• 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)

  • 3A. Birth Sex
  • 3B. Self-Identified Gender Identity
  • 4. Are you Spanish, Hispanic, or Latino
  • 5. What is your race? (You may check more than one. Information is required for statistical purposes only.)
  • 8A. Date of Birth (MM/DD/YYYY)
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 12. Type of Benefit(s) Applying For
  • 13. Current Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 16. I am enrolling to obtain minimum essential coverage under the affordable care act
  • 18. Would you like for VA to contact you to schedule your first appointment?

  • SECTION II - MILITARY SERVICE INFORMATION

  • 1B. Last Entry Date
     / /
  • 1C. Future Discharge Date (Currently Serving in U.S. Military)
     / /
  • 1D. Last Discharge Date
     / /

  • 2. Military History

  • A. Are you a Purple Heart Award Recipient?
  • B. Are you a former prisoner of war?
  • C. Did you serve in a combat theater of operations after 11/11/1998
  • D. Were you discharged or retired from military for a disability incurred in the line of duty?
  • E. Are you receiving disability retirement pay instead of VA compensation?
  • F. Did you serve in SW Asia during the Gulf War Between August 2, 1990 and November 11, 1998?
  • G. Do you have a VA service-connected rating?

  • If "Yes" , what is your rated percentage %

  • H. Did you serve in Vietnam between January 9, 1962 and May 7, 1975?
  • I. Were you exposed to radiation while in the Military?
  • J. Did you receive nose and throat radium treatments while in the military?
  • K. Did you serve on active duty at least 30 days at Camp Lejeune from August 1, 1953 through December 31, 1987?

  • Section III - Insurance Information

  • 5. Are you eligible of Medicaid?
  • 6A. Are you enrolled in Medicare Hospital Insurance Part A?
  • 6B. Effective Date
     - -

  • Section IV - Dependent Information

  • 1B. Spouse's Date of Birth (MM/DD/YYYY)
     / /
  • 1C. Spouse Self-Identified Gender Identity
  • 1D. Date of Marriage (MM/DD/YYYY)
     / /
  • 3. If your spouse or dependent child did not live with you last year, did you provide support?
  • Do you have a dependent child currently living with you?
  • 2A. Child's Date of Birth (MM/DD/YYYY)
     / /
  • 2C. Date Child Became Your Dependent (MM/DD/YYYY)
     / /
  • 2D. Child's Relationship to you (Check one)
  • 2E. Was child permanently and totally disabled before the age of 18?
  • 2F. If child is between 18 and 23 years of age, did child attend school last calendar year?

  • Section V - Employment Information

  • 1A. Veteran's Employment Status (Check one)
  • 1B. Date of Retirement
     / /

  • 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

  • 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

  •    

  • DATE
     / /
  • Should be Empty: