Va Form 10 10Hs PDF Details

In today's increasingly complex healthcare landscape, the financial burden of medical expenses can be particularly challenging for veterans. Recognizing this, the Department of Veterans Affairs (VA) provides an essential tool through the VA 10-10HS form, officially known as the Request for Hardship Determination. This form serves a crucial role for veterans facing substantial financial challenges, acting as a gateway to potential relief from hospital and medical care copayments. Specifically designed to assess whether a veteran's projected annual income will fall significantly below the VA means test threshold—due to factors like a decrease in income or an increase in allowable deductible expenses—the form's completion can lead to enrollment in Priority Group 5, ensuring vital healthcare benefits without the stress of copayment charges. This determination is dependent on a thorough evaluation of the veteran's current financial situation, incorporating factors such as household income, expenses, and changes in familial or living circumstances. With an estimated completion time of only 15 minutes, the VA 10-10HS form emphasizes efficiency and accessibility. Furthermore, it underscores the VA's commitment to privacy and data security, adhering to the Paperwork Reduction Act and various privacy regulations. It also signifies the broader efforts to support veterans in maintaining their health and wellbeing without the added strain of financial hardship. The stringent penalties for false statements ensure the integrity of the process, safeguarding this valuable resource for those veterans genuinely in need.

QuestionAnswer
Form NameVa Form 10 10Hs
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesva granted exemption form, form 10 10hs, hardship form, va form 10 10hs form

Form Preview Example

OMB Approved No. 2900-0091

Estimated Burden Avg. 15 min

Expiration Date: 06/30/2024

REQUEST FOR HARDSHIP DETERMINATION

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. Veterans determined to have a financial hardship will be exempt from payment of hospital and medical care copays and qualify for enrollment in Priority Group 5, unless otherwise eligible for enrollment in a higher priority, from the date of request through the last day of the same calendar year.

GENERAL INFORMATION

1.VETERAN'S NAME (Last, First, Middle Name)

2. SOCIAL SECURITY NUMBER

3. PERMANENT ADDRESS (STREET)

3A. CITY

3B. STATE

3C. ZIP CODE (9 digits)

3D. COUNTY

3E. HOME TELEPHONE NUMBER (Include area code)

3F. CELLULAR TELEPHONE NUMBER (Include area code)

REASON/CIRCUMSTANCE FOR HARDSHIP REQUEST (Check all that apply and add explanation as needed below)

Reduction of household income

Paid out of pocket medical expenses

Increase in number of dependents

 

Moved to a higher cost of living area

 

Other - explain below

Provide explanation, as needed, and attach documentation supporting your request.

PROJECTED HOUSEHOLD INCOME AND DEDUCTIBLE EXPENSES FOR THE CURRENT CALENDAR YEAR

Veteran

Spouse

Children

1.HOUSEHOLD INCOME (Includes gross income from employment, net income from farm or ranch, and other income amounts.)

2.DEDUCTIBLE EXPENSES (Includes non-reimbursed medical expenses paid by you or your spouse, funeral and burial expenses and expenses for the veteran's education.)

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 15 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.

SIGNATURE AND DATE

VETERAN'S SIGNATURE

DATE (MM/DD/YYYY)

PENALTY: The law provides severe penalties which include fine or imprisonment or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.

VA FORM

10-10HS

HEC

Page 1

JUL 2021

HARDSHIP DETERMINATION (to be completed by VA)

Hardship Granted: (check one)

YES - Hardship is granted

Note: The exemption is effective from the date the Veteran submitted the request until the last day of the calendar year in which the request was made.

NO. State reason not granted in comments.

Date Veteran's electronic record updated in VA's information system (MM/DD/YYYY):

VHA STAFF SIGNATURE

DATE (MM/DD/YYYY)

COMMENTS

Document and/or attach any pertinent information impacting on the final decision.

VETERAN NOTIFICATION

Date Veteran notified (MM/DD/YYYY):

If hardship not granted, provide Veteran with VA Form 10-0998, Your Rights To Seek Further Review Of Our Health Care Benefits Decision.

VA FORM 10-10HS, JUL 2021

HEC Page 2

How to Edit Va Form 10 10Hs Online for Free

Dealing with PDF forms online is certainly simple with our PDF editor. You can fill out va gov vaforms medical pdf vha 10 10hs pdf here and use many other options we provide. To keep our tool on the cutting edge of practicality, we strive to implement user-driven capabilities and improvements on a regular basis. We're always grateful for any suggestions - join us in revolutionizing how we work with PDF forms. In case you are seeking to get going, here is what it's going to take:

Step 1: Just hit the "Get Form Button" at the top of this site to start up our pdf editing tool. Here you'll find everything that is necessary to fill out your file.

Step 2: The tool will give you the ability to change the majority of PDF files in various ways. Enhance it by adding any text, correct what is already in the PDF, and add a signature - all within several mouse clicks!

This form will require particular details to be typed in, hence make sure to take your time to enter what's required:

1. The va gov vaforms medical pdf vha 10 10hs pdf involves particular information to be typed in. Make certain the following blank fields are filled out:

Completing section 1 of va form 10 10hs form

2. Once your current task is complete, take the next step – fill out all of these fields - DEDUCTIBLE EXPENSES Includes, expenses paid by you or your, PAPERWORK REDUCTION ACT AND, The Paperwork Reduction Act of, VETERANS SIGNATURE, DATE MMDDYYYY, SIGNATURE AND DATE, and PENALTY The law provides severe with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

VETERANS SIGNATURE, expenses paid by you or your, and DATE MMDDYYYY of va form 10 10hs form

3. In this specific stage, check out YES Hardship is granted Note The, NO State reason not granted in, Date Veterans electronic record, VHA STAFF SIGNATURE, DATE MMDDYYYY, Document andor attach any, and COMMENTS. These have to be taken care of with greatest attention to detail.

Step no. 3 in completing va form 10 10hs form

Many people often make errors while completing YES Hardship is granted Note The in this area. Ensure you revise whatever you enter here.

4. All set to start working on this next part! Here you will get all of these Date Veteran notified MMDDYYYY, VETERAN NOTIFICATION, If hardship not granted provide, VA FORM HS JUL, HEC, and Page fields to fill out.

Stage number 4 for completing va form 10 10hs form

Step 3: Spell-check the details you have typed into the blanks and then press the "Done" button. Grab your va gov vaforms medical pdf vha 10 10hs pdf the instant you sign up for a 7-day free trial. Instantly get access to the form from your personal account, along with any modifications and changes all preserved! FormsPal ensures your data privacy by having a protected method that never records or distributes any personal information used in the file. Be confident knowing your paperwork are kept confidential whenever you work with our service!