VA CAREGIVER SUPPORT PROGRAM APPLICATION

Program of Comprehensive Assistance for Family Caregivers (PCAFC)

DEPARTMENT OF VETERANS AFFAIRS
Veterans Health Administration
Caregiver Support Program

SECTION 1: PROGRAM OVERVIEW

The Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides support to family caregivers of eligible veterans who have sustained serious injuries or illnesses in the line of duty.

Benefits Include:
- Monthly stipend payment to Primary Family Caregiver
- Access to health care coverage (CHAMPVA) if not otherwise eligible
- Mental health services and counseling
- Respite care (at least 30 days per year)
- Caregiver training and education
- Financial planning services
- Legal services assistance

SECTION 2: VETERAN INFORMATION

Veteran's Full Legal Name: _______________________________________________

VA File Number: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Gender: ☐ Male ☐ Female ☐ Other

Current Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

SECTION 3: VETERAN ELIGIBILITY CRITERIA

A. Service Requirements

Branch of Service: _______________________________________________

Service Dates: From _______________ To _______________

Character of Discharge: _______________________________________________

Eligible Service Period:

☐ Legacy Program Eligibility (Pre-October 1, 2020):
Serious injury incurred or aggravated in the line of duty on or after September 11, 2001

☐ Expanded Eligibility (October 1, 2020 - September 30, 2022):
Serious injury incurred or aggravated in the line of duty on or after May 7, 1975 (Vietnam Era)

☐ Full Expansion (October 1, 2022 and after):
Serious injury incurred or aggravated in the line of duty during any period of service

B. Enrollment in VA Healthcare

☐ Veteran is enrolled in VA healthcare
☐ Veteran is receiving VA healthcare at: _______________________________________________

VA Medical Center: _______________________________________________

Primary Care Provider: _______________________________________________

C. Serious Injury or Illness

The veteran has a serious injury or illness that:

☐ Was incurred or aggravated in the line of duty
☐ Creates a need for personal care services
☐ Results in functional impairment requiring caregiver assistance

SECTION 4: NEED FOR PERSONAL CARE SERVICES

For PCAFC eligibility, the veteran must require personal care services due to an inability to perform one or more Activities of Daily Living (ADLs) AND/OR need supervision, protection, or instruction due to neurological/psychological impairment.

A. Activities of Daily Living (ADLs) Assessment

The veteran requires assistance with the following ADLs:

☐ Dressing/Undressing
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

☐ Bathing
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

☐ Grooming (oral care, hair care, shaving)
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

☐ Toileting
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

☐ Eating/Feeding
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

☐ Adjusting Prosthetic/Orthotic Devices
- Level of assistance needed: ☐ Supervision ☐ Partial assistance ☐ Total assistance
- Description: _______________________________________________

B. Supervision/Protection/Instruction (SPI) Needs

The veteran requires supervision, protection, or instruction due to:

☐ Neurological Impairment
- Traumatic Brain Injury (TBI)
- Stroke
- Other neurological condition: _______________________________________________

☐ Psychological Impairment
- Post-Traumatic Stress Disorder (PTSD)
- Severe anxiety disorder
- Other psychological condition: _______________________________________________

SPI Needs Description:

☐ Cannot be left alone safely
☐ Needs reminders to complete tasks
☐ Needs guidance to make decisions
☐ At risk of self-harm
☐ At risk of harming others
☐ Wanders/gets lost
☐ Other: _______________________________________________

Detailed Explanation of SPI Needs:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 5: CONDITIONS REQUIRING CAREGIVER ASSISTANCE

List all conditions that contribute to the need for caregiver assistance:

PACT Act Conditions

☐ Veteran has PACT Act presumptive condition(s) requiring caregiver assistance

SECTION 6: PRIMARY FAMILY CAREGIVER INFORMATION

Caregiver's Full Legal Name: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Gender: ☐ Male ☐ Female ☐ Other

Current Mailing Address:
_______________________________________________
_______________________________________________
_______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Relationship to Veteran

Relationship:
☐ Spouse
☐ Parent
☐ Child (adult)
☐ Step-family member
☐ Extended family member
☐ Non-family member who lives with veteran
☐ Other: _______________________________________________

Caregiver Eligibility Requirements

☐ Caregiver is at least 18 years of age
☐ Caregiver is a family member or lives with the veteran
☐ Caregiver is not a member of the Armed Forces or active duty
☐ Caregiver has no felony convictions in the past 7 years
☐ Caregiver is willing and able to provide personal care services
☐ Caregiver will undergo required training

Caregiver Health Insurance Status

☐ Has health insurance through employer
☐ Has Medicare
☐ Has Medicaid
☐ Has TRICARE
☐ Has private insurance
☐ No health insurance (may be eligible for CHAMPVA through PCAFC)

SECTION 7: SECONDARY FAMILY CAREGIVER(S) INFORMATION

Up to two Secondary Family Caregivers may be designated

Secondary Caregiver 1

Full Legal Name: _______________________________________________

Date of Birth: _______________________________________________

Relationship to Veteran: _______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Address: _______________________________________________

Secondary Caregiver 2

Full Legal Name: _______________________________________________

Date of Birth: _______________________________________________

Relationship to Veteran: _______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Address: _______________________________________________

SECTION 8: CURRENT CARE ARRANGEMENT

A. Hours of Care Provided

Estimated hours of personal care services provided per week:

B. Types of Care Provided

☐ Assistance with ADLs (as detailed in Section 4)
☐ Transportation to medical appointments
☐ Medication management
☐ Medical equipment assistance
☐ Supervision for safety
☐ Behavioral/emotional support
☐ Coordination of care with healthcare providers
☐ Other: _______________________________________________

C. Care Schedule Description

Describe the typical daily care routine:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 9: RESIDENCE INFORMATION

Living Arrangement:
☐ Veteran lives in own home
☐ Veteran lives with caregiver
☐ Caregiver lives with veteran
☐ Other arrangement: _______________________________________________

Address Where Care is Provided:
_______________________________________________
_______________________________________________

Is the residence accessible for the veteran's needs?
☐ Yes
☐ No - Modifications needed: _______________________________________________

SECTION 10: FINANCIAL INFORMATION

A. Primary Caregiver Employment Status

☐ Employed full-time
☐ Employed part-time
☐ Self-employed
☐ Not employed (caregiving duties prevent employment)
☐ Retired
☐ Other: _______________________________________________

If employed, has caregiving affected your employment?
☐ Reduced hours
☐ Changed positions
☐ Declined opportunities
☐ Left employment
☐ Other: _______________________________________________

B. Veteran's Income Sources

☐ VA disability compensation
☐ Social Security Disability
☐ Social Security Retirement
☐ Pension
☐ Employment income
☐ Other: _______________________________________________

C. Stipend Payment Information

Primary Family Caregiver will receive monthly stipend based on:
- Tier level assigned after clinical assessment
- Geographic location (GS pay scale area)

Direct Deposit Information:

Bank Name: _______________________________________________

Routing Number: _______________________________________________

Account Number: _______________________________________________

Account Type: ☐ Checking ☐ Savings

SECTION 11: WELLNESS CONTACT

Provide a contact person who can be reached if unable to contact the veteran or primary caregiver

Wellness Contact Name: _______________________________________________

Relationship: _______________________________________________

Phone Number: _______________________________________________

Email Address: _______________________________________________

Address:
_______________________________________________
_______________________________________________

SECTION 12: CLINICAL ASSESSMENT INFORMATION

The following will be assessed during the clinical evaluation:

A. Veteran Assessment Areas

☐ Physical health status
☐ Mental health status
☐ Functional capabilities
☐ Cognitive abilities
☐ Personal care service needs
☐ Current care plan adequacy
☐ Safety in the home

B. Caregiver Assessment Areas

☐ Understanding of veteran's conditions
☐ Ability to provide required care
☐ Available support systems
☐ Caregiver burnout risk
☐ Training needs
☐ Physical capability to provide care

C. Tier Level Determination

PCAFC uses a tiered system to determine stipend amounts:

Tier level is determined through clinical assessment based on veteran's care needs.

SECTION 13: TRAINING REQUIREMENTS

Required Training Acknowledgment:

☐ I understand that the Primary Family Caregiver must complete required training
☐ I understand that ongoing training may be required
☐ I am willing to participate in training programs

Training Topics May Include:
- Basic personal care techniques
- Condition-specific care
- Medication management
- Emergency procedures
- Self-care for caregivers
- Accessing VA resources

SECTION 14: SUPPORTING DOCUMENTATION

Required Documents:

☐ DD Form 214 (Veteran's discharge document)
☐ Proof of relationship (if not spouse):
- Birth certificate
- Marriage certificate
- Adoption decree
- Other: _______________________________________________

☐ Proof of residence (utility bill, lease agreement)
☐ Photo identification for veteran and caregiver(s)

Medical Documentation:

☐ Medical records documenting conditions
☐ Treatment records showing ongoing care needs
☐ Physician statement regarding care needs
☐ Mental health records (if applicable)
☐ VA disability rating decision (if applicable)

Additional Supporting Evidence:

☐ Letters from healthcare providers describing care needs
☐ Daily care log demonstrating care provided
☐ Letters of support from family members
☐ Other: _______________________________________________

SECTION 15: CERTIFICATIONS AND AGREEMENTS

Veteran Certification:

I certify that:
☐ The information provided is true and accurate
☐ I consent to the designated caregiver(s) providing personal care services
☐ I understand the program requirements and agree to participate
☐ I authorize VA to verify the information provided
☐ I understand benefits may be terminated if eligibility requirements are not met

Veteran's Signature: _______________________________________________

Date: _______________________________________________

Primary Family Caregiver Certification:

I certify that:
☐ The information provided is true and accurate
☐ I am willing and able to provide personal care services to the veteran
☐ I agree to complete required training
☐ I agree to participate in clinical assessments and reassessments
☐ I understand I must report changes in circumstances
☐ I authorize VA to verify the information provided
☐ I have not been convicted of a felony in the past 7 years
☐ I am not currently a member of the active duty Armed Forces

Primary Caregiver's Signature: _______________________________________________

Date: _______________________________________________

Secondary Family Caregiver Certification(s):

Secondary Caregiver 1:

I certify that I meet all eligibility requirements and agree to program terms.

Signature: _______________________________________________

Date: _______________________________________________

Secondary Caregiver 2:

I certify that I meet all eligibility requirements and agree to program terms.

Signature: _______________________________________________

Date: _______________________________________________

SECTION 16: REVOCATION AND DISCHARGE INFORMATION

Reasons Program Participation May End:

☐ Veteran no longer meets eligibility criteria
☐ Caregiver no longer meets eligibility criteria
☐ Veteran or caregiver requests discharge
☐ Caregiver no longer provides required care
☐ Veteran's condition improves (no longer needs personal care services)
☐ Caregiver commits disqualifying felony
☐ Other program violations

Appeal Rights:

If denied or discharged from PCAFC, the veteran has the right to appeal the decision through the VA clinical appeals process.

SUBMISSION INSTRUCTIONS

Online Application:
www.va.gov/family-member-benefits/apply-for-caregiver-assistance-form-10-10cg/

Mail Application to:
Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Suite 200
Atlanta, GA 30329-1647

In Person:
Submit at local VA Medical Center Caregiver Support Program office

VA Caregiver Support Line:
1-855-260-3274

IMPORTANT LEGAL REFERENCES

• 38 USC § 1720G - Assistance and support services for caregivers
• 38 CFR § 71 - Caregiver benefits program regulations
• PACT Act (P.L. 117-168) - Expanded eligibility provisions

REASSESSMENT INFORMATION

Annual Reassessment:
- Program participants will be reassessed at least annually
- Reassessments determine continued eligibility and tier level
- Changes in veteran's condition may affect tier assignment

Wellness Contacts:
- VA will conduct regular wellness contacts
- Contacts verify veteran's status and caregiver's wellbeing
- Failure to respond may result in program discharge

This template is designed to assist in preparing a VA Caregiver Support Program application. Individual circumstances vary, and this document should be reviewed with VA Caregiver Support staff before submission.