Fillable Printable VA Form 10-0408A
Fillable Printable VA Form 10-0408A
VA Form 10-0408A
SCHEDULED CARE FOR ELIGIBLE VETERAN OR ACTIVE DUTY SERVICE MEMBER
ACCOMPANYING INDIVIDUAL
VHA FISHER HOUSE OR OTHER
TEMPORARY LODGING APPLICATION
OMB Number 2900-0630
Estimated Burden 10 minutes
VA FORM
JAN 2012
10-0408A
1. VETERANS INTEGRATED
SERVICE NETWORK (VISN) #
3. DATE (mm/dd/yyyy)
2. NAME OF VETERANS HEALTH ADMINISTRATION (VHA) FACILITY
4. LOCATION OF VHA FACILITY
12. START DATE (mm/dd/yyyy)
7. TELEPHONE NUMBER6. TITLE
5. NAME OF FACILITY CONTACT PERSON
13. TIME
14. EPISODE OF CARE
15. END DATE (mm/dd/yyyy)
16. NAME
MALE
FEMALE
17. GENDER
18. RELATIONSHIP TO VETERAN OR ACTIVE
DUTY SERVICE MEMBER
ESTIMATE FROM APPLICANT'S HOME TO VA HEALTHCARE FACILITY
19. DISTANCE20. TIME
22. CIRCUMSTANCES THAT MAY AFFECT TIME OF TRAVEL FROM APPLICANT'S HOME TO VA HEALTHCARE FACILITY
25. REQUESTED DATES FOR TEMPORARY LODGING (mm/dd/yyyy)
21. MODE OF TRANSPORTATION (Click to choose)
to
8. TYPE OF LODGING ACCOMODATION
HOPTEL (Non-utilized beds and rooms
at a VA healthcare facility)
TEMPORARY LODGING FACILITY (Hotel, Motel)
FISHER HOUSE RESIDENCE
9. NAME OF VETERAN OR ACTIVE DUTY SERVICE MEMBER
11.
REQUESTED LODGING FOR
SELF
ACCOMPANYING
INDIVIDUAL
10. SOCIAL SECURITY NUMBER
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The Paperwork Reduction Act & Privacy Act Statements
The Paperwork Reduction Act of 1995requires us to notify you that this information collection is in accordance
with the clearance requirements of section 3507 of this Act. 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. The information on this
form is solicited under the authority of Public Law 106-419, the Veterans Benefits and Health Care Act of 2000.
These statutory provisions have been codified at 38 USC 1708, and are administered by the Department of
Veterans Affairs. 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 the instructions, gather the necessary facts and fill out the
form. Completion of this form is entirely voluntary. However, if you do not provide the requested information, it
may not be possible for VA to determine your eligibility for temporary lodging. Failure to furnish this information
will have no adverse impact on any benefits to which you may have been entitled. The purpose of this form is to
determine eligibility for temporary lodging while the veteran undergoes extensive treatment or procedures.
Information may be disclosed outside the VA as permitted by law. Possible disclosures include those described in
the "routine uses" identified in the VA system of records 24VA19 “Patient Medical Record - VA”, published in the
Federal Register (and as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at
//www.access.gpo.gov/su_docs/aces/2003_pa.html.) in accordance with the Privacy Act of 1974.
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OMB Number 2900-0630
Estimated Burden 10 minutes
VA FORM
JAN 2012
10-0408A
