10-1394 Application For Adaptive Equipment Motor Vehicle

OMB Number: 2900-0188
Estimated Burden: 15 minutes
Expiration Date: XX/XX/XXXX

APPLICATION FOR ADAPTIVE EQUIPMENT
AUTOMOBILE OR OTHER CONVEYENCE
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be
used to determine your eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment, and identify your medical
records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed
outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is
voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to
furnish the information will have no adverse effect on any other benefits to which you may be entitled.
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 15 minutes.
This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
PART I - (To be completed by Veteran or Servicemember, if more space is needed, attach a separate sheet and identify by item number.)
1. NAME OF VETERAN/SERVICE MEMBER (LAST NAME, FIRST NAME, MI)

2. VETERAN/SERIVCEMEMBER SSN

3. MAILING ADDRESS OF VETERAN/SERVICEMEMBER (No. and Street or Rural Route, City or P.O., State and Zip Code)

4. TELEPHONE NUMBER (INCLUDE AREA
CODE)

6. DATE OF VA CERTIFICATE OF ELIGIBILITY

5. DO YOU HAVE A VALID DRIVER'S LICENSE OR PERMIT IN POSSESSION?
YES

(VA 21-4502) (If available, please attach a copy to this

application)

NO

7. LIST SERVICE CONNECTED DISABILITY(IES) REQUIRING USE OF AUTOMOBILE ADAPTIVE EQUIPMENT

8. VEHICLE(S) FOR WHICH ADAPTIVE EQUIPMENT IS REQUIRED
8A. TYPE OF
AUTOMOBILE OR
CONVEYANCE
(e.g., automobile, station
wagon, van, truck, SUV,
other)

8B. PURCHASED WITH
VA AUTOMOBILE
ALLOWANCE? (Y/N)
NOTE: If yes,
reimbursement for
non-standard
equipment may be
approved.

8C. YEAR

8D. MAKE

8E. MODEL

8F. VEHICLE IDENTIFICATION NUMBER

8G. DATE ADAPTIVE
EQUIPMENT PROVIDED
(mm/dd/yyyy)
NOTE: Complete if
applying for repairs,
replacement or
reinstallations

9. VEHICLE(S) FOR WHICH ADAPTIVE EQUIPMENT WAS PROVIDED OR ALREADY ON RECORD 38 USC§3903(c)(1)(3)
9A.TYPE OF
AUTOMOBILE OR
CONVEYANCE
(e.g., automobile, station
wagon, van, truck, SUV,
other)

9B. PURCHASED WITH
VA AUTOMOBILE
ALLOWANCE? (Y/N)

9C. YEAR

9D. MAKE

9E. MODEL

9G. DATE ADAPTIVE

9F. VEHICLE IDENTIFICATION NUMBER EQUIPMENT PROVIDED
(mm/dd/yyyy)

I have provided an itemized estimate of charges to include installation fees for automobile adaptive equipment, age of automobile adaptive equipment and submitted the
estimated cost to my local VHA Prosthetic and Sensory Aids Service for authorization. I understand that VA is not responsible for any reimbursement or payment until Part II
has been completed.
10. SIGNATURE OF VETERAN/SERVICEMEMBER

14. DATE (mm/dd/yyyy)

RETURN TO YOUR PROSTHETIC REPRESENTATIVE
VA FORM
JAN 2015

10-1394

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PART II - ELIGIBILITY AND AUTHORIZATION FOR REIMBURSMENT OR PAYMENT
(To be completed by Prosthetic Representative)
ITEMS AUTHORIZED

AMOUNT TO BE PAID

ITEMS AUTHORIZED

AMOUNT TO BE PAID

REIMBURSEMENT AND/OR PAYMENT TO:
VETERAN/SERVICEMEMBER (For all standard items) AMOUNT AUTHORIZED TO BE REIMBURSED OR PAID
QUALIFIED MODIFIER (For all non standard and customized items) AMOUNT AUTHORIZED TO BE REIMBURESED OR PAID
Provide full name and address where payment should be made:

$
$

NOT ENTITLED FOR REASONS:

AUTHORIZING OFFICIAL NAME AND TITLE (Please Print)

NAME AND ADDRESS OF VA FACILITY

SIGNATURE OF AUTHORIZING OFFICIAL

DATE (mm/dd/yyyy)

PART III - Certification of Receipt
I certify that I have received and satisfied with
the items and services authorized in Part II.

SIGNATURE OF VETERAN/SERVICEMEMBER

DATE (mm/dd/yyyy)

I certify that I meet the definition of modifier and my registration is current in the National Modifiers Database with the National Highway and
Transportation Safety Administration (NHTSA).
I certify the items or services authorized in Part II of this form are compliant with all applicable NHTSA and Federal Motor Vehicle Safety Standards (49
CFR 595.6), state and local authorities. Attached to this form is a certified invoice to include itemized prices including labor/installation charges not to
exceed the amount in the Automobile Adaptive Equipment Schedule.
SIGNATURE OF QUALIFIED MODIFIER

DATE (mm/dd/yyyy)

INSTRUCTIONS TO VETERAN/SERVICEMEMBER & QUALIFIED MODIFIER
1. The Veteran/Servicemember should contact their local Prosthetics Service at the local VA medical center prior to any purchase, installation, or
repair of AAE.
2. The Veteran/Servicemember will complete all items in Part I of this form and sign Item #10.
3. Once Part I and Item #10 has been signed, the Veteran/Servicemember will provide Prosthetics Service a copy of the itemized estimate before
Part II is completed.
4. After Part II is completed and the Veteran/Service member will be notified by Prosthetics on their eligibility for AAE items and services in Part II.
5. After Part II has been approved, the Veteran/Servicemember will provide the original of this form to the qualified modifier that may provide AAE
equipment and/or perform services as authorized for the specified amount in Part II on the form.
6. After AAE items and services have been completed, the Veteran/Servicemember will sign Part III. For standard equipment, only the Veteran/
Servicemember is required to certify Part III. For qualified modifier, requesting reimbursement of payment, all of part III must be certified.

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VA FORM
JAN 2015

10-1394