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Forms on this site are available in several formats. Fillable pdf can be filled on-line, printed, saved and edited. XFT forms can be filled on-line, printed, and saved to your pc but cannot be edited later (TURN OFF YOUR POP-UP BLOCKER TO USE XFT). Some PDF are printable blank forms.

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To find a form, enter the form number (example: 12-1234 or 1234) or a word from the form's title or subject.
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Number Title Issue Date Revision Date # Pages
10-0455a Clinical Trial Inclusion/Enrollment Report 06/01/2007 1
10-0459 Credentialing Release of Information Authorization 01/01/2008 1
10-0460 Request for Prescription Drugs from an Eligible Veteran in a State Home 02/28/2009 02/2008 3
10-0462 Political Activities Fact Sheet and Certification 05/05/2008 8/2015 1
10-0474 Application for Biospecimen Storage at a For-Profit Institution 08/10/2009 1/2011 4
10-0484 Revocation for Release of Individually-Identifiable Health Information- Fillable 01/31/2011 12/2013 1
10-0485 Request for and Authorization to Release Protected Health Information to eHealth Exchange 10/02/2012 12/2016 1
10-0491 Academic Verification - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 5
10-0491A Addendum to Application for Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491C Annual VA Employment or Deferment Verification - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491D Education Program Completion Notice/Service Obligation Placement - HPSP $ VIOMPSP 12/01/2013 01/2018 1
10-0491E Evaluation & Recommendation Form - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491F HEALTH PROFESSIONAL SCHOLARSHIP PROGRAM (HPSP) AGREEMENT 12/01/2013 01/2018 2
10-0491G APPLICATION Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 7
10-0491H Notice of Approaching Graduation - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491I Notice of Change and/or Annual Academic Status - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491J Request for Deferment for Advanced Education - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491K VA Scholarship Offer Response - Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) 12/01/2013 01/2018 1
10-0491L VA VISUAL IMPAIRMENT AND ORIENTATION AND MOBILITY PROFESSIONALS SCHOLARSHIP PROGRAM (VIOMPSP) AGREEMENT 12/01/2013 01/2018 2
10-0525 RESTRICTION OF THE RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH INFORMATION THROUGH eHEALTH EXCHANGE 02/01/2014 02/2014 1
10-0525a RESTRICTION OF THE RELEASE OF INDIVIDUALLY-IDENTIFIABLE HEALTH INFORMATION THROUGH eHEALTH EXCHANGE 06/01/2013 06/2013 2
10-0527 Request and Authorization to Release Protected Health Information to the Choice Program 02/01/2015 10/2015 1
10-0998 Your Rights To Seek Further Review Of Our HealthCare Benefits Decision 03/13/2019 2
10-10-493 TRICARE Affirmation 06/01/2013 4/2016 1
10-10-493a TRICARE For Life Affirmation 06/01/2013 4/2016 1
10-10065 Ethics Consultation Feedback Tool 02/01/2010 05/2016 1
10-10072 Supportive Services for Veteran Families (SSVF) Program APPLICATION FOR SUPPORTIVE SERVICES GRANT 01/15/2014 08/2013 10
10-10072A Supportive Services for Veteran Families (SSVF) Program Participant Satisfaction Survey 01/15/2014 04/2011 3
10-10072B Supportive Services for Veteran Families (SSVF) Program QUARTERLY GRANTEE PERFORMANCE REPORT 01/15/2014 08/2015 3
10-10072C Supportive Services for Veteran Families (SSVF) Program RENEWAL APPLICATION FOR SUPPORTIVE SERVICES GRANT 01/15/2014 08/2012 14
10-10118 Designee for Patient Personal Property 12/02/2014 02/2015 1
10-10145 DEPARTMENT OF VETERANS AFFAIRS VETERANS HEALTH ADMINISTRATION (VHA) VETERANS CHOICE PROGRAM PROVIDER AGREEMENT 12/10/2015 2/2016 6
10-10152 Reimbursement Request for Qualifying Adoption Expenses 03/05/2018 04/2018 5
10-10154 Empoyee Incentive Scholarship Program Mobility Agreement 01/26/2018 01/2018 1
10-10163 Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges 09/26/2019 09/2019 1
10-10164 Opt-Out of Sharing Protected Health Information Through Health Information Exchanges 09/23/2019 09/2019 1
10-10171 Veterans Care Agreement 05/16/2019 05/2019 16
10-10172 Community Care Provider - Request for Service 05/31/2019 2
10-1023 Information Regarding Possible Claim Against Third Party fillable Stock #F01399 04/02/2004 2
10-1086 Research Consent Form - fillable 03/04/1999 8/2015 1
10-10CG Instructions for Completing Application for Comprehensive Assistance for Family Caregivers Program 05/01/2011 04/2016 4
10-10d Application for CHAMPVA Benefits- Fillable 09/17/2004 07/2014 3
10-10EC Application For Extended Care Services 04/12/2019 07/2014 5
10-10EZ Instrucciones Para Solicitar La Afiliacion A Los Beneficios Medicos 07/13/2018 7/2018 3
10-10EZ Instructions For Completing Enrollment Application For Health Benefits Online Application 08/06/2004 03/2015 1
10-10EZ (pdf) Instructions For Completing Enrollment Application For Health Benefits 07/10/2016 08/2017 4
10-10EZR Health Benefits Renewal Form (Fillable) 11/01/2004 08/2017 4
10-10HS Request for Hardship Determination 10/01/2008 03/2015 2
10-10M Medical Certificate 06/05/2003 12/2016 3
10-10SH State Home Program Application For Veteran Care Medical Certification 06/01/2016 09/2016 5
 
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