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VHA Office of Community Care

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Provider Reference Library

Fact Sheets–Veteran Programs | Fact Sheets–Family Member Programs
Forms | Training and Presentations

Fact Sheets

The fact sheets listed below provide specific information that providers and office managers need to know in order to participate in VHA Community Care Programs. You can view fact sheets about our Veteran programs and beneficiary programs on our Fact Sheets page.

Veteran Programs

Family Member Programs

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Forms

Below are forms frequently used by our providers. Forms for other VHA Community Care programs can be found on our Forms page.

  • FSC Vendor File Request Form, VA Form 10091 (Fillable PDF)
    This form enables all vendors to apply for payment via Electronic Funds Transfer, or to submit changes/updates to their Financial Management System (FMS) Vendor Record in order to receive VA payments that comply with the 1996 Debt Collection Improvement Act. For questions regarding VA Form 10091, send an email to VAFSCVENDOT@VA.GOV or call 1-877-353-9791.
  • CMS-1500 (OMB NO. 0938-0999), Health Insurance Claim Form
    (Print-Only PDF)
  • UB-04 CMS-1450 (OMB NO. 0938-0997), Medical Billing Claim Form
    You can download a sample of the form from the CMS Forms – CMS 1450 Details web page. However, copies of the CMS-1450 should not be downloaded for submission of claims, since they may not accurately replicate colors included in the form. These colors are needed to enable automated reading of information on the form. Visit the Institutional Paper Claim Form (CMS-1450) web page for information on obtaining the CMS-1450.
  • UB-92 HCFA-1450 (OMB NO. 0938-0279), Medical Billing Claim Form
    As of May 23, 2007, the use of form UB-92 HCFA-1450 has been discontinued; only the new UB-04 billing form is to be used. All rebilling of claims should use the UB-04 billing form, even though earlier submissions may have been on the UB-92. For more information, visit the National Uniform Billing Committee website at www.nubc.org.

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 Email Updates

Providers can stay up to date with VHA Office of Community Care programs by subscribing to our email distribution list. Click the image link above and include your name in the body of the email.