VA Form 10-1394
Application for Adaptive Equipment - Motor Vehicle
You already have a vehicle but need adaptive equipment (hand controls, wheelchair lift, etc.), OR your existing adaptive equipment needs repair or replacement.
- Who fills it
- veteran
- Journey phase
- Specialty Benefits
- Estimated time
- 20-30 minutes.
- When to file
- When you need new or replacement adaptive equipment.
Official VA form page: https://www.va.gov/find-forms/about-form-10-1394/
Gather before you start
- ▸VA disability rating for qualifying SC condition
- ▸VA physiatrist prescription for specific adaptive equipment
- ▸Vendor/installer quotes for the equipment
- ▸Current vehicle information (make, model, year, VIN)
Attach with the form
- ▸Physician's prescription for adaptive equipment
- ▸Equipment vendor quote
Section I - Veteran Identification
Blocks 1-5Name, SSN, VA File NumberPII
Your identifying information. Processed by your VAMC prosthetics department.
(legal name, SSN, VA file number)
Common mistakes
- ×Not contacting prosthetics before ordering equipment - VA must authorize and pay the vendor directly.
Section II - Equipment Requested
Blocks 6-12Specific adaptive equipment, prescription, and vendor estimate
List the specific adaptive equipment with prescription from VA physiatrist and vendor quote: hand controls, wheelchair lift/ramp, spinner knob, left accelerator ring, transfer seat base, voice control, modified mirrors, or other equipment prescribed for your disability.
e.g., Gas/brake hand controls (prescribed by Dr. Jones, Phoenix VA Prosthetics, for bilateral LE weakness): Quote: Adaptive Mobility LLC, $850 installed.
Common mistakes
- ×Equipment not specifically prescribed - each item needs a physician prescription.
- ×Not getting the prescription from a VA physiatrist or rehabilitation physician - primary care prescriptions may not be accepted.
Authority
- 38 USC 3901 - One-time automobile allowance and ongoing adaptive equipment for veterans with qualifying SC physical disabilities.
Section III - Certification
Blocks 13-14Veteran signature and datePII
Sign and date. Your VAMC prosthetics coordinator will coordinate the payment to the vendor.
(signature/date)
Common mistakes
- ×Paying the vendor out-of-pocket and expecting reimbursement - VA pays vendors directly.
Statutory and regulatory authority
- 38 USC 3901 - One-time automobile allowance and ongoing adaptive equipment for veterans with qualifying SC physical disabilities.