Community Care

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. Please visit the VA Forms page for other forms not listed here or to search for a specific VA form.

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On this page:

• CHAMPVA
• Foreign Medical Program
• Meds by Mail
• 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 Misceláneos, Forma S10-7959e (PDF Rellenable)
  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 (PDF Rellenable)
• Formulario de Reclamo CHAMPVA, Forma S10-7959a (PDF Rellenable)
  NOTA: Este formulario no es para uso del proveedor.
• Certificacion CHAMPVA de Otros Seguros de Salud, Forma S10-7959c (PDF Rellenable)

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 (PDF Rellenable)

Department of Program Integrity

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