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)
If "Yes" , what is your rated percentage 00 %
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.
I understand that pusuant 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 fro my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any clam I may have against any person or entity who is or may be legally responsible for hte payment of hte cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right t orecover 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 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 hte 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 pary or administrative agency to disclose to the VA any information regarding my claim.
All applicants must sign and date this form.