308 lines
16 KiB
Plaintext
308 lines
16 KiB
Plaintext
English French Notes Complete/Exclude
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SUM OF ALL LINES FIXED AND LIQUID ASSETS
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TOTAL ASSETS
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Current income, e.g. gross income (including, but not limited
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to, wages and income from
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a business, bonuses, tips, severance pay, accrued benefits,
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cash gifts)
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Social Security Retirement/Disability
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Interest/Dividends (i.e., interest income, standard dividend
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income from non tax deferred
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Retirement and Pension income
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Civil Service Retirement
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US Railroad Retirement
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VA Pension
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Spouse VA disability/compensation
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Unemployment Benefits/Compensation
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Other compensation, e.g. Workers Compensation and Black Lung
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Court Mandated (e.g. alimony, child support) (Veteran and Spouse)
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Other Income (i.e., inheritance amounts, tort settlement
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SECTION VI - EXPENSES
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1. Education (veteran, spouse or dependent)
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2. Funeral and Burial (spouse or child)
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5. Car Payment Only (excludes gas, insurance, parking fees)
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7. Non-reimbursed medical expenses
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8. Court-ordered payments
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9. Insurance (exclude life insurance)
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10. Taxes (on any amount include in gross income, property, personal)
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SECTION
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- CONSENT FOR ASSIGNMENT OF BENEFITS
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I hereby authorize the Department of Veterans Affairs to disclose any such history, diagnostic and treatment information from my
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medical records to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of
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the expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization at
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any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this consent
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will automatically expire when all action arising from VA's claim for reimbursement from my medical care has been completed.
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I authorize payment of medical benefits to VA for any services for which payment is accepted.
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- CONSENT AND AGREEMENT TO MAKE COPAYMENTS
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has received a copy of the Privacy Act Statement and agrees to make appropriate copayments.
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I certify the foregoing statement(s) are true and correct to the best of my knowledge and belief and agree to make the applicable
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copayment for extended care services as required by law.
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Additional Comments:
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This output requires a 132 column printer.
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1010EC PRINT
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APPLICATION FOR EXTENDED CARE SERVICES
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SECTION I - GENERAL INFORMATION
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APPLICATION FOR EXTENDED CARE SERVICES, Continued
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| Social Security Number
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VA FORM 10-10EC DEC
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1. Primary Residence (Market value minus mortgages or liens.
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Exclude if veteran receiving only
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non-institutional extended care services or spouse or dependent residing in community. If the
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veteran and spouse maintain separate residences, and the veteran is receiving institutional
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(inpatient) extended care services, include value of the veteran's primary residence.)
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This would
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include a second home, vacation home, rental property.)
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3. Vehicle(s) (Value minus outstanding lien. Exclude primary vehicle if veteran
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institutional (inpatient) extended care services, include value of veteran's primary vehicle.)
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1. Cash, Amount in Bank Accounts (e.g., checking and savings accounts, certificates
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of deposit
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individual retirement accounts, stocks and bonds.)
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2. Value of Other Liquid Assets (e.g., art, rare coins, stamp collections, collectibles) Minus
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the amount you owe on these items. Exclude household effects, clothing, jewelry, and personal
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items if veteran receiving only non-institutional extended care services or spouse or
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dependent residing in the community.
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SUM OF ALL LINES FIXED AND LIQUID ASSETS
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| TOTAL ASSETS
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SECTION VI - CURRENT GROSS INCOME OF VETERAN AND SPOUSE
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1. Gross annual income from employment (e.g., wages, bonuses, tips, severance pay
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accrued benefits)
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2. Net income from your farm/ranch, property or business.
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3. List other income amounts (e.g., Social Security, retirement and pension,
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interest, dividends) Refer to instructions.
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SECTION VII - DEDUCTIBLE EXPENSES
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1. Educational expenses of veteran, spouse or dependent (e.g., tuition, books, fees, material, etc.)
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2. Funeral and Burial (spouse or child, amount you paid for funeral and burial expenses, including prepaid
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3. Rent/Mortgage (monthly amount or annual amount)
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4. Utilities (calculate by average monthly amounts over the past 12 months)
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5. Car Payment for one vehicle only (exclude gas, automobile insurance, parking fees, repairs)
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6. Food (for veteran, spouse and dependent)
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7. Non-reimbursed medical expenses paid by you or spouse (e.g., copayments for physicians, dentists,
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medications, Medicare, health insurance, hospital and nursing home expenses)
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8. Court-ordered payments (e.g., alimony, child support)
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9. Insurance (e.g., automobile insurance, homeowners insurance) Exclude life insurance
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10. Taxes (e.g., personal property for home, automobile) Include average monthly expense for taxes paid on
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income over the past 12 months.
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SECTION X - PAPERWORK PRIVACY ACT INFORMATION
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The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
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requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
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respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all
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individuals who must complete this form will average 90 minutes. This includes the time it will take to read instructions, gather
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the necessary facts and fill out the form. If you have comments regarding this burden estimate or any other aspect of this
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collection, call 202.273.8247 for mailing information on where to send your comments.
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Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,
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sections 1710, 1712, 1722 and 1729 in order for VA to determine your eligibility for extended care benefits and to establish
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financial eligibility, if applicable, when placed in extended care services. The information you supply may be verified through a
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computer-matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a
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routine use
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disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the
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VHA Notice of Privacy Practices. You do not have to provide the information to VA, but if you don't, VA will be unable to process
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your request and serve your medical needs. Failure to furnish the information will not have any affect on any other benefits to
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which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may
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also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other
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purposes authorized or required by law.
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Patient is not a Veteran.
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Date of LTC Copay Test:
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The date of test must be after the date of the last test on
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An LTC Copay Test already exists on
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Are you sure you want to add a new test
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LTC COPAY
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Use the 'EASEC
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TEST EDIT' Option.
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TEST VIEW' Option.
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Is veteran EXEMPT from LTC copayments
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Enter either 'Y' or 'N'.
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Answer 'Yes' if the veteran is exempt from LTC copayments
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for a reason other than low income.
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Reason for Exemption
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A reason for exemption must be entered. LTC Copay Test cannot be added.
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Veteran is NOT EXEMPT from Long Term Care copayments based
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on last year's income and must complete a 10-10EC form.
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Enter in this field the annual amount of Social Security
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received during the current calendar year.
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A monthly amount can be entered with an '*' after it.
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Enter in this field the annual amount of U.S. Civil Service
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Enter in this field the annual amount of Military Retirement
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Enter in this field the annual amount of Other Retirement received
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during the current calendar year. This includes company, state,
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Enter in this field the annual amount of Gross Income received during
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the current year. This includes, but is not limited to, wages and
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income from a business, bonuses, tips, severance pay, accrued
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benefits, cash gifts.
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Enter in this field the annual amount of Net Income received during
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the current calendar year from the operation of a farm, ranch,
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property or business.
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Enter in this field the annual amount of Interest and Dividend
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Income received during the current calendar year (i.e., interest
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income, standard dividend income from non tax deferred annuities).
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Enter in this field the annual amount of Workers Compensation or
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Black Lung Benefits received during the current calendar year.
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Enter in this field the annual amount of All Other Income received
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during the current calendar year, including retirement and pension
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income, Social Security Retirement and Social Security Disability
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income, compensation benefits such as unemployment, Workers and
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Black Lung, or VA disability. Also cash gifts, court mandated
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payments, inheritance amounts, tort settlement payments, interest
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and dividends, including tax exempt earnings and distributions from
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Individual Retirement Accounts (IRAs) or annuities.
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received during the current calendar year (i.e., inheritance amounts,
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tort settlement payments).
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Enter in this field the total amount of unreimbursed medical expenses
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paid by the veteran during the current calendar year. The expenses
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can be for the veteran or for members of the veteran's family.
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Reportable medical expenses include amounts paid for the following:
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fees of physicians, dentists, and other providers of health services;
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hospital and nursing home fees; medical insurance premiums (including
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the Medicare premium); drugs and medicines; eyeglasses; any other
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expenses that are reasonable related to medical care. The expenses
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must actually have been paid by the veteran. Do not list expenses
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which have not been paid or which have been paid by someone other
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than the veteran. Do not list expenses which the veteran has paid if
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the veteran expects to receive reimbursement from insurance or some
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other source.
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calendar year for funeral or burial expenses of the veteran's
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spouse or child, or pre-paid arrangements for the veteran.
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Do not report amounts paid for funeral or burial expenses of other
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relatives such as parents, siblings, etc.
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Enter in this field the total amount paid by the veteran for
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educational expenses during the current calendar year. This
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includes educational expenses for the veteran, spouse and children.
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Educational expenses are tuition, fees, and books if enrolled in a
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program of education.
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Enter in this field cash and amounts in bank accounts. This
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includes checking accounts, savings accounts, money markets,
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interest, dividends from IRA, 401K's, and other tax deferred
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Enter in this field the current value of stocks, bonds, mutual
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funds, SEP's, and other retirement accounts (e.g., IRA, 401K,
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annuities, self-employed person).
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has no LTC copay (10-10EC) tests on file.
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This LTC Copay Test (10-10EC) is uneditable and cannot be deleted.
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Display test
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<OK, nothing deleted!>
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<LTC Copay Test deleted.>
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Pat ID:
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LTC Copay Test Date Status:
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Source:
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EASEC DEPENDENTS
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Cannot edit when viewing a LTC copay test.
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Not a LTC copay test - use LTC copay test options.
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as a dependent to the LTC copay test.
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Not applicable for LTC copay test
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Married This Year:
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Legally Separated:
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Spouse Residing in Community:
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Living with Spouse:
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Dependent Residing in Community:
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Dependent Living with You:
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EASEC EXPAND PROFILE
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Select DATE OF LTC COPAY TEST:
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Warning: Uneditable LTC Copay test. The source of this test is
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Would you like to view the LTC Copay test or print the 10-10EC
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Enter a date that is less than or equal to today.
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Enter the date of the LTC Copay Test.
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Are you sure you want to change the date of the LTC Copay Test
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must complete a 10-10EC form.
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Report of LTC Copayment Tests
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Enter 1 or 2
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Indicate whether the report should include:
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(1) a list of veterans whose LTC Copayment Test is pending expiration (i.e.,
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the anniversary date of the test is approaching) within a user-specified
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number of days, or
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(2) a list of veterans whose LTC Copayment Test has already expired (i.e.,
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the anniversary date of the test has passed) since a user-specified date.
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Enter number of days to report
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Enter a start date
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Sort report by Name or Date
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Indicate whether the report should be sorted by the
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Veteran's Name or the LTC Copay Test Anniversary Date
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Report Cancelled!
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LTC COPAY TESTS
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Report
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Queued!
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Cancelled!
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*** No records to print ***
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VETERANS WITH LONG TERM CARE COPAYMENT TESTS THAT
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ARE PENDING EXPIRATION IN
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HAVE EXPIRED SINCE
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SORTED BY
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REPORT DATE:
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LTC Test
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Veteran's Name
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Anniversary Date
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The income threshold check could not be completed due to an error.
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Means Test
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LTC Copay Exemption Test
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The previous year's financial information is not on file for this veteran.
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is required.
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at this time
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Report of Calculated Long Term Care Copayments
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No LTC Copayment Test on file for this veteran!
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Copayment rates for LTC are not available at this time.
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The LTC Copayment Test is incomplete!
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This veteran is Exempt from LTC copayments!
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This LTC Copayment Test contains an invalid status!
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Enter the LTC Admission Date
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Enter the admission date for the current institutional
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Long Term Care episode.
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Enter the Report Start Date (Month/Year)
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Enter the starting date for the report in the format month/year (e.g. 9/03).
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The report will print 12 months of copayments starting with the
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month and year entered.
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Report Start Date cannot be before LTC Admission Date!
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LTC Copay Calculation Report
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SPOUSE RESIDING IN THE COMMUNITY
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*** DECLINED TO PROVIDE INCOME INFORMATION -- AGREED TO PAY COPAYMENTS ***
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*** VETERAN IS INELIGIBLE FOR LTC SERVICES -- REFUSED TO SIGN 10-10EC ***
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LTC COPAY TEST DATE:
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LTC ADMISSION DATE:
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LTC COPAYMENT CALCULATION
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FOR DAYS 1-180
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FOR DAYS 181+
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TOT ASSETS
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TOT INCOME
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TOT EXPENSES
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TOT ALLOWANCE
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CALC COPAY
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MAX COPAY
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VET COPAY
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LONG TERM CARE ESTIMATED COPAYMENTS FOR
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NON-
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INSTITUTIONAL SERVICES
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TOTAL INCOME - TOTAL EXPENSES - TOTAL ALLOWANCE
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(TOTAL ASSETS + TOTAL INCOME) - TOTAL EXPENSES - TOTAL ALLOWANCE
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(TOTAL ASSETS + TOTAL INCOME) - TOTAL ALLOWANCE
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IMPORTANT NOTICE: The copayment amounts shown in this report are
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based on calculations of the copayment amount for
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an entire month. The
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copayment amounts will be adjusted to
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reflect the actual start date of LTC
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services and the
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copayment exemption for the first 21 days of service. The VET
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COPAY amount is based on the assumption that the veteran
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will be responsible
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to pay the lesser of EITHER the calculated
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copayment (CALC COPAY) OR the
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maximum copayment (MAX COPAY).
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In the event that the calculated copayment
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(CALC COPAY) is a
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negative figure, the veteran copayment (VET COPAY)
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will be adjusted to zero (0). If the veteran declined to provide
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information, the veteran will be obligated to pay the
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maximum copayment.
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EXPLANATION OF ASSET SPEND DOWN CALCULATION:
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The veteran's assets are included in the calculation of copayments
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after 180 days of institutional LTC services. The assets then may
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be reduced each month according to the following formula:
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Single Veteran:
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TOTAL ASSETS-(VET COPAY-(INCOME-ALLOWANCE))
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Married Veteran (spouse residing in the community):
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TOTAL ASSETS-(VET COPAY-(INCOME-EXPENSES-ALLOWANCE))
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In other words, the assets will be reduced by the amount of the
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veteran's copayment that is not covered by the veteran's income
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after all expenses and allowances are subtracted. If the amount
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of the veteran's income after all expenses and allowances are
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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