Fillable Form VA Travel Reimbursement 10-3542

VA Travel Reimbursement 10-3542 is completed within the 30 days of travel by an eligible veterans and beneficiaries to decide if the travel expenses are qualified for reimbursement.

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What is Form VA 10-3542?


Form VA 10-3542, Veteran/Beneficiary Claim for Reimbursement of Travel Expenses, is a Department of Veterans Affairs form used by the veteran or beneficiary to cover trip expenses for getting professional medical help in another state or country.


If you are a veteran or beneficiary receiving a Veterans Affairs (VA) pension or if your income is lower than the pension, you are entitled to travel compensation. The purpose of the travel eligible for reimbursement must be linked to your condition, treatment, or service.


VA Travel Reimbursement 10-3542 is completed within the 30 days of travel by eligible veterans and beneficiaries to decide if the travel expenses are qualified for reimbursement. To be considered eligible, the claimant has to belong to one of the following categories:

  • Veterans rated by the Veterans Affairs 30% or more service-connected for travel relating to any condition.

  • Veterans rated by the Veterans Affairs less than 30% for travel relating to their service-connected condition.

  • Veterans receiving from the Veterans Affairs pension benefits for travel relating to any condition.

  • Veterans with an annual income below the maximum applicable annual rate of pension for any condition.

  • Veterans who are unable to defray the cost of travel (as defined in current Beneficiary Travel regulations).

  • Veterans traveling in relation to a Compensation and Pension (C&P) examination.

  • Certain veterans in certain emergency situations.

  • Beneficiaries of other Federal Agencies when authorized by that agency.

  • Allied beneficiaries when authorized by the appropriate foreign government agency.

  • Certain non-veterans when related to care of a veteran (caregivers under the National Caregivers Program, medically required attendants, VA transplant care donor and support person, or other claimants subject to current regulatory guidelines).

    • Form VA 10 3542 is completed by a veteran-claimant or their representative.


    Non-mileage charges, such as bridge, road, and tunnel tolls, as well as parking, ferry fares, meals, lodging, and transit by bus, train, taxi, or other public transportation, all require receipts. Prior approval is required for meals and lodging.


    The claim will be evaluated to determine eligibility for travel benefits and services. It will be processed for payment at the currently allowed rate, subject to any mandatory deductibles, if it is proven eligible.


    The VA 10-3542 Form must be completed with the following details:

  • Section A requires the traveler’s information. The claimant’s full name, date of birth, social security number, and current status must all be provided. It is advised to enter the correct information from official papers such as passport or ID card. The form also requires the veteran’s name, social security number, and date of birth.

  • Section B is for providing details about the trip. The departure and arrival addresses, as well as the date and time of the travel, should be submitted. To avoid making mistakes, a claimant should prepare the tickets and other documents containing this information.

  • If an individual wishes to request further reimbursement, they must identify all of the expenses they wish to be reimbursed for, such as tolls, parking, housing, meals, and so on. Each item for which a claimant wishes to be paid must be accompanied by a receipt. The name and address of the treating facility, which could be a VA or non-VA clinic, must be also provided.

  • Section C is for the certification. The claimant asserts that they have provided true-to-life and up-to-date information and have incurred a cost in relation to the travel claimed; has not obtained transportation at government expense, through the use of government-owned conveyance, or government purchased tickets or tokens or received other transportation resources at no cost to them. In addition, the claimant must confirm that they have never received any previous veteran trip reimbursement and that they are the only ones claiming for the travel listed. When signing the form, the claimant must understand that they are fully responsible for the information submitted. False, fabricated, or fraudulent information can result in serious criminal and civil penalties, including fines, imprisonment, or both.

    • VA Form VA 10-3542 may be presented in person or mailed to the VA health care facility where this care was provided. The addresses of all VA health care facilities can be found on the VA website.


    One of the methods to apply for travel reimbursement is to send VA Form VA 10 3542 via secure fax or mail to the local Beneficiary Travel Office. Contact information, including phone numbers and fax numbers of VA health care facilities, can be found at the VA website.


    How to fill out Form VA 10-3542?


    Using PDFQuick, you can electronically fill out and download a PDF copy of the VA 10 3542 Form in minutes. Fill it out by following the instructions below.


    Section A – Traveler’s Information


    Line 1a


    Enter your full name following the format: Last Name, First Name, Middle Initial.


    Line 1b


    Enter your social security number (SSN).


    Line 1c


    Enter your date of birth following the format: MM/DD/YYYY.


    Line 2a


    Mark the appropriate box indicating your status. You may select:

  • Veteran

  • Caregiver (National Caregiver Program)

  • Attendant (Medically Authorized by VA)

  • Donor (VA Transplant Care)

  • Other

    • Complete lines 3a through 3c if you marked “Caregiver,” “Attendant,” or “Donor.” Otherwise, leave the spaces blank.


    Line 3a


    Enter your name following the format: Last Name, First Name, Middle Initial.


    Line 3b


    Enter your social security number (SSN).


    Line 3c


    Enter your date of birth following the format: MM/DD/YYYY.


    Section B – Trip Information


    Line 1a


    Enter the address where your trip was, including street number, city, state, and ZIP code.


    Line 1b


    Enter the date when your trip began, following the format: MM/DD/YYYY.


    Line 1c


    Enter your mode of travel (for example: car, train, bus, taxi).


    Line 2a


    Mark the appropriate box if you’re claiming your return travel reimbursement to the address stated in line 1a. You may select:

  • Yes

  • No – On the space provided, enter the address where you want your travel reimbursement to be returned. Include street number, city, state, and ZIP code.

    • Line 2b


    Enter the date when your trip ended, following the format: MM/DD/YYYY.


    Line 2c


    Enter your mode of travel (for example: car, train, bus, taxi).


    Line 3


    Mark the appropriate box if you’re claiming reimbursement of expenses other than mileage, such as tolls, parking, lodging, and meals. You may select:

  • Yes

  • No

    • If you marked “Yes,” itemize the expenses on the space provided and include a receipt for each expense claimed. Use reverse (back of the page) if additional space is required.


    Line 4


    Enter the treating facility name.


    Line 5


    Enter the treating facility address.


    Section C – Statements and Certifications


    By signing, you agree that you have incurred a cost in relation to the travel claimed. You have not obtained transportation at Government expense, through the use of Government-owned conveyance, or Government purchased tickets or tokens, or received other transportation resources at no cost to you. You are the only person claiming for the travel listed. You have not previously received payment for the transportation claimed. And you certify that the above information is correct.


    Note that there are severe criminal and civil penalties, including fines or imprisonment, or both, for knowingly submitting a false, fictitious, or fraudulent claim.


    Signature of Claimant


    Affix your signature.


    Date


    Enter the date you signed the form, following the format: MM/DD/YYYY.

     

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    Fillable Form VA Travel Reimbursement 10-3542