Home → VA Prosthetics → VA Handbook 1173.14 - Home Improvements and Structural Alterations (HISA) Program → Application for HISA Benefits
Application For HISA Benefits - Download HISA Application PDF
a. A prescription from a VA, or fee-basis physician for HISA modifications is required and must include the following:
(1) The specific item(s) needed, such as: wheelchair ramp, widening of doorways, bathroom modifications. NOTE: If the physician needs assistance in determining what modifications are needed, the patient is to be referred to Physical Medicine and Rehabilitation Service for consultation.
(2) Diagnosis and medical justification for the item or modification(s) requested.
(3) Veteran's name, address, last four digits of Social Security Number (SSN), and phone number.
b. The veteran must provide the following:
(1) A completed and signed VA Form 10-0103, Veterans Application for Assistance in Acquiring HISA.
(2) If the veteran leases or rents a home, a written statement from the owner of the property authorizing the project to be done. NOTE: The veteran is responsible for all costs above the limit to which the veteran is entitled.
(3) Three competitive bids from licensed or bonded contractors, if required by state law. However, if the veteran is unable to obtain three bids, one bid may be sufficient as long as it is documented as a sole source. NOTE: The local Prosthetic Service staff, taking steps to avoid specific recommendations, may supply a list of contractors who have provided prior services to assist veterans in finding available contractors. Each bid must include the following:
(a) The contractor's name, address, telephone number, and last four digits of SSN or Federal tax identification (ID) number along with the contractor's applicable license and bonding information.
(b) The veteran's name, address, and telephone number.
(c) A written statement and the plans for the project that is to be performed to include a detailed drawing or sketch of the work to be completed.
(d) An itemized list of materials, material costs, and labor costs for each part of the project.
(e) The total cost for labor and materials for the entire project.
(f) Permits, if required by local government agency. Obtaining permits is the licensed or bonded contractor's responsibility.
(4) A signed acknowledgement that VA:
(a) Assumes no responsibility for maintenance, item repair or replacement;
(b) Assumes no liability for the product;
(c) Extends no warranties, either expressed or implied;
(d) Assumes no liability for damage caused by such equipment or devices, or for their removal, when the equipment or device(s) is no longer needed or wanted.
c. The following is required from the contractor.
(1) The contractor must:
(a) Be willing to accept a government purchase order.
(b) Understand that the payment will not be made until completion of the authorized work.
(c) Understand that the receipt of a signed letter of satisfaction from the veteran and a photo of the completed work must be submitted with final invoice.
(d) Obtain all required permits.
(e) Comply with all state and local building codes.
(f) Certify, upon completion, that the work meets, or exceeds VA Minimum Property Requirements and VA specifications as contained in the scope of work.
(g) Warrant the work against defects or poor workmanship for at least 1 year.
(h) Include a statement that certifies the charges contained in the invoice do not exceed the usual and customary charges for that type of work.
(2) Contractor bids must provide a complete description of the proposed project to include:
(a) A detailed and dimensioned set of construction plans of the area to be altered, or improved, as it currently appears. It must show the location of permanent fixtures such as walls, doors, windows, shower stalls, driveways, or walks, if appropriate. The plans must include measurements and specifications of these items.
(b) A detailed and dimensioned set of construction plans showing the area as it will appear after the proposed project including a photo of the proposed work site prior to the approval of the bid. NOTE: The items mentioned in preceding subparagraph 7c(2)(a), need to be shown with the new specifications and measurements.
(c) If a ramp is to be constructed, an individual detailed and dimensioned set of construction plans of the ramp indicating type of construction materials, slope width, and slope height.
1. The slope of a ramp cannot be approved if it exceeds 1 inch increase in height per running foot of ramp. In general, a ramp cannot be approved if it has more than 5 percent grade, or has a maximum slope of 1:12 or less.
2. A new ramp or walkway must have a minimum width of 48 inches, and must be constructed to be non-slip, or be treated to prevent slipping when wet.
a. Any ramp must include railings and low curb or guard rails on both sides to prevent a wheelchair or scooter from running off the edges.
b. A 5'x 5' rest platform must be provided every 30 feet or less depending on the design, or the veteran's ability. NOTE: VA Minimum Property Requirements are the standard for VHA (see subpar. 3c).
(d) If a driveway or walkway is to be improved, information about the material composing the existing area, such as: gravel, concrete, asphalt, etc. NOTE: Requirements for slope are the same as ramp requirements.