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

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