Application for Health Benefits

Section III - Insurance 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 of Medicaid?

Yes No
6A. Are you enrolled in Medicare Hospital Insurance Part A?

Yes No
6B. Effective Date

Month Day Year
Date

Section V - Employment Information
1A. Veteran's Employment Status (Check one)

Full Time Part Time Not Employed Retired
1B. Date of Retirement

Month Day Year
Date
1C. Company Name (Complete if employed or retired)
1D. Company Address (Complete if employed or retired - Street, City, State, Zip)
1E. Company Phone Number (Complete if employed or retired)

Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse, & Dependent Children
1A. Veteran's Gross Annual Income from Employment (wages, bonuses, tips, etc.) Excluding income from your farm, ranch, property or business
1B. Veteran's Net Income from your Farm, Ranch, Property or Business
1C. List Veteran's other income amount (e.g., Social Security, compensation, pension, interest, dividends) Excluding Welfare
2A. Spouse's Gross Annual Income from Employment (wages, bonuses, tips, etc.) Excluding income from your farm, ranch, property or business
2B. Spouse's Net Income from your Farm, Ranch, Property or Business
2C. List Spouse's other income amount (e.g., Social Security, compensation, pension, interest, dividends) Excluding Welfare
3A. Dependent's Gross Annual Income from Employment (wages, bonuses, tips, etc.) Excluding income from your farm, ranch, property or business
3B. Dependent's Net Income from your Farm, Ranch, Property or Business
3C. List Dependent's other income amount (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.

Section VIII - Consent to Co-Pays 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 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.
SIGNATURE OF APPLICANT
Clear
DATE

Month Day Year
Date
Should be Empty:

APPLICATION FOR HEALTH BENEFITS

SECTION I - GENERAL INFORMATION

SECTION II - MILITARY SERVICE INFORMATION

2. Military History

Section III - Insurance Information

Section IV - Dependent Information

Section V - Employment Information

Section VI - Previous Calendar Year Gross Annual Income of Veteran, Spouse, & Dependent Children

Section VII - Previous Calendar Year Deductible Expenses

Section VIII - Consent to Co-Pays and to Receive Communications

Assignment of Benefits

SIGNATURE OF APPLICANT