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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)  
Meds by Mail - Prescription Order Form 10-0426 Fillable (pdf)  
CHAMPVA Other Health Insurance Certification 10-7959c Fillable (pdf)  


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)