers would yourself spouse or dependent