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Forms for VHA Office of Community Care Programs
Forms on this site are available in several formats. Fillable Portable Document Formats can be completed online, edited, saved and printed. Other forms are blank, printable forms which need to be completed offline and mailed.
Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer.
- CHAMPVA
- Foreign Medical Program
- Meds by Mail
- State Homes
- Retail Immunization Care Coordination Program
- Department of Program Integrity
- Forms for Providers
Authorization for Release of Medical Records
- Request For and Authorization To Release Medical Records, VA Form 10-5345 (Fillable PDF)
NOTE: Only use this form for one time release of information.
Care in the Community
- Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF)
Claim for Miscellaneous Expenses
- Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF)
NOTE: This form is not for provider use. - Reclamo de Gastos Miscelaneos, Forma S10-7959e (Fillable PDF)
NOTA: Este formulario no es para uso del proveedor.
CHAMPVA
- CHAMPVA Application for Benefits, VA Form 10-10d (Fillable PDF)
- CHAMPVA Claim Form, VA Form 10-7959a (Fillable PDF)
NOTE: This form is not for provider use. - CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10-7959c (Fillable PDF)
- CHAMPVA School Enrollment Certification Letter (Fillable PDF)
Solicitudes Para Beneficios de CHAMPVA en Espanol
- Aplicación a los Beneficios CHAMPVA, Forma S10-10d (Fillable PDF)
- Formulario de Reclamo CHAMPVA, Forma S10-7959a (Fillable PDF)
NOTA: Este formulario no es para uso del proveedor. - Certificacion CHAMPVA de Otros Seguros de Salud, Forma S10-7959c (Fillable PDF)
Foreign Medical Program (FMP)
- FMP Registration Form, VA Form 10-7959f-1 (Fillable PDF)
- FMP Claim Cover Sheet, VA Form 10-7959f-2 (Fillable PDF)
Meds by Mail
- Meds by Mail Prescription Order Form, VA Form 10-0426 (Fillable PDF)
- Formulario De Pedido Para Medicinas por Correo, Forma S10-0426 (Fillable PDF)
Retail Immunization Care Coordination Program
- VA-Walgreens Information Sheet and Flu Form
Veterans enrolled in the VA Health Care System can download, print and complete the Information Sheet/Flu Form to make it easier to get a flu shot from your local Walgreens.
State Homes Per Diem Program
- State Home Report and Statement of Federal Aid Claimed, VA Form 10-5588 (Fillable PDF)
- Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive Service Connection, VA Form 10-5588A (Fillable PDF)
- State Home Program Application for Veteran Care Medical Certification, VA Form 10-10SH (Fillable PDF)
- Request for Prescription Drugs from an Eligible Veteran in a State Home, VA Form 10-0460 (Fillable PDF)
- Application for Health Benefits, VA Form 10-10EZ (Fillable PDF)
- VA Advance Directive: Durable Power of Attorney for Health Care and Living Will, VA Form 10-0137
(Fillable PDF)
Department of Program Integrity
- Fraud, Waste and Abuse Complaint Form, VA Form 10-0500 (Fillable PDF)
IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. If you do not have Adobe Reader, you can download this FREE software from the Adobe website. (By clicking on the Adobe website link, you will leave the VHA OCC website. We do not endorse and are not responsible for the content of the linked website.)
