-
DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER
921 Northeast 13th Street Oklahoma City, OK 73104-5028
Dear Veteran: The Department of Veteran Affairs has implemented
a Persian Gulf Registry Progrem for concerned participants of the
“Operation Desert Shield/Storm” and or Operation Iraqi Freedom.
Establishment of the PGR (Persian Gulf Registry) will assist the VA
to identify possible adverse health conditions which may result
from service of U.S. military personnel in certain areas to
Southwest Asia. To allow us to accurately evaluate the type of
exposure(s) involved in your particular experience, please answer
all the questions on the enclosed questionaire and the 10-10
applications. For your convience we have mailed these forms to your
home where you have access to military and other documents
necessary to provide the information required. It is in your best
interest to complete these forms to the best of your ability.
Please return the completed forms along with a copy of your
DD214(s) to: VA Medical Center 921 NE 13th Street Oklahoma City, OK
73104 Atten: Shelia Ray 136 Your application will be processed and
you will be scheduled for a medical evaluation at this VA Medical
Center. The examination will be at no cost to the veteran. You are
entitled to cost-free treatment for conditions related to exposure
from the Persian Gulf. If a medical condition is found not related,
you will be responsible for partial co-payment which is determined
by your income unless the VA Regional Office determines that your
health problems are service connected. If you have any questions,
please call (405) 456-5201.
Please note that this examination does not constitute a formal
claim for VA benefits. Although the results maybe used to support a
compensation claim, the examination will not in itself be
considered such a claim. If you wish to file a claim for service
connection of a medical disability related to your military
service, please contact a Veterans Benefit Counselor at the
Muskogee VA Regional Office (1-800-827-1000) or at the nearest VA
Medical Center. Sincerely, Shelia Ray Veteans’ Registry Coordinator
Special Examination Unit
-
Demographics
Race
Ethnicity
Periods of Service
Last, First-Middle
(mm/dd/yyyy)
-
Military
-
Exposure Periods
Exposures
-
Exposures (continued)
Sodium Dichromate Exposure
-
Experiences
Self Assessment
Birth Data
-
Birth Data (continued)
-
Mosul
Tikrit
Tigris
-
Federal law provides criminal penalties, including a fine and/or
imprisonment for up to 5 years, for concealing a material fact or
making a materially false statement. (See 18 U.S.C. 1001)
4. ARE YOU SPANISH, HISPANIC, OR LATINO?
6. SOCIAL SECURITY NUMBER
PAGE 1VA FORMMAR 2015 10-10EZ
APPLICATION FOR HEALTH BENEFITS
1. VETERAN'S NAME (Last, First, Middle Name) 2. MOTHER'S MAIDEN
NAME 3. GENDER
5. WHAT IS YOUR RACE? (You may check more than one. Information
is required for statistical purposes only.)
SECTION I - GENERAL INFORMATION
7. DATE OF BIRTH (mm/dd/yyyy) 7A. PLACE OF BIRTH (City and
State)
OMB Approved No. 2900-0091Estimated Burden Avg. 30 min.
PREVIOUS EDITIONS OF THIS FORM ARE NOT TO BE USED
8F. MOBILE TELEPHONE NUMBER (Include area code)
8B. STATE8A. CITY 8C. ZIP CODE 8. PERMANENT ADDRESS (Street)
8G. E-MAIL ADDRESS
8D. COUNTY 8E. HOME TELEPHONE NUMBER (Include area code)
11. WHICH VA MEDICAL CENTER OR OUTPATIENT CLINIC DO YOU PREFER?
(for listing of facilities visit www.va.gov/directory)
12. WOULD YOU LIKE FOR VA TO CONTACT YOU TO SCHEDULE YOUR FIRST
APPOINTMENT?
SECTION III - INSURANCE INFORMATION (Use a separate sheet for
additional information) 1. ENTER YOUR HEALTH INSURANCE COMPANY
NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse
or other person)
4. GROUP CODE 2. NAME OF POLICY HOLDER 3. POLICY NUMBER 5. ARE
YOU ELIGIBLE FOR MEDICAID?
6. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
SECTION II - MILITARY SERVICE INFORMATION1. LAST BRANCH OF
SERVICE 1A. LAST ENTRY DATE 1B. LAST DISCHARGE DATE 1C. DISCHARGE
TYPE
2. MILITARY HISTORY (Check yes or no) YES NO
A. ARE YOU A PURPLE HEART AWARD RECIPIENT? E. DID YOU SERVE IN
SW ASIA DURING THE GULF WAR BETWEEN AUGUST 2, 1990 AND NOVEMBER 11,
1998?
C. DID YOU SERVE IN A COMBAT THEATER OF OPERATIONS AFTER
11/11/1998?
D. WERE YOU DISCHARGED OR RETIRED FROM MILITARY FOR A DISABILITY
INCURRED IN THE LINE OF DUTY?
F. DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND MAY 7,
1975?
G. WERE YOU EXPOSED TO RADIATION WHILE IN THE MILITARY?
H. DID YOU RECEIVE NOSE AND THROAT RADIUM TREATMENTS WHILE IN
THE MILITARY?
I. DID YOU SERVE ON ACTIVE DUTY AT LEAST 30 DAYS AT CAMP LEJEUNE
FROM AUGUST 1, 1953 THROUGH DECEMBER 31, 1987?
YES NO
B. ARE YOU A FORMER PRISONER OF WAR?
9. CURRENT MARTIAL STATUS
10. I AM ENROLLING TO OBTAIN MINIMUM ESSENTIAL COVERAGE UNDER
THE AFFORDABLE CARE ACT
YES
NO
MALE FEMALE
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN WHITE
BLACK OR AFRICAN AMERICAN
NATIVE AMERICAN OR OTHER PACIFIC ISLANDER
YES NOYES NO
MARRIED NEVER MARRIED SEPARATED WIDOWED DIVORCED
YES
NO
YES NO
6A. EFFECTIVE DATE (mm/dd/yyyy)
-
APPLICATION FOR HEALTH BENEFITS, ContinuedVETERAN'S NAME (Last,
First, Middle) SOCIAL SECURITY NUMBER
PAGE 210-10EZ VA FORMMAR 2015
2F. IF CHILD IS BETWEEN 18 AND 23 YEARS OF AGE, DID CHILD ATTEND
SCHOOL LAST CALENDAR YEAR?
2B. CHILD'S SOCIAL SECURITY NUMBER
2C. DATE CHILD BECAME YOUR DEPENDENT (mm/dd/yyyy)
2E. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF
18?
3. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST
YEAR, DID YOU PROVIDE SUPPORT?
1B. SPOUSE'S DATE OF BIRTH (mm/dd/yyyy)
1C. DATE OF MARRIAGE (mm/dd/yyyy)
2A. CHILD'S DATE OF BIRTH (mm/dd/yyyy)
2D. CHILD'S RELATIONSHIP TO YOU (Check one)
1. SPOUSE'S NAME (Last, First, Middle Name) 2. CHILD'S NAME
(Last, First, Middle Name)
1D. SPOUSE'S ADDRESS AND TELEPHONE NUMBER (Street, City, State,
ZIP - if different from Veteran's)
2G. EXPENSES PAID BY YOUR DEPENDENT CHILD FOR COLLEGE,
VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books,
materials)
SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for
additional dependents)
1A. SPOUSE'S SOCIAL SECURITY NUMBER
SECTION V - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF
VETERAN, SPOUSE AND DEPENDENT CHILDREN (Use a separate sheet for
additional dependents)
VETERAN SPOUSE CHILD 1
1. GROSS ANNUAL INCOME FROM EMPLOYMENT (wages, bonuses, tips,
etc.) EXCLUDING INCOME FROM YOUR FARM, RANCH, PROPERTY OR
BUSINESS
2. NET INCOME FROM YOUR FARM, RANCH, PROPERTY OR BUSINESS
3. LIST OTHER INCOME AMOUNTS (e.g., Social Security,
compensation, pension interest, dividends) EXCLUDING WELFARE.
$
$
$
$
$
$
$
$
$
SECTION VI - PREVIOUS CALENDAR YEAR DEDUCTIBLE EXPENSES
1. TOTAL NON-REIMBURSED MEDICAL EXPENSES PAID BY YOU OR YOUR
SPOUSE (e.g., payments for doctors, dentists, medications,
Medicare, health insurance, hospital and nursing home) VA will
calculate a deductible and the net medical expenses you may
claim.
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL
EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR YOUR DECEASED
SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information
in Section VI.)
3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR
VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees,
materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.
$
$
$
SECTION VII - CONSENT TO COPAYS AND TO RECEIVE COMMUNICATIONSBy
submitting this application you are agreeing to pay the applicable
VA copays for treatment or services of your NSC conditions as
required by law. You also agree to receive communications from VA
to your supplied email or mobile number.
ASSIGNMENT OF BENEFITS
I understand that pursuant to 38 U.S.C. Section 1729 and 42
U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized
to recover or collect from my health plan (HP) or any other legally
responsible third party for the reasonable charges of
nonservice-connected VA medical care or services furnished or
provided to me. I hereby authorize payment directly to VA from any
HP under which I am covered (including coverage provided under my
spouse's HP) that is responsible for payment of the charges for my
medical care, including benefits otherwise payable to me or my
spouse. Furthermore, I hereby assign to the VA any claim I may have
against any person or entity who is or may be legally responsible
for the payment of the cost of medical services provided to me by
the VA. I understand that this assignment shall not limit or
prejudice my right to recover for my own benefit any amount in
excess of the cost of medical services provided to me by the VA or
any other amount to which I may be entitled. I hereby appoint the
Attorney General of the United States and the Secretary of
Veterans' Affairs and their designees as my Attorneys-in-fact to
take all necessary and appropriate actions in order to recover and
receive all or part of the amount herein assigned. I hereby
authorize the VA to disclose, to my attorney and to any third party
or administrative agency who may be responsible for payment of the
cost of medical services provided to me, information from my
medical records as necessary to verify my claim. Further, I hereby
authorize any such third party or administrative agency to disclose
to the VA any information regarding my claim.
ALL APPLICANTS MUST SIGN AND DATE THIS FORM. REFER TO
INSTRUCTIONS WHICH DEFINE WHO CAN SIGN ON BEHALF OF THE
VETERAN.
STEPDAUGHTER
YES NO
YES NO
YES NO
SIGNATURE OF APPLICANT DATE
STEPSONDAUGHTER SON
mil35: mil36: mil37: mil38: mil39: mil40: mil41: mil42: mil43:
exposure1: exposure2: exposure3: exposure4: exposure5: exposure6:
exposure7: exposure8: exposure9: exposure10: exposure11:
exposure12: exposure13: exposure14: exposure15: exposure16:
exposure17: exposure18: exposure19: exposure20: exposure21:
exposure22: exposure23: exposure24: exposure25: exposure26:
exposure27: exposure28: exposure29: exposure30: exposure31:
exposure32: exposure33: exposure34: exposure35: exposure36:
exposure37: exposure38: exposure39: exposure40: exposure41:
exposure42: exposure43: exposure44: exposure45: exposure46:
exposure47: exposure48: exposure49: exposure50: exposure51:
exposure52: exp1: exp2: exp3: exp4: exp5: exp6: self1: self2:
self3: birth1: birth2: birth3: birth4: birth5: birth7: birth8:
birth9: birth10: birth11: birth12: birth13: birth14: birth15:
birth16: birth17: birth18: birth19: birth20: birth21: birth22:
birth23: birth24: birth25: birth26: birth27: birth28: birth29:
birth30: MedHis1: OffMedHis2: OffMedHis3: MedHis4: Med1: Med2:
Med3: Med4: Med5: Med6: Med7: Med8: Med9: Med10: Med11: Med12:
Med13: Med14: Med15: Med16: Med17: Med18: Med19: Med20: Med21:
Med22: Med23: Med24: Med25: Med26: Med27: Med28: Med29: Med30:
hosp1: hosp2: hosp3: hosp4: hosp5: hosp6: hosp7: hosp8: hosp9:
hosp10: hosp11: hosp12: hosp13: hosp14: hosp15: illness1: illness2:
illness3: illness4: illness5: illness6: dr1: dr2: dr3: dr4:
problem1: problem2: problem3: problem4: habit1: Offhabit2:
Offhabit3: habit4: habit5: Offhabit6: Offhabit7: habit8: habit9:
Offhabit10: Offhabit11: habit12: habit13: habit14: Offhabit15:
Offhabit16: habit17: habit18: Offhabit19: Offhabit20: Offhabit21:
Offhabit22: Offhabit23: Offhabit24: habit25: ssn2: last3: first4:
middle5: plus11: sex13: married14: Race15: [ ]CollectionMethod16: [
]EthnicityCode17: [ ]CollectionMethod18: [ ]Service19: startdate20:
enddate21: remarks22: service23: startdate24: enddate25: remarks26:
service27: startdate28: enddate29: remarks30: service31:
startdate32: enddate33: remarks34: name1: maiden: untitled2:
Offuntitled3: Offuntitled4: Offuntitled5: Offuntitled6:
Offuntitled7: Offuntitled8: Offuntitled9: Offuntitled10: Offbirth6:
untitled11: address7: city8: state9: zip10: county12: phone1:
phone2: email: untitled12: Offuntitled13: Offuntitled14:
Offuntitled15: Offuntitled16: Offuntitled17: Offuntitled18:
OffVAMC: untitled19: Offuntitled20: Offuntitled21: untitled22:
untitled23: untitled24: untitled25: Offuntitled26: Offuntitled27:
Offuntitled28: Offuntitled29: Offuntitled30: Offuntitled31:
Offuntitled32: Offuntitled33: Offuntitled34: Offuntitled35:
Offuntitled36: Offuntitled37: Offuntitled38: Offuntitled39:
Offuntitled40: Offuntitled41: Offuntitled42: Offuntitled43:
untitled44: untitled45: untitled46: untitled47: Offuntitled48:
Offuntitled49: Offuntitled50: Offuntitled51: spouse: spouse ssn:
spouse dob: marriage: spouse address: untitled53: untitled54:
untitled55: untitled56: untitled57: Offuntitled58: Offuntitled59:
Offuntitled60: Offuntitled61: Offuntitled62: Offuntitled63:
Offuntitled64: Offuntitled65: untitled66: Offuntitled67:
Offuntitled68: untitled69: untitled70: untitled71: untitled72:
untitled73: untitled74: untitled75: untitled76: untitled77:
untitled78: untitled79: