Va Form 10 3542 PDF Details

The VA 10 3542 form serves as a vital document for veterans and beneficiaries seeking reimbursement for travel expenses incurred in relation to medical treatment, examinations, or care related to their service. This form, officially titled "Veteran/Beneficiary Claim for Reimbursement of Travel Expenses," asks for comprehensive details about the claimant, including personal identification, travel information, and specifics about the travel expenses for which reimbursement is sought. It offers a structured pathway for individuals such as veterans, certain caregivers, attendants, donors involved in VA transplant care, and others qualifying under specific conditions, to recover costs associated with travel to and from healthcare facilities. The form not only outlines eligibility criteria—ranging from service connection ratings, pension benefit status, income levels, to situations of financial hardship—but also sets clear instructions for submission, including a 30-day window for filing after travel, requirements for supporting documentation like receipts, and guidelines for electronic funds transfer as a preferred method of payment. Furthermore, it emphasizes the importance of accuracy and honesty in claiming reimbursements, underlining the legal penalties for fraudulent claims. By encompassing details such as the necessary traveler's information, trip specifics, and the requisite certifications and penalties, the VA 10 3542 form embodies a crucial resource for facilitating access to entitled travel benefits, encapsulating the logistical and regulatory framework designed to support veterans and other beneficiaries in their healthcare journeys.

QuestionAnswer
Form NameVa Form 10 3542
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvha 10 3542 fill va form 10 3542

Form Preview Example

OMB Number: 2900-0798

Estimated Burden: 15 minutes

VETERAN/BENEFICIARY CLAIM FOR

REIMBURSEMENT OF TRAVEL EXPENSES

Section A. Traveler's Information

1.a Name of Person Claiming Travel Reimbursement (Last, First, Middle)

1.b Claimant's SSN

1.c Claimant's Date of Birth (mm/dd/yyyy)

2.a

Claimant's status: (check one)

Complete 3.a, 3.b, 3.c and 3.d

if Caregiver, Attendant or Donor is checked.

 

 

Veteran

 

Caregiver

Attendant

Donor

Other

 

(National Caregiver Program)

(Medically authorized by VA)

(VA Transplant Care)

 

 

 

3.a Name of Veteran (Last, First, Middle)

 

3.b Veteran's SSN

 

 

 

 

 

3.c

Veteran's Date of Birth (mm/dd/yyyy)

Section B. Trip Information

1.a I am claiming travel reimbursement from address:

(Street, City, State, Zip)

2.a I am claiming return travel reimbursement to the address in B.1.a above

 

YES

 

NO (if no, provide the Street, City, State, Zip below)

1.b Date Trip Began

1.c

Travel by:

(mm/dd/yyyy)

(e.g., car, train, bus,

 

taxi)

 

 

 

 

2.b Date Trip Ended

2.c

Travel by:

(mm/dd/yyyy)

(e.g., car, train, bus,

 

taxi)

 

 

 

 

3. I am claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, meals.

YES

NO

(If yes, itemize expenses below and provide a receipt for each expense claimed. Use reverse if additional space is required)

 

 

 

 

 

a.

 

 

 

 

 

 

 

b.

 

 

 

 

 

 

 

c.

 

 

 

 

 

 

 

d.

 

 

 

 

 

 

 

e.

 

 

 

 

 

 

 

f.

 

 

 

 

 

 

 

g.

 

 

 

 

 

 

 

h.

 

 

 

 

 

 

4. Treating Facility Name (VA or Non-VA location)

5. Treating Facility Address (Optional)

 

 

 

 

 

Section C. Statements and Certifications

Penalty Statement: There are severe criminal and civil penalties including fine or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent claim

Certification: I have incurred a cost in relation to the travel claimed. I have not obtained transportation at Government expense, through the use of Government owned conveyance, or Government purchased tickets/tokens, or received other transportation resources at no-cost to me. I am the only person claiming for the travel listed. I have not previously received payment for the transportation claimed. I certify that the above information is correct.

Signature of Claimant

Date (mm/dd/yyyy)

NOV 2013

10-3542

VA FORM

INSTRUCTIONS FOR COMPLETING

VETERAN/BENEFICIARY CLAIM FOR REIMBURSEMENT OF TRAVEL EXPENSES

Who is Eligible for Reimbursement of Travel Expenses

1.Veterans rated by VA 30% or more service-connected for travel relating to any condition

2.Veterans rated by VA less than 30% for travel relating to their service-connected condition

3.Veterans receiving VA pension benefits for travel relating to any condition

4.Veterans with annual income below the maximum applicable annual rate of pension for any condition

5.Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations)

6.Veterans traveling in relation to a Compensation and Pension (C&P) examination

7.Certain Veterans in certain emergency situations

8.Beneficiaries of other Federal Agencies when authorized by that agency

9.Allied beneficiaries when authorized by appropriate foreign government agency

10.Certain non-Veterans when related to care of a Veteran (Caregivers under the National Caregivers Program, medically required attendants, VA transplant care donor and support person, or other claimants subject to current regulatory guidelines)

Instructions

1.The claimant or legal representative of claimant may complete this form.

2.Allied beneficiaries and beneficiaries of other federal agencies are not required to complete Section A, Question 3a-c.

3.The form may be presented in person or mailed to VA health care facility where care was provided. Addresses of VA health care facilities can be found at: http://www.va.gov/directory Note: The claim for travel benefits may also be done in person at a VA health care facility.

4.Application for travel reimbursement must be done within 30 days of travel. Exception: application beyond 30 days may occur when claim is a result of change in Beneficiary Travel eligibility.

5.Receipts are required for allowable non-mileage expenses, e.g., bridge, road and tunnel tolls; parking; ferry fares; meals; lodging; and transport by bus, train, taxi or other public transportation. Prior approval is required for meals and lodging.

6.Application will be evaluated to determine eligibility for travel benefits and services received. If eligible, the claim will be processed for payment at currently authorized rate subject to any required deductibles.

7.Payment will be by electronic funds transfer (EFT) unless other arrangements have been made.

8.For assistance in completing the form, call 1-877-222-VETS (8387)

The Paperwork Reduction Act of 1995 requires VA to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of this Act. We anticipate the time expended by individuals who must complete this form will average 3 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. No person will be penalized for failing to furnish this information if it does not display a currently valid OMB control number. This information is collected under 38 CFR 70 and is intended to fulfill the need for Veterans and beneficiaries to claim Beneficiary Travel benefits and for VA to determine the individual's eligibility for the benefit.

Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 111 to determine your eligibility for Beneficiary Travel benefits and will be used for that purpose. 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; possible disclosures include those described in the “routine use" identified in the VA systems of records 24VA19 Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. 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 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.

NOV 2013

10-3542

VA FORM

How to Edit Va Form 10 3542 Online for Free

You can easily create the Va Form 10 3542 form with our PDF editor. The following steps will help you quickly create your document.

Step 1: Press the "Get Form Now" button to start out.

Step 2: You are now allowed to change Va Form 10 3542. You have lots of options with our multifunctional toolbar - you can include, eliminate, or alter the text, highlight its certain elements, and conduct similar commands.

These segments will compose the PDF template that you'll be creating:

Va Form 10 3542 blanks to complete

Type in the expected details in the Treating Facility Name VA or, Treating Facility Address Optional, Section C Statements and, Penalty Statement There are severe, and Certification I have incurred a field.

Va Form 10 3542 Treating Facility Name VA or, Treating Facility Address Optional, Section C Statements and, Penalty Statement There are severe, and Certification I have incurred a blanks to fill out

The program will request you to provide certain important details to instantly fill out the part Signature of Claimant, Date mmddyyyy, and VA FORM NOV.

Completing Va Form 10 3542 step 3

The Question ac, The form may be presented in, Addresses of VA health care, Application for travel, beyond days may occur when claim, Receipts are required for, ferry fares meals lodging and, Application will be evaluated to, Payment will be by electronic, The Paperwork Reduction Act of, and Privacy Act Information VA is section is the place where each party can place their rights and obligations.

Finishing Va Form 10 3542 stage 4

Step 3: Press the Done button to confirm that your finished form can be exported to any type of gadget you end up picking or forwarded to an email you specify.

Step 4: Be sure to stay clear of potential issues by making minimally two duplicates of the document.

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