Forms for VHA Office of Community Care Programs - Community Care
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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.

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 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)

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

Department of Program Integrity

  • Fraud, Waste and Abuse Complaint Form, VA Form 10-0500 (Fillable PDF)

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