Fillable Printable VA Form 10-1394
Fillable Printable VA Form 10-1394
VA Form 10-1394
10-1394
JAN 2008
VA FORM
*NOTE: ALL VAN MODIFICATIONS REQUIRE PRIOR AUTHORIZATION BEFORE PURCHASE
APPLICATION FOR ADAPTIVE EQUIPMENT
MOTOR VEHICLE
PART I - (To be completed by applicant-If more space is needed, attach a separate sheet and identify by item number.)
4. DRIVER'S LICENSE VERIFICATION (Check applicable block)
6. DATE OF VA CERTIFICATE OF ELIGIBILITY
(If January 11, 1971 or after)
5. YEAR YOU RECEIVED GRANT FOR VEHICLE
(If prior to January 11, 1971)
7. DISABILITIES - Check applicable box(es) 8. DESCRIPTION OF VEHICLE FOR WHICH ADAPTIVE EQUIPMENT IS REQUIRED
EXTREMITY
AND LEVEL
ANKYLOSIS LOSS OF USEAMPUTATlON
LEFT RIGHT LEFT RIGHT LEFT RIGHT
A. ARM AE
B. ARM BE
C. LEG AK (hip)
D. LEG BK (knee)
10. LIST OF ADAPTIVE EQUIPMENT REQUESTED (Check items required)
X
DESCRIPTION
ESTIMATED COST
$
X
DESCRIPTION
ESTIMATED COST
$
PAGE 1 OF 2
(mm/dd/yyyy)
OMB Number: 2900-0188
Estimated Burden: 15 minutes
(mm/dd/yyyy)
1. VETERAN'S NAME AND ADDRESS
(This is a mandatory field.)
3. Last 4 DIGITS OF SSN.
(This is a mandatory field.)
8A. DATE PURCHASED 8C. MAKE8B. YEAR 8D. MODEL
8E. VEHICLE IDENTIFICATION NUMBER
E. OTHER DISABILITIES AFFECTING DRIVING
9. LAST VEHICLE FOR WHICH
ADAPTIVE EQUIPMENT WAS
PROVIDED
9A. YEAR 9B. MAKE 9C. MODEL
9D. VEHICLE IDENTIFICATION NUMBER
9E. DATE ADAPTIVE EQUIPMENT PROVIDED
(mm/dd/yyyy)
VALID LICENSE OR PERMIT IN POSSESSION
NOT LICENSED
N. *SENSITIZED/LOW EFFORT STEERING
G. CRUISE CONTROL
F. TILT STEERING WHEEL P. *RAISED ROOF
O. *POWER DOOR OPENERS
M. *SENSITIZED/LOW EFFORT BRAKE
A. AUTOMATIC TRANSMISSION K. TRANSFER OF CONTROLS
B. POWER BRAKES L. HAND CONTROLS--ACCELERATOR & BRAKE
C. POWER STEERING
D. POWER SEAT (6 way/2 way)
E. POWER WINDOWS O. *DROP FLOOR
T. MINI-VAN CONVERSION
H. REAR WINDOW DEFROSTER R. *VAN LIFT
I. FOOT/HAND OPERATED PARKING BRAKE S. *POWER TRANSFER SEAT
J. AIR CONDITIONER
U. *OTHER (Describe)
V. JUSTIFICATION (Include full description and estimated cost of item T, if applicable)
13. SIGNATURE OF APPLICANT
AMOUNT TO BE PAID
11. MAKE PAYMENT TO THE FOLLOWING (Check appropriate box(es) and attach a certified invoiced:)
A. AUTOMOTIVE DEALER
B. ADAPTIVE EQUIPMENT SUPPLIER
C. PERSONAL REIMBURSEMENT
D. FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE E. FULL NAME AND ADDRESS WHERE PAYMENT SHOULD BE MADE
12. STATUS OF APPLICANT (Check one)
14. DATE (mm/dd/yyyy)
VETERAN MEMBER OF ARMED FORCES
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be
used to determine your eligibility/entitlement and reimbursement of individual claims for automotive adaptive equipment, and identify your medical
records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed
outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is
voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to
furnish the information will have no adverse effect on any other benefits to which you may be entitled.
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 15 minutes.
This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
10-1394
JAN 2008
VA FORM
PAGE 2 of 2
PART IV - CERTIFICATION OF RECEIPT (TO BE COMPLETED BY APPLICANT)
19. REIMBURSEMENT OR PAYMENT TO THE VENDOR(S) OR INDIVIDUAL(S) NAMED BELOW, IN THE TOTAL AMOUNTS SPECIFIED FOR EACH, IS AUTHORIZED AS
A PROPER CHARGE FOR ADAPTIVE EQUIPMENT PREVIOUSLY PURCHASED BY THE APPLICANT UNDER AUTHORITY OF CFR 3.808:
I CERTIFY THAT I have received the items
or services authorized in item 18 above.
ITEMS AUTHORIZED ITEMS AUTHORIZED
MAXIMUM
COST
MAXIMUM
COST
PART III - APPROVAL AND AUTHORIZATION (TO BE COMPLETED BY PROSTHETIC REPRESENTATIVE)
18. The following adaptive equipment is approved for inclusion with or installation on the specific vehicle described in item 8 on the front of this form. Costs
including installation, unless authorized separately, will not exceed the total amount indicated for each item.
"I certify that the amounts billed hereon do not exceed the usual and customary costs for the items or services furnished."
24. DATE (mm/dd/yyyy)
Signature of Company Official
19A. NAME AND ADDRESS OF PAYEE
19B. AMOUNT
19C. NAME AND ADDRESS OF PAYEE
19D. AMOUNT
20. NAME AND ADDRESS OF VA FIELD FACILITY 21. SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL
22. DATE (mm/dd/yyyy)
23. SIGNATURE OF APPLICANT
PART II - ELIGIBILITY (To be completed by Eligibility Clerk or Designee)
16. SIGNATURE AND TITLE OF ELIGIBILITY CLERK OR DESIGNEE
15. APPLICANT IS ELIGIBLE UNDER (Check one)
17. DATE
(Specify)
INELIGIBLE
PUB. L. 96-466 for vets in Voc Rehab
PUB. L. 91-666 (VAF 4-4502)
PUB. L. 97-66 for Ankylosis veterans
OTHER
3. Attach a copy of your certified invoice to the original of this form and mail to the VA Office shown in item 20.
4. Ensure that the applicant has signed in items 13 and 23 for receipt of the items or services.
5. VA expressly disavows any intent to enter into a contract with the seller; any agreement as to repairs or other services is between the seller/vendor
and the applicant.
2. After you and the applicant have entered into an agreement for the repair of items or services listed in item 18, and you have completed those repairs
or services, you may use the following reimbursement procedures. For repairs, items or services, prepare your own invoice, itemizing each separate
item or service provided with the cost of each. Identify the make, model, and year of the automobile or other conveyance and include the following
certification statement on your own invoice.
INSTRUCTIONS TO SELLER/VENDOR
INSTRUCTIONS TO VETERAN OR SERVICEPERSON
The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine your eligibility for
prosthetic benefits and provide basic data for your treatment. Disclosure is voluntary. However, failure to furnish the information will result in our
inability to process your request promptly. Failure to furnish this information will have no adverse effect on any other benefits to which you may be
entitled.
1. Contact should be made with the Prosthetics Service at your local VA medical center or outpatient clinic prior to any purchase of equipment.
2. Complete all item in Part I of this form in duplicate and sign the form.
3. If you are requesting adaptive equipment or services, VA will determine your eligibility and complete Part II.
4. After approval, you may give the original of this form to the seller/vendor of your choice, who will deliver the equipment or services authorized (see
also paragraphs 3 and 4 below).
5. In the event you must obtain some of the equipment on a mail-order basis, or cannot use this authorization for any other reason, you may pay for
an authorized item or service and apply for reimbursement from VA. In such cases, you must present a paid invoice properly certified (see paragraph
2 below).
6. After receipt of the items or services authorized, sign and date the receipt in items 23 and 24, and direct the seller/vendor's attention to the
instructions below. This certification signifies that the adaptive equipment, installation, or service is satisfactory, the servicing information on the
invoice has been verified to the best of your ability and the charges appear to be reasonable.
1. This is to inform you that if Part II and III of this form have been completed and signed by VA, the individual who is designated in this form as the
applicant has been authorized the services or items in Item 18 of this form. Note that the applicant is not entitled to services that exceed the maximum
costs, specified on item 18 of this form or approved on your quote.
