department-of-veterans-affairs/vets-website

import React from 'react';

const NoticeAgreement = () => (
  <>
    <h2>Agreement</h2>
    <p>By submitting this application, you agree to these statements:</p>
    <ul data-testid="ezr-agreement-statements">
      <li>
        You’ll pay any VA copays for care or services (including urgent care)
        that may apply, based on your priority group and other factors.
      </li>
      <li>
        You agree that we can contact you at the address and any email or phone
        number you gave us in this application.
      </li>
      <li>
        You agree to the assignment of benefits so we can bill your other health
        insurance or other responsible party for any charges for
        non-service-connected VA medical care or services that may apply.
      </li>
      <li>
        You’ve read and accept our privacy policy.{' '}
        <span className="vads-u-display--block">
          <a target="_blank" href="/privacy-policy/">
            Read our privacy policy
            <span className="vads-u-visibility--screen-reader">
              , will open in new tab
            </span>
            <span className="vads-u-margin-left--1">
              <va-icon icon="launch" size={3} />
            </span>
          </a>
        </span>
      </li>
    </ul>
    <va-additional-info
      trigger="Read more about the assignment of benefits"
      class="vads-u-margin-y--2 hydrated"
      uswds
    >
      <p>
        I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651,
        the Department of Veterans Affairs (VA) is authorized to recover or
        collect from my health plan (HP) or any other legally responsible third
        party for the reasonable charges of nonservice-connected VA medical care
        or services furnished or provided to me. I hereby authorize payment
        directly to VA from any HP under which I am covered (including coverage
        provided under my spouse’s HP) that is responsible for payment of the
        charges for my medical care, including benefits otherwise payable to me
        or my spouse. Furthermore, I hereby assign to the VA any claim I may
        have against any person or entity who is or may be legally responsible
        for the payment of the cost of medical services provided to me by the
        VA. I understand that this assignment shall not limit or prejudice my
        right to recover for my own benefit any amount in excess of the cost of
        medical services provided to me by the VA or any other amount to which I
        may be entitled. I hereby appoint the Attorney General of the United
        States and the Secretary of Veterans’ Affairs and their designees as my
        Attorneys-in-fact to take all necessary and appropriate actions in order
        to recover and receive all or part of the amount herein assigned. I
        hereby authorize the VA to disclose, to my attorney and to any third
        party or administrative agency who may be responsible for payment of the
        cost of medical services provided to me, information from my medical
        records as necessary to verify my claim. Further, I hereby authorize any
        such third party or administrative agency to disclose to the VA any
        information regarding my claim.
      </p>
    </va-additional-info>
    <p>
      <strong>Note:</strong> According to federal law, there are criminal
      penalties, including a fine and/or imprisonment for up to 5 years, for
      withholding information or for providing incorrect information. (See 18
      U.S.C. 1001)
    </p>
  </>
);

export default NoticeAgreement;