Form 10-334 Tribal Documentation Form

OMB Control Number: 2900-0920
Estimated Burden: 15 minutes
Expiration Date: 04/30/2026

TRIBAL DOCUMENTATION FORM
Personally Identifiable Information (PII) Form

VA DATE STAMP

(For VHA Use Only)

PAPERWORK REDUCTION ACT STATEMENT: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995.
Accordingly, VA 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 complete this form will average 15 minutes. This includes the time it will take to follow instructions, gather
the necessary facts, and respond to questions asked. Failure to furnish the requested information will have no adverse impact on any other VA benefit to which you
may be entitled.
PRIVACT ACT STATEMENT: The information requested on this form is solicited pursuant to section 3002 of the Veterans Health Care and Benefits
Improvement Act(Public Law 116-315). The purpose of this data collection is to provide your contact information and a copy of tribal documentation in support of
your claim for an exemption from co-payments for certain hospital care and medical services. Your disclosure of the information requested on this form is
voluntary. However, if information needed is not furnished completely and accurately, VA may be delayed or unable to comply with the request. VA may make a
“routine use” disclosure of information provided on this form as permitted by the Privacy Act when the information will be used for a purpose that is compatible
with the purpose for which VA collected the information.
IMPORTANT: In accordance with section 3002 of the Veterans Health Care and Benefits Improvement Act, Public Law 116-315, all co-payments for hospital
care and medical services received on or after January 5, 2022 are exempted for American Indian and Alaska Native Veterans eligible for VA health care. In order
to be eligible for these co-payment exemptions, this form, along with a copy of tribal documentation, must be completed and provided to VA (as further explained
below).
INSTRUCTIONS: Please fill out the below information in Section I. Submit this form, along with a COPY of the requested Tribal Documentation. Any
items provided will not be returned. Any field with a (*) is required for submission. To submit the form and supporting documentation, please utilize the mailing
address below:
Please mail documents to:
VHA Tribal Documentation
PO Box 5100
Janesville, WI 53547-5100

SECTION I: VETERAN IDENTIFICATION INFORMATION

(Note: Completion of this section is REQUIRED to process your request; any omission may delay processing.)
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or fraudulent statement or
representation. (See 18 U.S.C. 287 and 1001).
1. VETERANS NAME (Last, First, Middle)*

2. DATE OF BIRTH (MM/DD/YYYY)*

3A. CURRENT MAILING ADDRESS

3B. CITY

3C. STATE
4. MEMBER ID Number OR SOCIAL
SECURITY NUMBER*

3D. ZIP CODE

3E. COUNTY

5. EMAIL ADDRESS

7. VETERAN TELEPHONE NUMBER (Please select the best time of day to call)
MORNING
AFTERNOON

6. LOCAL VA MEDICAL CENTER
See List of VA Facilities. (If known)

EVENING

8. SIGNATURE*

9. DATE (MM/DD/YYYY)*

If you have any questions or need more information, please visit www.va.gov/health-care/copay-rates.

VA FORM
APR 2023

10-334

10T (OHT)

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