APPLICATION FOR HEALTH BENEFITS, Continued
VETERAN'S NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
SECTION II - INSURANCE INFORMATION (Use a separate sheet for additional information) 1. ARE YOU COVERED BY HEALTH INSURANCE? (Including coverage 2. HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
through a spouse or another person)
3. NAME OF POLICY HOLDER
4. POLICY NUMBER
5. GROUP CODE
6. ARE YOU ELIGIBLE FOR MEDICAID?
ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART B?
7A. EFFECTIVE DATE
8A. EFFECTIVE DATE
9. NAME EXACTLY AS IT APPEARS ON YOUR MEDICARE CARD
10. MEDICARE CLAIM NUMBER
11. IS NEED FOR CARE DUE TO ON THE JOB INJURY? (Check one)
12. IS NEED FOR CARE DUE TO ACCIDENT? (Check One)
SECTION III - EMPLOYMENT INFORMATION
1. VETERAN'S EMPLOYMENT STATUS (Check one)
1A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
If employed or retired, complete item 1A
2. SPOUSE'S EMPLOYMENT STATUS (Check one)
Date of retirement
2A. COMPANY NAME, ADDRESS AND TELEPHONE NUMBER
If employed or retired, complete item 2A
Date of retirement (mm/dd/yyyy)
SECTION IV - MILITARY SERVICE INFORMATION
1. LAST BRANCH OF SERVICE
1A. LAST ENTRY DATE
1B. LAST DISCHARGE DATE
1C. DISCHARGE TYPE
1D. MILITARY SERVICE NUMBER
CHECK YES OR NO
ARE YOU A PURPLE HEART AWARD RECIPIENT?
ARE YOU A FORMER PRISONER OF WAR?
DO YOU HAVE A VA SERVICE-CONNECTED RATING?
C1. IF YES, WHAT IS YOUR RATED PERCENTAGE?
D. DID YOU SERVE IN COMBAT AFTER 11/11/1998?
E. WAS YOUR DISCHARGE FROM MILITARY FOR A DISABILITY INCURRED OR AGGRAVATED IN THE LINE OF DUTY?
E1. ARE YOU RECEIVING DISABILITY RETIREMENT PAY INSTEAD OF VA COMPENSATION?
F. DO YOU NEED CARE OF CONDITIONS POTENTIALLY RELATED TO SERVICE IN SW ASIA DURING THE GULF WAR?
G. WERE YOU EXPOSED TO AGENT ORANGE WHILE SERVING IN VIETNAM?
WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?
DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS
WHILE IN THE MILITARY?
J. DO YOU HAVE A SPINAL CORD INJURY?
SECTION V - PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 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 it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 45 minutes. This includes the time 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 information on this form under 38 U.S.C. Sections 1705, 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. Information you supply may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits. Failure to furnish the information will not 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 VA benefits. VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.
VA FORM JUL 2008