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Health Administration Center

Forms

IMPORTANT: You must have at least Adobe Reader version 6.0 on your computer to fully utilize all the forms on this site. You can download software at: Free Adobe Reader Download. Forms on this site are available in several formats. Fillable pdf can be filled on-line, printed, saved and edited. XFT forms can be filled on-line, printed, and saved to your pc but cannot be edited later (TURN OFF YOUR POP-UP BLOCKER TO USE XFT). Some PDF are printable blank forms.

Forms for Providers


Form    
SF-3881 Form * Fillable (pdf)  
* Providers, if you want to apply for payment via Electronic Funds Transfer, complete the "Payee/Company Information" and "Financial Institution" sections of the SF-3881 form, and mail the signed form to:

     Department of Veterans Affairs
     Financial Services Center
     PO Box 149971
     Austin, TX 78714-8971

Or, fax the signed form to: (512) 460-5221


Forms for CHAMPVA Beneficiaries


Form    
CHAMPVA Application for Benefits 10-10d Fillable (pdf)  
CHAMPVA Claim Form (not for providers) 10-7959a Fillable (pdf)  
Forma 10-7959a Formulario de Reclamo CHAMPVA   Print-Only (pdf)
Meds By Mail - Patient Profile Form 10-0426a Fillable (pdf)  
Meds by Mail - Prescription Order Form 10-0426 Fillable (pdf)  
Medicinas por Correo Formulario de Pedido   Print-Only (pdf)
CHAMPVA Other Health Insurance Certification 10-7959c Fillable (pdf)  
Forma 10-7959c Certificacion CHAMPVA de Otros Seguros de Salud (OSS) *   Print-Only (pdf)
* NOTE: To ensure proper formatting of the Forma 10-7959c Certificacion CHAMPVA de Otros Seguros de Salud (OSS) (special printing required, see below instructions)
  1. Click link to open form.
  2. From the File menu, click print.
  3. In the print dialogue screen, make sure that 'Shrink oversized pages to paper size' in the Copies and Adjustments section is clicked off (no checkmark will appear).
  4. Click OK to print form.


Forms for Spina Bifida Beneficiaries


Form    
Spina Bifida Miscellaneous Claim Form 10-7959e (not for providers) Fillable (pdf)  


Forms for Foreign Medical Program (FMP)


Form    
FMP Registration Form - VA Form 10-7959f-1 Fillable (pdf)  
FMP Claim Cover Sheet - VA Form 10-7959f-2 Fillable (pdf)  


Authorization for Release of Medical Records and Release of Information


Form    
Recurring Authorization VA Form10-5345 + Fact Sheet 06-01.
Note: Use this form for continuous release of your information to a spouse, relative, or other designee. 		  Print-Only (pdf)
Authorization Form VA Form10-5345
Note: Only use this form for one time release of information.		 Fillable (pdf)