Health Care - VA Hospitals Forms

• Application for Furnishing Nursing Home Care to Beneficiaries of Veteran's Affairs
  Prospective care providers should submit this form to the Veteran's Administration to qualify to provide long term care to VA patients.
• Research & Development Letter of Intent Cover Page
  Use this form if you are a scientific researcher and want to apply for research grants from the Veteran's Administration. (10-1313-13)
• VA Geriatrics and Extended Care (GEC) Referral
  Use this form if you are a veteran, or the veteran's care giver, and wish to have the veteran placed in a Veteran's Administration Geriatric Care facility. (10-0415)
• Medical Certificate
  This form is used when a patient checks into a Veteran's Administration hospital. (10-10m)
• VA Advance Directive: Living Will & Durable Power of Attorney for Health Care
  A living will is a document that enables you to make decisions for your care now if you are unable to do so in the future because of an incapacity. This is a sample that you can use. (10-0137)
• Claim for Payment of Cost of Unauthorized Medical Services
  Use this form to claim reimbursement for medical costs that you incurred at a non-Veteran's Administration hospital which you receive VA benefits for. (10-583)
• Authorization and Invoice For Medical and Hospital Services
  Submit this form to the VA to receive reimbursement for health care services at a non-Veteran's Administration hospital for a procedure that was previously authorized. (10-7078)
• Authority and Invoice for Travel by Ambulance or Other Hired Vehicle
  If you were billed by an ambulance to transport you to a hospital for a covered disability submit this form to receive reimbursement for those costs by the Veteran's Administration. (10-2511)
• VA/Department of Defense Sharing Agreement
  Use this form if you will be using both Veteran's Administration and Department of Defense medical facilities for a covered disability. This form will be used to determine which agency will pay for the medical services. (10-1245c)
• Occupational and Environmental Exposure History
  This form detailing your prior work history must be submitted if you have filed a claim with the Veteran's Administration for benefits due to a service connected lung disease. (10-0445)