Provider Reference Library
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The fact sheets listed below provide specific information that providers and office managers need to know in order to participate in Community Care programs.You can view fact sheets for all VHA Office of Community Care (VHA OCC) Veteran and family member programs on the Community Care Fact Sheets page.
Below are forms frequently used by our providers. Forms for other Community Care programs can be found on tHe VHA OCC Forms page.
|Form Title||Form description|
|CHAMPVA Mental Health Preauthorization Request – Fillable PDF||This form is for mental health preauthorization for CHAMPVA, a Veterans Affairs family member program.|
|Community Care Provider-Request for Service (RFS), VA Form 10-10172||A standardized form for Community Providers to request additional or continued care or services for Veterans. The purpose of the Community Care Provider-Request for Service, VA Form 10-10172, is to manage requests from community providers and to allow for placement, tracking, managing, and reporting of those requests. The use of the RFS form is recommended for clinical requests from a community provider to facilitate review and authorization.|
|Health Insurance Claim Form (CMS-1500) – Print-Only form||The CMS-1500 Claim Form is the basic paper claim form prescribed by many health care payers for claims submitted by physicians, other providers, and suppliers, and in some cases, for ambulance services.|
|Medical Billing Claim Form, UB-04 (CMS‑1450) Institutional Paper Claim Form*||The CMS-1450 form can be used by an institutional provider to bill a Medicare fiscal intermediary when a provider qualifies for a waiver from the Administrative Simplification Compliance Act requirement for electronic submission of claims. It is also used for billing of institutional charges to most Medicaid State Agencies.|
|Refusal of Transfer to VA Health Care Facility, VA Form 10-8001 – Fillable PDF||VA Form 10-8001 is used when a Veteran refuses to transfer to a VA Health Care Facility.|
|VA-FSC Vendor File Request Form,
VA Form 10091 – Fillable PDF
|VA Form 10091 enables all vendors to apply for payment via Electronic Funds Transfer (EFT), or to submit changes/updates to their Financial Management System Vendor Record in order to receive VA payments that comply with the 1996 Debt Collection Improvement Act.
For questions regarding VA Form 10091, please contact the Nationwide Vendor File Division via email or phone listed below.
PLEASE NOTE: You can download a sample CMS-1450 from the CMS.gov website. However, copies of the form 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.