VA Form 10-1394
Application for Adaptive Equipment - Motor Vehicle
Who fills it
veteran
Journey phase
Specialty Benefits
Estimated time
20-30 minutes.
When to file
When you need new or replacement adaptive equipment.
You already have a vehicle but need adaptive equipment (hand controls, wheelchair lift, etc.), OR your existing adaptive equipment needs repair or replacement.
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.
Example
(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.
Example
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.
Example
(signature/date)
Common mistakes
- Paying the vendor out-of-pocket and expecting reimbursement - VA pays vendors directly.
Statutory & regulatory authority
38 USC 3901 - One-time automobile allowance and ongoing adaptive equipment for veterans with qualifying SC physical disabilities.