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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the 'Name of Claimant'. This should be the living veteran or a single surviving spouse, not a deceased veteran.
- Next, fill in the 'Name of Veteran', which must always be the veteran's name regardless of their status.
- Input the 'VA Claim Number or Veteran's Social Security Number'. If you have no VA claim number, use the veteran's social security number.
- List all 'Recurring monthly charges' for care services. Specify amounts separately for both the veteran and spouse if applicable.
- Enter 'Monthly health insurance premiums' for any applicable plans, including Medicare and employer insurance.
- Document 'Monthly Ongoing Prescriptions', ensuring only ongoing costs are included.
- Detail any other deductible recurring medical expenses that can be proven to recur over the next 12 months.
- Calculate and enter the subtotal of all recurring expenses and subtract any reimbursements to find your total monthly out-of-pocket costs.
- Finally, ensure that the 'Signature of Claimant' is completed correctly based on whether the veteran is living or deceased.
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