Form VA Form 10-10CG VA Form 10-10CG Application for Comprehensive Assistance for Family Care

INSTRUCTIONS FOR COMPLETING APPLICATION FOR THE PROGRAM
OF COMPREHENSIVE ASSISTANCE FOR FAMILY CAREGIVERS
Please Read Before You Start...
What is VA Form 10-10CG used for?
To apply for VA's Program of Comprehensive Assistance for Family Caregivers. VA will use the information on this form to assist in
determining your eligibility. An eligible Veteran may appoint one (1) Primary Family Caregiver and up to two (2) Secondary Family
Caregivers. On average, it will take 15 minutes to complete the application including the time it will take you to read instructions, gather the
necessary facts and fill out the form. Each time a new caregiver is appointed a new Form 10-10CG is required.
Where can I get help filling out the form and answers to questions?
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). Access
VA's website at http://www.va.gov and select "Contact Us". Locate and contact the Caregiver Support Coordinator at your nearest VA health
care facility. A Caregiver Support Coordinator locator is available at http://www.caregiver.va.gov/. Contact the National Caregiver Support
Line by calling 1-855-260-3274 or a Veterans Service Organization.

Definitions of terms used in this form

Caregiver Support Coordinator (CSC):
A VA clinical professional who connects caregivers of Veterans with VA and community resources offering supportive programs and
services. Caregiver Support Coordinators are located at every VA medical center and are designated specialists in caregiving issues.
Family Member:
A member of the Veteran's or Servicemember's family (including a parent, a spouse, a son or daughter, a step-family member, and an
extended family member), or an individual who lives full-time with the Veteran or Servicemember, or will do so if approved as a Primary or
Secondary Family Caregiver.
Injured in the Line of Duty (LOD):
An injury incurred or aggravated during active military service, unless the injury resulted from the Veteran's or Servicemember's willful
misconduct or abuse of alcohol or drugs, or it occurred while that individual was avoiding duty by desertion, or absent without leave which
materially interfered with the performance of military duty.
Power of Attorney (POA):
A Power of Attorney is an authorization for someone to act on the Veteran's or Servicemember's behalf when completing this form.
Primary Family Caregiver:
A Family Member (defined herein), who is designated as a "primary provider of personal care services" under 38 U.S.C. §1720G(a)(7)(A);
and who meets the requirements of 38 C.F.R. §71.25.
Representative:
Refers to a Veteran's or Servicemember's court-appointed legal guardian or special guardian, Durable POA for Health Care, or other
designated health care agent. Attach POA/Representation documents to the application if applicable.
Secondary Family Caregiver:
An individual approved as a "provider of personal care services" for the eligible Veteran under 38 U.S.C. §1720G(a)(7)(A); meets the
requirements of 38 C.F.R. §71.25; and generally serves as a back-up to the Primary Family Caregiver.
Stipend:
An allowance given to a Primary Family Caregiver in acknowledgement of the sacrifices they are making to care for a seriously injured
eligible Veteran (as defined in 38 C.F.R §71.15).

Who should apply for VA's Program of Comprehensive Assistance for Family Caregivers?
IF THE INDIVIDUAL IS A:
Veteran
or
Servicemember
who has been issued a
date of medical discharge
from the military

VA FORM
JAN 2020

10-10CG

AND
AND
Requires at least 6 months
Requires on-going supervision or assistance
with performing basic functions of everyday
of continuous caregiver
life due to a serious injury or mental disorder
support
(including traumatic brain injury, psychological
trauma or other mental disorder) incurred or
aggravated in the line of duty on or after
September 11, 2001

THEN
The Veteran or Servicemember
may meet the criteria for VA's
Program of Comprehensive
Assistance for Family Caregivers.
Complete this form to apply

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VA MISSION Act of 2018 expands eligibility to Family Caregivers of eligible Veterans of all eras and VA will announce when applications are
able to be considered under the expanded eligibility. Until such announcement is made, eligibility is limited to Veterans and Servicemembers
who incurred or aggravated a serious injury in the line of duty on or after September 11, 2001.
Veterans and Servicemembers who do not meet the criteria for VA's Program of Comprehensive Assistance for Family Caregivers may be
eligible for VA health benefits and other caregiver support services. To find out about other caregiver support services, contact the Caregiver
Support Coordinator (CSC) at your local VA health care facility. To obtain the name of your local CSC, contact the Caregiver Support Line at
1-855-260-3274 or go to http://www.caregiver.va.gov/. and use the Find Your Local Caregiver Support Coordinator option.

Getting Started:
Answer all questions on the form. If you are not enrolled in VA's health care system or are currently Active Duty undergoing medical
discharge, submit VA Form 10-10EZ "Application for Health Benefits" with this form. Enrolled Veterans may submit VA Form 10-10EZR
"Health Benefits Renewal Form" with their completed VA Form 10-10CG to provide information updates. Do NOT exceed the designated
spaces (e.g., do NOT extend Last Name into First Name area). The Veteran's or Servicemember's representative or POA may complete this
application; however the POA/Representation documents must be provided with this application.
SECTION I --VETERAN AND SERVICEMEMBER GENERAL INFORMATION
Directions for Section I --Veteran/Servicemember, representative or POA, please answer all questions, sign and date.
SECTION II --PRIMARY FAMILY CAREGIVER GENERAL INFORMATION
Directions for Section II --Primary Family Caregiver applicant, please answer all questions, including health insurance information, sign and
date.
SECTION III --SECONDARY FAMILY CAREGIVER(S) GENERAL INFORMATION
Directions for Section III --Secondary Family Caregiver applicant(s) please answer all questions, sign, and date. A Veteran/Servicemember
may appoint up to two Secondary Family Caregivers but this is not required. If a Veteran/Servicemenber elects to appoint a Secondary
Family Caregiver at a later time, Sections I and III in a new 10-10CG must be completed.

Submitting your application:
1. Read Paperwork Reduction and Privacy Act Information.
2. The Veteran or an individual delegated as the Veteran's representative/POA must sign and date the form.
3. Attach POA/Representation documents to the application, if applicable.
4. Submit the completed form to the Health Eligibility Center using the address below or submit the form to your local VA Medical Center
Caregiver Support Coordinator. If you do not know the name and address of your local Caregiver Support Coordinator(s) you can go
to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator feature. You may also contact the Caregiver
Support Line at 1-855-260-3274.
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Ste 200
Atlanta, GA 30329-1647
If you prefer to present or take this application in person, you may hand carry the printed and signed application to your local VA Medical
Center Caregiver Support Coordinator (CSC). To obtain the name of your local CSC, contact the Caregiver Support Line at 1-855-260-3274
or go to http://www.caregiver.va.gov and use the Find Your Local Caregiver Support Coordinator option.

THE PAPERWORK REDUCTION ACT
This information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection
of information is estimated to average 15 minutes per response, including the time to read instructions, gather necessary data, and fill out the form. Respondents should be aware
that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number. Completion of this form is mandatory for eligible Veterans who wish to participate in the Caregiver Program.

PRIVACY ACT INFORMATION
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 101, 5303A, 1705, 1710, 1720B, and 1720G, 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, “Patient Medical Records -VA” (24VA19), “Enrollment and Eligibility Records --VA” (147VA16), and “Health Administration Center Civilian Health and Medical program Records--VA” (54VA17) and
in accordance with the VHA Notice of Privacy Practices. Providing the requested information, including Social Security Number, 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 10-10CG, JAN 2020

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Estimated Burden: 15 min.
OMB Number 2900-0768
Expiration Date: 04/30/2018

APPLICATION FOR COMPREHENSIVE ASSISTANCE FOR FAMILY
CAREGIVERS PROGRAM
Attention: Complete the application (print or typewritten only) and mail it to Program of Comprehensive Assistance for Family Caregivers, Health
Eligibility Center, 2957 Clairmont Road NE, Ste 200, Atlanta, GA 30329-1647. You may also, mail or hand carry it to your local VA Medical Center Caregiver
Support Coordinator (CSC) for processing. At this time, VA does not provide the Program of Comprehensive Assistance for Family Caregivers to Veterans/
Service members and Family Caregivers living in a foreign country.

SECTION I - VETERAN/SERVICEMEMBER
Last Name

First Name

Social Security Number/Tax Identification Number

Middle Name
Date of Birth (MM/DD/YYYY)

Sex
Male

Unknown

Female

Current Street Address
City

State

Zip Code

Primary Telephone Number (Including Area Code)

Alternate Telephone Number (Including Area Code)

Email Address
Name of VA medical center or clinic where you receive or plan to receive health care services:
Name of facility where you last received medical treatment:

Hospital

Clinic

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that I give consent to the individual(s) named in this application to perform personal care services for me upon being approved as
Primary and/or Secondary Caregiver(s) in the Program of Comprehensive Assistance for Family Caregivers. I certify that the information
above is correct and true to the best of my knowledge and belief.

Date

Veteran/Servicemember/Representative/POA Signature

SECTION II - PRIMARY FAMILY CAREGIVER
Last Name

First Name

Middle Name
Date of Birth (MM/DD/YYYY)

Social Security Number/Tax Identification Number

Sex
Male

Female

Unknown

Current Street Address
City

State

Zip Code

Primary Telephone Number (Including Area Code)

Alternate Telephone Number (Including Area Code)

Email Address

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)

Currently enrolled in Medicaid?

Yes

No

Currently enrolled in Medicare?

Yes

No

Currently enrolled in Tricare?

Yes

No

Currently enrolled in CHAMPVA?

Yes

No

Other Health Insurance?

Yes

No

Name:

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

VA FORM 10-10CG, JAN 2020

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SECTION II - PRIMARY FAMILY CAREGIVER (continued)
I certify that I am at least 18 years of age.
Check one:
I certify that I am a family member of the Veteran or Servicemember named in this application.
OR

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
I agree to perform personal care services as the Primary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran or Veteran’s surrogate may initiate my revocation as a Primary Family Caregiver at any time and that the VA may
immediately revoke this designation if I fail to comply with the Program requirements for continued participation in the Program.
I understand that participation in the Program of Comprehensive Assistance for Family Caregivers does not create an employment
relationship with the Department of Veterans Affairs.
I certify that the information above is correct and true to the best of my knowledge and belief.

Primary Family Caregiver Signature

Date

SECTION III - SECONDARY FAMILY CAREGIVER (Complete if appointing a Secondary Caregiver)
Last Name

First Name

Social Security Number/Tax Identification Number

Middle Name
Date of Birth (MM/DD/YYYY)

Sex
Male

Female

Unknown

Current Street Address
City

State

Zip Code

Primary Telephone Number (Including Area Code)

Alternate Telephone Number (Including Area Code)

Email Address

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that I am at least 18 years of age.
Check one:
I certify that I am a family member of the Veteran or Servicemember named in this application.
OR

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran or Veteran’s surrogate may initiate my revocation as a Secondary Family Caregiver at any time and that the VA
may immediately revoke this designation if I fail to comply with the Program requirements for continued participation in the Program.
I certify that the information above is correct and true to the best of my knowledge and belief.

Secondary Caregiver Signature

VA FORM 10-10CG, JAN 2020

Date

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Last Name

SECTION III - SECONDARY FAMILY CAREGIVER (Continued)
(Complete if appointing more than one Secondary Caregiver)
First Name

Social Security Number/Tax Identification Number

Middle Name

Date of Birth (MM/DD/YYYY)

Sex
Male

Female

Unknown

Current Street Address
City

State

Zip Code

Primary Telephone Number (Including Area Code)

Alternate Telephone Number (Including Area Code)

Email Address

Relationship to Veteran (e.g., Spouse, Parent, Child, Other)

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting false, fictitious or fraudulent statements or claims

I certify that I am at least 18 years of age.
Check one:
I certify that I am a family member of the Veteran or Servicemember named in this application.
OR

I certify I am not a family member and I reside with the Veteran or Servicemember or will do so upon approval.
I agree to perform personal care services as the Secondary Family Caregiver for the Veteran or Servicemember named on this application.
I understand that the Veteran or Veteran’s surrogate may initiate my revocation as a Secondary Family Caregiver at any time and that the VA
may immediately revoke this designation if I fail to comply with the Program requirements for continued participation in the Program.
I certify that the information above is correct and true to the best of my knowledge and belief.

Secondary Caregiver Signature

VA FORM 10-10CG, JAN 2020

Date

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