VA Form 10-0455a – Clinical Trial Inclusion/Enrollment Report

VAFORMS.NETVA Form 10-0455a – Clinical Trial Inclusion/Enrollment Report – VA Form 10-0455a is a legal form that authorizes the sharing of health information between a VA institution and a third-party organization. This form can be filled out online and is safe and secure. It also meets the latest security requirements. It can be completed by a veteran or they’re next of kin.

Download VA Form 10-0455a – Clinical Trial Inclusion/Enrollment Report

Form Number Clinical Trial Inclusion/Enrollment Report
Form Title VA Form 10-0455a
Edition Date March 2022
File Size 699 KB

Traditionally, the form has been used by VA medical facilities to notify us about the status of a Veteran, such as when the Veteran enters or leaves a nursing home. However, the deployment of CAPRI has substantially reduced the need for this form. Although some VA medical facilities still maintain paper records, they may continue to use this form to notify us of changes to the Veteran’s status. Additionally, the Veterans Benefits Administration may access health information for business purposes using this form.

Where Can I Find a VA Form 10-0455a?

VA Form 10-0455a is a form used by veterans to apply for healthcare benefits and update their personal and financial information. The form is available online and is protected using the latest security measures. Once you fill it out, you must submit it to the Health Eligibility Center in Atlanta, Georgia.

This form is required to apply for a VA Pension, sometimes referred to as an Aid and Attendance Benefit. To qualify, you must provide the VA with a certified copy of your military discharge. Often, the VA will also request a copy of your marriage or death certificate. You will also need to provide proof of ongoing care expenses such as receipts or statements from a care provider. In addition to these documents, you will also need to provide proof of payment. If you are paying for ongoing care, you will need to provide VA Form 21-2680. The proof of care includes invoices marked paid.

The form asks for personal information. If you fail to provide the information, your benefits may be delayed. However, this will not affect your other benefits. Your Social Security Number is used by the VA to administer your benefits. It may also be used to identify veterans and others receiving VA benefits. It is important that you provide the right information to the VA in order to obtain benefits.

VA Form 10-0455a – Clinical Trial Inclusion/Enrollment Report

The VA Form 10-0455a – Clinical Trial Inclusion/Enrollment Report must be completed and submitted to the Research Office within five business days of the clinical trial application date. In addition, the application must contain a confidentiality statement. It also needs to be accompanied by a consent document signed by each participant. The IRB reviews this form and determines whether the research is compliant.

In addition to completing the VA Form 10-0455a, participants must disclose any conflicts of interest. These conflicts are disclosed to the IRB. The VA research compliance officer may attend IRB meetings. Affiliated IRBs must follow VA financial conflict of interest policies and procedures.

Besides completing Form 10-0455a, study teams must submit other documents as well. For example, a signed Enterprise Research Data Security Plan (ERDSP) must be included. The Service Chief’s signature is required on the Request for R&D Approval (R&DA). Finally, the PI must complete a Research Protocol Safety Survey. Failure to submit these documents may delay the review process.

VA Form 10-0455a Example

VA Form 10-0455a

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