Form 10-10143a Veterans Community Care Health Insurance Certification

OMB Number 2900-0823
Estimated burden: 10 minutes

Veterans Community Care Health Insurance Certification
VA Form 10-10143a is used by VA to obtain and update other health insurance information for the Veterans Community
Care program.
For questions on completing this form, you may call XXXXXXX.
The term “Other Health Insurance” refers to insurance or benefits you may have other than VA.
VETERANS MUST COMPLETE ALL SECTIONS
Failure to complete all applicable sections will result in a denial of Veterans Community Care benefits.
Completing the form.
1. Read the Paperwork Reduction and Privacy Act Information.
2. Sign and Date the form.
3. Attach any continuation sheets, a copy of your health insurance member ID card (front and back), and a copy of
your Medicare card to your form (do NOT send the original).
Submitting your information.
Mail the completed VA Form 10-10143a and any supporting materials to the XXX.
SECTION I: GENERAL INFORMATION

LAST NAME

MI

FIRST NAME

SOCIAL SECURITY NUMBER

PHONE # (INCLUDE AREA CODE)

GENDER

Male

Female

ADDRESS (NUMBER, STREET, PO BOX, APT #)

CHECK IF NEW ADDRESS

CITY

STATE

Do you have health insurance?

ZIP CODE

YES

NO

IF NO, go to Section IV

SECTION II: MEDICARE INFORMATION

Part A:

YES

NO

YES

Part B:

NO

Part D:

YES

NO

EFFECTIVE DATE

EFFECTIVE DATE

EFFECTIVE DATE

PART A CARRIER NAME

PART B CARRIER NAME

PART D CARRIER NAME

(MMDDYYYY)

(MMDDYYYY)

(MMDDYYYY)

Does your Medicare provide prescription benefits?

YES

NO

Did you choose a Medicare Advantage Plan for your Medicare coverage?

YES

NO

Do you have health insurance other than Medicare?

YES

NO

IF NO, go to Section IV

SECTION III: OTHER HEALTH INSURANCE INFORMATION (Use a separate sheet for additional information)

Name of insurance # 1
EFFECTIVE DATE
(MMDDYYYY)

Is this insurance through employment?
What type of insurance?
Medigap [if Medigap, specify
Comments
VA FORM 10-10143a
APR 2020

TERMINATION DATE
(MMDDYYYY)

YES
HMO
(A-J)]

NO
PPO

Only put in the termination date if the
policy is inactive.

Does the insurance cover prescriptions?
Medicaid/State Assistance

Other (specialty or limited coverage)

YES

NO

Prescription Discount

Veterans Community Care Health Insurance Certification (Continued)
SECTION III: OTHER HEALTH INSURANCE INFORMATION Continued (Use a separate sheet for additional information)

Name of insurance # 2
EFFECTIVE DATE

TERMINATION DATE

(MMDDYYYY)

Enter the termination date if the policy is
inactive.

(MMDDYYYY)

Is this insurance through employment?

YES

NO

Does the insurance cover prescriptions?

Does the insurance provide an explanation of benefits for prescriptions?
What type of insurance?

HMO

Medigap [if Medigap, specify

PPO
(A-J)]

YES

Medicaid/State Assistance

YES

NO

NO
Prescription Discount

Other (specialty or limited coverage)

Comments
SECTION IV: NON-DISCLOSURE OF INSURANCE INFORMATION

Did you decline to provide your other health insurance information?

YES

NO

If you answered YES, by refusing to provide your other health insurance information to VA, you are not eligible to receive
health care benefits under the Veterans Community Care program.
PAPERWORK REDUCTION AND PRIVACY ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who must complete this form will average 10 minutes. This includes the time it will take to read instructions, gather the necessary
facts and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Section 1703 in order for VA to
determine your eligibility for the Veterans Community Care program. Information you supply may be verified from initial submission
forward through a computer matching program. VA may disclose the information that you put on the form as permitted by law. VA
may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance
with the Notice of Privacy Practices. Providing the requested information is required for eligibility for the Veterans Community Care
program. If any or all of the requested information is not provided, it may delay or result in denial of your request for the Veterans
Community Care program. Failure to furnish the information will not have any effect on any other benefits to which you may be
entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits. VA may also use this
information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or
required by law.

SECTION V: CERTIFICATION BY VETERAN

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making false,
fictitious or fraudulent statements of claims.
l declare under penalty of perjury that the foregoing is true and accurate to the best of my knowledge. I understand that any
materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or
imprisonment pursuant to title 18, United States Code, Sections 287 and 1001.
If there is any change in my health insurance information, I agree to promptly notify XXXX of the new information within 60
days of when the change occurred.
SIGNATURE (type if electronic):

VA FORM 10-10143a
APR 2020

DATE: