Get Extended Care Application Form

Go to your nearest VA medical center or clinic. Bring a signed Application for Health Benefits (VA Form 10-10EZ) with you. Or get help through your state's Department of Veterans Affairs.

Where do I send my application? Mail the original application and supporting materials to the Health Eligibility Center, 2957 Clairmont Road, Suite 200, Atlanta, GA 30329.

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.

income threshold: VA will bill your insurance carrier for your nonservice- connected medical treatment and for medications. You will be responsible for copays for nonservice-connected medical treatment, medications and extended care services, that are not covered by your health insurance payments to VA.

Fill out a Request for Hardship Determination (VA Form 10-10HS). Write a letter explaining why you're requesting a hardship determination. The letter should describe the financial issues that make it hard for you to pay your copays.

Fully Developed Claims Step 1: Log on to eBenefits.va.gov. Click "Apply for Benefits". ... Step 2: Tell us about your Federal/State records: ... Step 3: Gather non-Federal records (as applicable): ... Step 4: Choose Your Type of Claim: ... Step 5: Upload the documents:

We need to collect information regarding income, assets and expenses for you and your spouse. If you do not wish to provide this information you must sign agreeing to make copayments and will be charged the maximum copayment amount for all services.

To complete an application, use VA Form 10-8678, "Application for Annual Clothing Allowance." Applicants should send their applications to the Prosthetics and Sensory Aids Service (PSASat) at the nearest VA medical center. You can visit our Facility Locator to locate your nearest VA health care facility.