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OMB Approval No. 2900-0160 Estimated Burden Avg. 30 min. STATE HOME PROGRAM APPLICATION FOR VETERAN CARE MEDICAL CERTIFICATION PART I - ADMINISTRATIVE STATE HOME FACILITY DATE ADMITTED GENDER M F RESIDENT S NAME Last First Middle This is a mandatory field SOCIAL SECURITY NUMBER. Mandatory field RESIDENT S STREET ADDRESS AGE CITY STATE AND ZIP CODE ADVANCED MEDICAL DIRECTIVE DATE OF BIRTH mm/dd/yyyy NO YES PART II - HISTORY AND PHYSICAL Use separa.

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The Request for Hardship Determination form is used to determine whether the veteran's projected income for the current year will be substantially below the VA means test threshold due to a loss of income or increase in allowable deductible expenses.

Please mail or drop off the completed request and VA Form 10-10HS to your local VA Medical Center Enrollment Office. If your gross household income has decreased, you may be eligible for enrollment in a more beneficial Priority Group which may qualify you for copayment exemption.

Use the Health Benefits Update Form (VA Form 10-10EZR) to update your personal, financial, and insurance information after you're enrolled in VA health care.

Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.

If you did not receive a Form 1095-B from VA explaining your health care coverage for each year you are or have been enrolled, call 1-877-222-VETS (8387) Monday through Friday from 8 a.m. until 8 p.m. ET. This form is for your records only and should not be sent to the IRS or returned to VA.

Use VA Form 10-10EZ if you're a Veteran and want to apply for VA health care. You must be enrolled in VA health care to get care at VA health facilities or to have us cover your care at a community care provider (an approved non-VA provider).

Enrolled Veterans can provide or update their insurance information by: Using the online Health Benefits Renewal form (10-10-EZR) at .vets.gov/healthcare/apply/ Calling 1-877-222-VETS (8387) Monday through Friday between 8 a.m. and 8 p.m. ET.

Go to eBenefits.va.gov to find a Veterans Service Officer who can provide free, expert assistance. Gather supporting documents, including your DD-214, service and private medical records, and buddy statements. Initiate your claim at eBenefits.va.gov or call 1-800-827-1000 for assistance.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232