Va Form 10 2570D PDF Details

The VA Form 10-2570D is a crucial document for veterans seeking outpatient dental care services through the Department of Veterans Affairs (VA). Designed as a multipurpose form, it encompasses authorization for dental examinations, outlines treatment procedures recommended by dental professionals, and also functions as an invoice for the services provided. This form serves as the bedrock for ensuring that veterans receive the necessary dental care, with particular focus on treatments deemed service-incurred and therefore covered at government expense. The form clearly delineates the roles and responsibilities of participating dentists, emphasizing the need for pre-authorization by the VA for all treatments to ensure eligibility for payment. It addresses various scenarios including emergency care, adjustments to treatment plans, and referrals to specialists or general practitioners, ensuring a comprehensive framework for the administration of dental care to veterans. Additionally, it outlines the necessity for timely completion of treatments and adherence to the stipulated procedures for the submission of treatment information and claims for payment. With its detailed instructions and structured process, VA Form 10-2570D plays a pivotal role in facilitating access to dental care services for veterans, guiding dentists through the VA’s protocols, and maintaining the integrity of the treatment authorization and payment system.

QuestionAnswer
Form NameVa Form 10 2570D
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesva form 10 2570g, va form 10 2570, va 10 2570d, va 10 2570

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NOTE: INSTRUCTIONS ARE WRITTEN FOR A MULTI-PART FORM. PRINT ADDITIONAL COPIES AS NECESSARY

DENTAL RECORD AUTHORIZATION AND

INVOICE FOR OUTPATIENT SERVICES

PART I - EXAMINATION PROCEDURE INSTRUCTIONS FOR THE PARTICIPATING FEE DENTIST

1.Examination Authorization. The Department of Veterans Affairs (VA) has authorized this veteran to choose a general practitioner who will complete a thorough oral examination and treatment plan. The VA must be apprised of the veteran's current dental needs so as to make a determination of the extent and type of treatment to be authorized. The allowable fees for radiographs and examination have been indicated in Item 14 on page 3 of this form. The fee for radiographs is based on a full mouth series. This is a basic requirement when no diagnostically usable radiograph record exists relating to a complete dentition. In a circumstance where depleted dentition or edentulous status exists, the requirement for radiographs should be modified by the examining dentist. Any modification from a full mouth series should be annotated by specifying the radiographs actually exposed. The fee will be adjusted, accordingly, by the VA. On subsequent examinations, only radiographs necessary for proper diagnosis and treatment should be taken. Where pre-existing radiographs will serve to satisfactorily augment a thorough clinical evaluation, the pre-printed entry in Item 9 should be crossed out and initiated by the examining dentist.

WHEN IS ITEM 11 COMPLETED? WHICH ITEM AUTHORIZES TREATMENT?

2.Inappropriate selection of fee dentist. If you are a specialist, your practice is restricted to a specialty, or you are currently on active military duty and engaged in part-time private practice, the veteran has made an inappropriate selection of a fee dentist. (VA is prohibited from making payment of fees to a member of the military services.) Return this authorization and allied papers to the veteran and clarify that a Civilian General Practice Dentist must be chosen for examination and treatment plan purposes. If the veteran needs assistance, the Chief of Dental Service at the VA issuing office may be contacted.

3.Use of form. VA Form 10-2570d will serve for examination record, treatment recommendations, record of treatment and invoice for services provided. When you receive the carbon-interleafed VA Form 10-2570d, please keep all copies together. Entries must be made with a typewriter or ball point pen only. Use heavy pressure with a ball point pen. Inspect the last copy to see if all entries have been recorded legibly. Supply all data requested in Items 2 through 5. Be certain to include your telephone number (including area code) in Item 2A.

4.Examination authorized. The examination authorization is your authority to proceed with radiographs and examination only. You may not proceed with definitive dental care for your veteran patient. Payment will not be made for unauthorized treatment. The only exception is for limited EMERGENCY dental care. To obviate an emergency situation, care which is needed at the time of the examination (relief of pain, etc.) can be provided. However, the VA office (shown in Item 1) issuing this authorization must be notified of the details and treatment within 15 days or there is no authority to make payment for these emergency services.

5.Dental examination. Chart all missing teeth in Item 6. Enter the date examination was conducted and radiographs were taken in Item

10opposite the appropriate pre-printed entries in Item 9. During the examination, take care to discuss options and not commit to any specific treatment plan. If there are significant differences between what VA considers reasonable and appropriate and the proposed treatment plan, VA may reexamine the veteran prior to treatment authorization to determine a treatment plan that provides a satisfactory resolution of needs and is compatible with cost containment measures. List all treatment recommendations under Items 7, 8 and 9. Types of abutments and pontics for fixed partial dentures must be stipulated and teeth to be clasped for removable partial dentures must be specified. Enter your usual and customary fee for each line entry under Item 12. Enter statements in Item 13 (Remarks) which will further clarify data under Item 9. Please identify specific teeth which the veteran states were extracted while he was in active military service. Details as to appropriate dates and places of extractions are necessary to determine if replacements can be authorized. When all appropriate entries have been completed, return the packet along with the patient's radiographs to the issuing office (shown in Item 1) for treatment authorization.

6.Requirement to review radiographs. The VA outpatient dental care program operates under legal restriction and, with few exceptions, only those dental conditions determined to be "service-incurred" may be corrected at Government expense. Therefore, it is necessary that treatment recommendations and radiographs be returned to the issuing office (Item 1) for determination of the extent of allowable treatment at VA expense and establishment of authorized fees for these services. Radiographs will be returned to you with the treatment authorization and may be retained by you for your records.

7.Time limitation. There is a time limitation indicated in Item 19. Examination should be completed and findings returned by this date. If veteran does not respond for examination, return the authorization to the issuing office. If there is a good reason an extension of time is required, contact the issuing office (Item 1) for an extension of the time limitation.

8.Payment for Services. Payment for examination and treatment will be made following completion or termination of treatment.

9.Precaution. There may be instances in which recently discharged veterans will report directly to your office requesting that certain dental treatment initiated by the Military during service be completed at Government expense. While it is possible that such veterans, after making application, may be determined eligible for treatment, VA will not be responsible for dental services provided prior to the date treatment is appropriately authorized.

VA FORM

10-2570D DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA

Instructions

MAR 2008 (R)

NOTE: INSTRUCTIONS ARE WRITTEN FOR A MULTI-PART FORM. PRINT ADDITIONAL COPIES AS NECESSARY

PART II - TREATMENT PROCEDURE INSTRUCTIONS FOR THE PARTICIPATING FEE DENTIST

1.Treatment Authorization. The Department of Veterans Affairs (VA) has authorized all dental treatment recommended under Item 9 which has not been lined out. The fees specified in Item 12 are approved unless changed in Item 14. Your acceptance of the treatment authorization constitutes a contract to provide the authorized services for the approved fees, as payment in full. DO NOT request the veteran to pay any difference between the fees authorized and your usual customary fees. If you are unable to provide the services for the fees specified, the authorization should be promptly returned to the VA issuing office shown in Item 1. There is no objection to making separate arrangements with the veteran for any need service which legally the VA is unable to authorize.

2.Treatment. When services indicated under Item 9 have been provided, enter the date each service was completed under Item 10. This dated entry in Item 10 will constitute a validation of the service provided by you and claim for payment of said service. When all treatment has been completed, remove the third copy of the form for your records and return the remaining packet to the authorizing office for payment. No separate invoice or letterhead is necessary. In order to avoid any misunderstanding concerning fraud, submission of the completed form to the VA should not take place until all the treatment for which claim is being made has been provided.

3.Change in Treatment Plan by VA. The VA is the primary provider of dental care for VA beneficiaries and not a third-party carrier. Treatment cases which are beyond the VA's capability to provide care in timely fashion are referred to fee dentists as alternate providers. Consequently, there is need for consistency between the type and amount of care provided by the VA and that provided by private dentists. If on review of your treatment plan, the VA disagrees with either of these factors, the Chief of Dental Service will contact you to discuss the change or it will be noted on the VA Form 10-2570d as an altered plan prior to treatment authorization.

4.Change in Treatment plan by Fee Dentist. If circumstances necessitate a change in the treatment plan or if you disagree with the approved treatment plan, it will be necessary to contact the Chief of Dental Service at the issuing VA office (shown in Item 1) for approval of the change in the authorized services and fees prior to proceeding with the altered plan.

5.Spot check examinations. The VA routinely conducts a program of post-treatment clinical evaluations to assure satisfactory conclusion of the care authorized in the veteran's behalf. Pre-treatment examinations are also employed, as indicated, to assure consistency and appropriateness of planned treatment.

6.Time limitation for treatment. Treatment should be completed by the date shown in Item 28. If the patient does not respond for appointment, return the authorization to the issuing VA office (shown in Item 1). If, for good reason, an extension of time is required, please contact the same issuing office.

7.Restriction of Treatment. The VA outpatient dental care program operates under legal restrictions and, with few exceptions, only those conditions having been determined by VA to be "service-incurred" may be corrected at government expense.

8.Referral of Treatment.

a.If you find it necessary to refer any part of the authorized plan to another General Practitioner you may do so if the other dentist agrees to provide the care for the pre-authorized fees. The VA must be notified as to the identity of the other dentist and the specific services to be provided. Your original authorization must be amended by you to reflect your altered participation as well as the change to total fees which will be due to you.

b.If you find it necessary to refer any part of the authorized treatment to a Specialist you must first contact the Chief of Dental Service at the issuing VA office (shown in Item 1) prior to any referral (except in a true emergency). The VA must: (1) concur in the need for referral to a specialist; (2) confirm the specialty status of that individual; (3) negotiate with the specialist on appropriate fees for the specific services to be provided; or (4) determine if these services should be provided by VA staff.

9.Incomplete treatment. If for reasons beyond your control, you are unable to complete treatment as authorized, you should return the VA Form 10-2570d indicating the completed portions of treatment with an explanation of circumstances attached. If the patient has moved and has contacted you, please include the new address. Undelivered prostheses should be forwarded to the issuing VA office (shown in Item 1) along with your returned documents.

10.Questions concerning treatment or procedure. If any questions arise concerning dental care or procedures, contact the Chief of Dental Service at the issuing VA office (shown in Item 1). Clarification and/or concurrence will provide for proper procedure sequences and avoid undue problems.

11.Exclusion of dentists on active military duty. Dentists who are currently on active military duty and engaged in part-time private practice may not participate as fee dentists in the treatment of authorized veteran beneficiaries. The Comptroller General's decision 505, April 1, 1968 prohibits VA from making payments to members of the military service since, in their determination, it constitutes dual compensation of the dentist by the Federal Government. If dental treatment is provided under these circumstances, neither the VA or the veteran will be obligated for payment.

VA FORM

 

 

MAR 2008 (R) 10-2570D

DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA

Instructions

NOTE: If completing this form manually, please press firmly using a ballpoint pen.

OMB Number: 2900-0335

Estimated burden: 20 min.

DENTAL RECORD AUTHORIZATION AND

INVOICE FOR OUTPATIENT SERVICES

Paperwork Reduction Act: This data collection is in accordance with the clearance requirements of 5 CFR Part 1320. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This data is collected to authorize treatment, list the dental needs and serve as an invoice for treatment provided. Response is voluntary and failure to respond will have no impact on any benefits to which you may be entitled.

1. ISSUING OFFICE: VA MEDICAL CENTER

Fee Dentist: EXAMINATION

AUTHORIZATION

2. NAME, ADDRESS AND ZIP CODE OF FEE DENTIST

 

 

3. ARE YOU NOW

4. SSN OR IRS GROUP

DOES

NOT allow for proceeding beyond diagnoses

 

 

 

 

 

 

 

ON ACTIVE

 

NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MILITARY DUTY

 

 

 

 

 

 

 

 

 

 

 

 

 

and treatment

plan. Complete

all applicable items

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

through

13

and

return

(with X-rays) for

 

 

 

 

 

 

 

 

 

 

4A. LICENSE NUMBER

TREATMENT AUTHORIZATION. Acceptance of an

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

authorized treatment case constitutes a contract to

 

 

 

 

 

 

 

 

 

 

 

 

 

provide

the

authorized

services for the approved

2A. FEE DENTIST'S TELEPHONE NUMBER

 

 

 

5. SIGNATURE OF FEE DENTIST

 

fees,

 

as

payment in full. The patient must not be

 

(999) 999-9999

 

 

 

 

 

 

 

 

 

requested to pay additional fees for those services.

 

 

 

 

 

 

6. MARK OUT ANY MISSING TEETH

Permanent

 

Primary

 

Refer to attached instructions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 2

3 4 5 6 7 8

9 10 11 12 13 14 15 16 A B C D E F G H I

 

 

 

 

 

 

 

 

 

 

 

 

USE EXTRA PAGE FOR MORE SPACE.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32 31

30 29 28 27 26 25

24 23 22

21

20 19 18 17

T

S R Q P O

N M L

7.

 

 

 

8.

 

 

 

 

ENTER ONLY ONE TOOTH NUMBER, ONE PROCEDURE, ONE DATE OF SERVICE AND ONE FEE PER LINE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

S

 

 

 

9. DESCRIPTION OF SERVICE

 

 

 

10. DATE SERVICE

 

 

12. USUAL &

 

14. FEES

T

U

 

 

 

 

 

 

 

 

 

11. CODE NO.

CUSTOMARY

 

APPROVED

U

R

(MO,

(List specific treatment recommendations in this column & indicate your usual &

 

PERFORMED

 

 

O

 

 

 

 

FEE

 

BY VA

M

F

DO,

 

 

customary fee in column 12)

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

A

MOD,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

EXAMINATION (Indicate date)

 

 

 

 

 

 

 

 

 

 

 

 

 

E

C

ETC.)

 

 

 

 

 

 

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

 

 

 

 

 

 

RE

SLIST X-RAYS FIRST (Type & No.), THEN OTHER SERVICES

13.REMARKS: Include significant periodontal disease, soft tissue lesions, presence and serviceability of existing prostheses, pathogenicity of impacted teeth and statement concerning teeth extracted while in service. Attach additional sheet if necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTICE: Acceptance of this authorization and providing of such services or treatment

 

 

23. SERVICES NOT LINED OUT IN ITEM 9

DATE

 

subjects

you, the provider of care, to the provisions of Public Law 93-579, the Privacy

DENTAL

ARE APPROVED

 

 

 

Act

of

1974, to the extent of the records of the treatment of this veteran.

VA pertinent

REVIEW/

SIGNATURE OF CHIEF, DENTAL SERVICE OR DESIGNEE

 

(mm/dd/yyyy)

rules

and regulations

implementing this law are available on request at any VA

APPROVAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

facility.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. FISCAL SYMBOL

 

16. OB. NO. AND D.S.

17. VA REGULATION

24. FISCAL SYMBOL

25. OB. NO. AND D.S.

26. VA REGULATION

36

 

 

0160.001

 

 

 

 

36

 

0160.001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. AUTHORIZATION FOR: X-RAYS & EXAMINATION

$

 

27. AUTHORIZATION FOR

TREATMENT

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. EXPIRATION DATE

 

20. AUTHORIZING SIGNATURE AND DATE

(mm/dd/yyyy)

28. EXPIRATION DATE

29. AUTHORIZING SIGNATURE AND DATE

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL ADJUNCT CERTIFICATION

21. DENTAL TREATMENT

NECESSARY AS ADJUNCT TO MEDICAL DISABILITY OF:

 

IS

 

IS NOT

 

 

 

 

 

 

 

 

 

 

 

 

22. CERTIFYING SIGNATURE AND DATE

(mm/dd/yyyy)

 

 

 

 

 

 

31.PRINT OR TYPE BENEFICIARY'S NAME, IDENTIFICATION NUMBER, CURRENT ADDRESS, ZIP CODE, AREA CODE AND TELEPHONE NUMBER

30. TOTAL AMOUNT AUTHORIZED

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32. THE SERVICES AND FEES LISTED ARE APPROVED EXCEPT:

 

33. SIGNATURE OF APPROVING OFFICIAL

 

33A. DATE

 

 

(mm/dd/yyyy)

 

 

 

 

FOR FISCAL USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34. APPROVED

35. VOUCHER AUDIT

 

36. DATE

(mm/dd/yyyy)

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STA. #

 

PAT. #

T/C & S/C

 

INITIALS

 

DATE

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(999) 999-9999

CPF

LIQ. AMT.

$

1ST S/A

$

2ND S/A

$

VA FORM

10-2570D

DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA

MAR 2008 (R)

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Step # 1 for completing vha 10 2570d

2. Now that this part is complete, you'll want to put in the necessary details in REMARKS Include significant, NOTICE Acceptance of this, OB NO AND DS, VA REGULATION, DENTAL REVIEW APPROVAL, SERVICES NOT LINED OUT IN ITEM, DATE, SIGNATURE OF CHIEF DENTAL SERVICE, mmddyyyy, FISCAL SYMBOL, OB NO AND DS, VA REGULATION, AUTHORIZATION FOR XRAYS, EXAMINATION, and AUTHORIZATION FOR TREATMENT in order to move on to the next part.

vha 10 2570d conclusion process outlined (portion 2)

3. The following portion focuses on APPROVED STA, PAT, TC SC, INITIALS, DATE, mmddyyyy, CPF, LIQ AMT, ST SA, ND SA, VA FORM MAR R d, and DENTIST NO PAYMENT WILL BE MADE - fill in all of these fields.

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