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VHA Office of 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 (PDFs) can be completed on-line, edited, saved and printed. Other forms are blank, printable forms which need to be completed offline and mailed. All PDF forms require the use of Adobe Reader software to open them on your computer.

IMPORTANT: You must have the latest version of Adobe Reader on your computer to fully utilize all of the forms on this site. You can download this software from the Adobe website at https://get.adobe.com/reader/. (NOTE: By clicking on the Adobe website link, you will leave the VHA Office of Community Care website. VHA CC does not endorse and is not responsible for the content of the linked website.)

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.

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)

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 CHAMPVAForma S10-10d (Fillable PDF)
  • Formulario de Reclamo CHAMPVAForma S10-7959a (Fillable PDF)
  • Certificacion CHAMPVA de Otros Seguros de SaludForma 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)

Care in the Community

  • Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF)

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 Certificate, 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)

VA 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.

Department of Program Integrity

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

Forms for providers are located in the Provider Reference Library