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Continued .Section V- Employment Information: Veterans Employment Status Date of Retirement Company Name Company Address Company Phone NumberSection VI- Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent ChildrenReport: Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages, bonuses,tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay your householdexpenses. Net income from your farm, ranch, property, or business. Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability income,compensation benefits such as VA disability, unemployment, Workers and black lung, cash gifts, interest and dividends, including taxexempt earnings and distributions from Individual Retirement Accounts (IRAs) or annuities.Do Not Report:Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI) and need-based paymentsfrom a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on Individual RetirementAccounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement for casualty loss; loans; RadiationCompensation Exposure Act payments; Agent Orange settlement payments; Alaska Native Claims Settlement Acts Income, payments tofoster parent; amounts in joint accounts in banks and similar institutions acquired by reason of death of the other joint owner; Japaneseancestry restitution under Public Law 100-383; cash surrender value of life insurance; lump-sum proceeds of life insurance policy on aVeteran; and payments received under the Medicare transitional assistance program.Section VII - Previous Calendar Year Deductible ExpensesReport non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, drugs, eyeglasses,Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom you have a legalor moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other sources. Report lastillness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).Section VIII - Consent to Copays and to Receive CommunicationsBy submitting this application, you are agreeing to pay the applicable VA copayments for care or services (including urgent care) asrequired by law. You also agree to receive communications from VA to your supplied email, home phone number, or mobilenumber. However, providing your email, home phone number, or mobile number is voluntary.Submitting Your Application1. You or an individual to whom you have delegated your Power of Attorney must sign and date the form. If you sign with an "X", 2people you know must witness you as you sign. They must sign the form and print their names. If the form is not signed and datedappropriately, VA will return it for you to complete.2. Attach any continuation sheets, a copy of supporting materials and your Power of Attorney documents to your application.Where do I send my application?Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section3507 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 unless itdisplays a valid 0MB number. We anticipate that the time expended by all individuals who must complete this fo11n will average 30 minutes. This includes thetime it will take to read instructions, gather the necessary facts and fill out the form.Privacy Act Information: VA is asking you to provide the info1111ation on this fonn under 38 U.S.C. Sections 1705,1710, 1712, and 1722 in order for VA todetermine your eligibility for medical benefits. Information you supply may be verified from initial submission f01ward through a computer-matching program.VA may disclose the infonnation that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in thePrivacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested info11nation is voluntary, but if anyor all of the requested infonnation is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information willnot have any effect on any other benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VAbenefits. VA may also use this information to identify Veterans and persons claiming or receiving VA benefits and their records, and for other purposesauthorized or required by law.VA FORM 10-10EZ, JUL 20218

0MB Control No. 2900-009 IEstimated Burden Avg. 30 min.Expiration Date: 06/30/2024VA DATE STAMP(For VHA Use 011/y)Department of Veterans AffairsAPPLICATION FOR HEALTH BENEFITSSECTION 1- GENERAL INFORMATIONFederal law provides criminal penalties, including a fine and/or imprisonment for up to 5 years, for concealing amaterial fact or making a materially false statement. (See 18 U.S.C I 00 I)TYPE OF BENEFIT(S) APPLYING FOR00ENROLLMENT - VA Medical Benefits Package (Veteran meets and agrees to the enrollment eligibility criteria specified at 38 CFR 17.36)REGISTRATION - VA Health Services (Veterans meets the "Enrollment not required" eligibility criteria specified at 38 CFR 17.37)1A.VETERAN'S NAME (Last, First, Middle Name)3A. BIRTH SEX MALEFEMALE18. PREFERRED NAME38. SELF-IDENTIFIED GENDER IDENTITY MALE4. ARE YOU SPANISH,HISPANIC.OR LATINO? /TRANSWOMAN/MALE-TO-FEMALEYESNOCHOOSE NOT TO ANSWER7A. DATE OF BIRTH (mmlddlyyyy)6. SOCIAL SECURITY NO.9A. MAILING ADDRESS (Street)9G. MOBILE TELEPHONE NO. (optional)MARRIED 108. CITY NEVER MARRIED12A. NEXT OF KIN NAMEASIANWHITENATIVE HAWAIIAN OR OTHER PACIFIC ISLANDERCHOOSE NOT TO ANSWER8. RELIGION9D. ZIP CODE9E.COUNTY9H. E-MAIL ADDRESS (optional)SEPARATED10C. STATE WIDOWED 10D. ZIP CODE10E.COUNTYDIVORCED12C. NEXT OF KIN RELATIONSHIP12E. NEXT OF KIN WORK TELEPHONE NO.(Include Area Code)(Include Area Code) AMERICAN INDIAN OR ALASKA NATIVEBLACK OR AFRICAN AMERICAN128. NEXT OF KIN ADDRESS12D. NEXT OF KIN TELEPHONE NO. Information is required for statistical pwposes only.)(Include Area Code)10A. HOME ADDRESS (Street) 9C.STATE(Include Area Code)11. CURRENT MARTIAL STATUS5. WHAT IS YOUR RACE? (You may check more than one.78. PLACE OF BIRTH (City and State)98. CITY9F. HOME TELEPHONE NO. (optional)2. MOTHER'S MAIDEN NAME13. DESIGNEE - INDIVIDUAL TO RECEIVE POSSESSION OF YOUR PERSONALPROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOURDEPARTURE OR AT THE TIME OF DEATH (Note: This does not constitute awill or transfer of title)14. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?(for listing of facilities visit www.va.gov/find-locationsJ15. WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRSTAPPOINTMENT? YES NOSECTION 11- MILITARY SERVICE INFORMATION1A. LAST BRANCH OF SERVICE18. LAST ENTRY DATE (mmlddly;yy)1C. FUTURE DISCHARGE DATE (111111/ddlyyJ,y)1E. DISCHARGE TYPE1F. MILITARY SERVICE NUMBER2. MILITARY HISTORY (Check yes or no)YESA. 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 AFTER11/11/1998?D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR ADISABILITY INCURRED IN THE LINE OF DUTY?E.ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OFVA COMPENSATION?F. DID YOU SERVE IN SW ASIA DURING THE GULF WAR BETWEENAUGUST 2, 1990 AND NOVEMBER 11, 1998?VA FORM 10-10EZ, JUL 202110. LAST DISCHARGE DATE (mmlddlyyyJj NO 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, 1962AND MAY 7, 1975?I. WERE YOU EXPOSED TO RADIATION WHILE IN THEMILITARY?J. DID YOU RECEIVE NOSE AND THROAT RADIUMTREATMENTS WHILE IN THE MILITARY?K. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS ATCAMP LEJEUNE FROM AUGUST 1, 1953 THROUGHDECEMBER 31, 1987?YESNO PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED9

APPLICATION FOR HEALTH BENEFITSVETERAN'S NAME(Last, First, Middle)SOCIAL SECURITY NUMBERContinued1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coveragethrough spouse or other person)2. NAME OF POLICY HOLDER3. POLICY NUMBER5. ARE YOU ELIGIBLE FOR MEDICAID?6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A? (Federal health insurance for low income adults)1. SPOUSE'S NAME(Last, First, Middle Name) 000NOMiddle Name)2A. CHILD'S DATE OF BIRTH (,nm!dd!yyyy) 1C. SELF-IDENTIFIED GENDER IDENTITYMALE 2. CHILD'S NAME (Last, First,1A. SPOUSE'S SOCIAL SECURITY NUMBER1B. SPOUSE'S DATE OFBIRTH (mm!dd vyyy)YES4. GROUP CODE2B. CHILD'S SOCIAL SECURITY NO.2C. DATE CHILD BECAME YOUR LE-TO-MALE 2D. CHILD'S RELATIONSHIP TO R (Check one)STEPSONSTEPDAUGHTERCHOOSE NOT TO ANSWER--------. ------------------1 2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THEtAGE OF 18?10. DATE OF MARRIAGE (mm/ddlyyyy)1 E. SPOUSE'S ADDRESS AND TELEPHONE NUMBERif differentfrom Veteran's) (Street, City, State, ZIP YES NO2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTENDSCHOOL LAST CALENDAR YEAR? YES NO2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE,VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books,3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LASTYEAR, DID YOU PROVIDE SUPPORT? YESmaterials)NO 1A. VETERAN'S EMPLOYMENT STATUSFULL TIME1C. COMPANY NAME.(Complete ifemployed or retired) (Check one).PART TIMENOT EMPLOYED1B. DATE OF RETIREMENT1E. COMPANY PHONE NUMBER1D. COMPANY ADDRESS2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS3. LIST OTHER INCOME AMOUNTS (e.g., Social Security,pension, interest, dividends) EXCLUDING WELFARE.(Complete ifemployed or retired)(Include area code}(Complete ifemployed or retired - Street, City, State, ZIP)1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips,etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY POUSECHILD 1 (e.g., payments for doctors, dentists, medications,Medicare, health insurance, hospital and nursing home) VA w/11 calculate a deductible and the net medical expenses you may claim.1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR SPOUSE 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 VJ.) 3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSESfees, materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.(e.g., tuition, books, VA FORM 10-10EZ, JUL 202110

APPLICATION FOR HEAL TH BENEFITSVETERAN'S NAME (Last, First, Middle)SOCIAL SECURITY NUMBERContinuedI understand that pursuant 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 herebyauthorize 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 thecharges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person orentity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit orprejudice my right to recover 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 beentitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessaryand 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 partyor administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verifymy claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim.ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE VETERAN.SIGNATURE OF APPLICANT(Sign in ink)DATE (mmlddlyyyy)VA FORM 10-10EZ, JUL202111

VETERAN BENEFITS DOCUMENTATIONThe following documents (if applicable) are required for submission of claimsFor Veterans Benefits to the U.S. Department of Veterans AffairsDOCUMENTAttachedNot AvailableMilitary Discharge (DD-214 or Discharge Papers)Monthly IncomeMarriage LicenseSpouse Death CertificateDivorce DecreeBirth Certificate (Dependents Age 0-17)Post-High School Enrollment Verification (Dependents Age 18-23)Medical Insurance Verification(Copy of Insurance Cards)Is the Veteran enrolled in a VA health care program at any VA medical center? YesIf so, which?NoList the social security numbers for the applicant’s spouse (if applicable) and all minor children for whom theapplicant is financially responsible:Full Name of Spouse:Date of BirthSS#Full Name of Dependent (Minor Children Only)Date of BirthSS#SS#SS#SS#SS#Full Name of Dependent (Minor Children Only)Date of BirthFull Name of Dependent (Minor Children Only)Date of BirthFull Name of Dependent (Minor Children Only)Date of BirthFull Name of Dependent (Minor Children Only)Date of BirthApplicant NameDate12

LEGAL PROCEDURE DISCLOSURESA copy of appropriate legal documentation to verify any “yes” responseMUST BE ATTACHED to this application1. Has applicant ever been interdicted (declared incompetent by a Court of law)?YesNo2. Has applicant authorized anyone to act as his/her agent or attorney (power of attorney)?YesNo3. Does applicant have a DO NOT RESUSCITATE (DNR) request?YesNo4. Does applicant have a living will?YesNo5. Does applicant have pending legal charges?YesNoIf yes to any of the above, please give a brief description:I attest that the above information is true and correct to the best of my knowledge.Signature of Applicant/Authorized RepresentativeApplicant NameDateDate13

MONTHLY INCOME VERIFICATIONSOURCEAPPLICANTSPOUSEVA Service-Connected Compensation VA Non-Service Connected Pension Social Security Retirement Dividends and Interest Real Estate All Other Assets TOTAL PLEASE PROVIDE SUPPORTING DOCUMENTATION TO VERIFY THE INCOME NOTED ABOVESome examples are listed below:VA CompensationVA Non-Service CompensationSocial SecurityAward letter, copy of most recent checkAward letter, copy of most recent checkCopy of most recent check, last statement showing monthlyoncome or bank statement records showing most recentdepositRetirementCopy of most recent check, last statement showing monthlyincome or bank statement records showing most recentdepositDividends and InterestCopy of most recent check, last statement showing monthlyincome or bank statement records showing most recentdepositReal EstateCopy of real estate agreement or copy of most recentcanceled rent checkAll Other AssetsCopy of most recent statement of the incomeEvery resident of the facility shall be responsible for payment of the full resident Care and Maintenance fee. The facility’sadministrator may consider waiver of payment of Care and Maintenance fees only for the amount of difference of total incomeof the Veteran and spouse, when applicable, and the total charge for Care and Maintenance.The Care and Maintenance (C&M) fee for the Veteran is currently 2,050.00 per month. The C&M fee for the spouse of aVeteran or a “Gold Star Parent” is 4,500.00 per month. Please note that the C&M rate is not guaranteed and is based on totalcombined household financial resources. The rate is reviewed annually by Federal VA and tends to fluctuate. Every effort willbe made by the facility to communicate any changes to the C&M fee at least 30 days in advance of any change. At the time ofadmission, per Federal VA guidelines, C&M fees will be assessed based on all family income sources. Fees are subject to changewhen there is a change in family income, retroactive to the change. Our facility Veteran Assistance Counselor will assist youin applying for a Federal VA pension and Aid and Attendance (A&A), which is a Federal VA program designed to help reduceany financial burden related to the cost of admission to our facility.DateSignature of Applicant/Authorized RepresentativeDateWitnessApplicant NameDate14

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)Name of ApplicantAddressCityPROVIDER AUTHORIZED TO RELEASE THE PHIDOBSSNStateZipENTITY RECEIVING THE PHINameAddressCityAttention:LA ZipPurpose of this Disclosure: ADMISSION TO VETERANS HOMEPHI AND DATES OF PHI AUTHORIZED FOR USE OR DISCLOSUREDescriptionComplete Health RecordProgress NotesLaboratory TestsX-Ray Tests/Reports/ImagesHistory and Physical ExaminationDischarge SummaryConsultation ReportsItemized Billing StatementDiagnosis and TreatmentImmunization RecordsOtherThe following information will be released:DescriptionAIDS or HIV test resultsAlcohol, drug or substance abuse treatmentPsychiatric or mental care/treatmentOther (specify)Start DateEnd DateI UNDERSTAND THAT:1. I may refuse to sign this authorization, and it is strictly voluntary.2. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on my signing this authorization.3. I may revoke the authorization at any time, in writing, to the provider authorized to release the protected healthinformation, but, if I do, it will not have any effect on any actions taken prior to receiving the revocation.4. I have the right to receive a copy of this form after I sign it.5. A photocopy of this authorization will have the same effect as an original.6. This authorization will automatically expire and be ineffective twelve months after date signed.Signature of PatientSignature of Representative (if necessary)DateDateDatePersonal Representative’s Relationship to PatientApplicant NameDate15

PRIVACY ACT STATEMENT – HEALTH CARE RECORDSTHIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1974 (5USC 552a).THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU.1. AUTHORITY FOR COLLECTION OF INFORMATION, INCLUDING SOCIAL SECURITY NUMBER ANDWHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY. Authority for maintenance of the systemis given under Sections 1102(a), 1819(b)(3)(A), 1819(f), 1919(b)(3)(A) and 1864 of the Social SecurityAct.The system contains information on all residents of long-term care (LTC) facilities that are Medicarecertified or VA beds, including private pay individuals and not limited to Medicare enrollment andentitlement, and Medicare Secondary Payer data containing other party liability insuranceinformation necessary for appropriate Medicare claim payment.Medicare and VA participating LTC facilities are required to conduct comprehensive, accurate,standardized and reproducible assessments of each resident’s functional capacity and healthstatus. To implement this requirement, the facility must obtain information from every resident.This information is also used by the Centers for Medicare & Medicaid Services, Federal VA to ensurethat the facility meets quality standards and provides appropriate care to all residents. 42 CFR§483.20, requires LTC facilities to establish a database, the Minimum Data Set (MDS), of residentassessment information. The MDS data are required to be electronically transmitted to the CMSNational Repository and Federal VA.Because the law requires disclosure of this information to Federal and State sources as discussedabove, a resident does not have a right to refuse consent to these disclosures. These data areprotected under the requirements of the Federal Privacy Act of 1974 and the MDS LTC System ofRecords.2. PRINCIPAL PURPOSES OF THE SYSTEM FOR WHICH INFORMATION IS INTENDED TO BE USED. Theprimary purpose of the system is to aid in the administration of the survey and certification, andpayment to Medicare LTC services which include skilled nursing facilities (SNFs), nursing facilities(NFs) and non-critical access hospitals with a swing bed agreement.Information in this system is also used to study and improve the effectiveness and quality of caregiven in these facilities. This system will only collect the minimum amount of personal datanecessary to achieve the purposes of the MDS, reimbursement, policy and research functions.3. ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM. The information collected will beentered into the LTC MDS System of Records, System No. 09-07-0528.Applicant NameDate16

This system will only disclose the minimum amount of personal data necessary to accomplish thepurposes of disclosure. Information from this system may be disclosed to the following entitiesunder specific circumstances (routine uses), which include:1) To support Agency contractors, consultants, or grante

You may use ANY of the following to request assistance: Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387). Go to www.va.gov/health-care for information about VA health benefits. Contact the Enrollment Coordinator at your local VA health care facility. Contact a National or State Veterans Service Organization.