Va Form 10 583 PDF Details

Navigating the complexities of healthcare reimbursement for veterans, particularly when it concerns unauthorized medical services, can be daunting. The VA Form 10-583, titled "Claim for Payment of Cost of Unauthorized Medical Services," emerges as a crucial document in this process. This form is meticulously designed under the authorization of the Paperwork Reduction Act of 1995 and adheres to the provisions laid out under Title 38 of the United States Code, which governs veterans' benefits. The form's primary purpose is to facilitate veterans or their representatives in seeking reimbursement for medical services that were availed outside the VA medical system without prior authorization. The estimated time to complete this form is around 15 minutes, which accounts for reading the instructions, gathering necessary information, and filling out the form. The privacy of the applicant is protected under the Privacy Act Information clause, ensuring the information collected is solely used to determine entitlement to reimbursement. Notably, the absence of requested information may hinder the processing of a claim, yet it does not affect any other benefits a veteran may be entitled to. The document necessitates specific details about the veteran, the provider of the unauthorized services, the circumstances under which the services were provided, and the financial claim being made. An important aspect of completing and submitting the VA Form 10-583 is its prerequisite for being sent to the VA Medical Facility where the veteran is enrolled, underscoring a vital link in the administrative chain aimed at managing healthcare costs while ensuring veterans receive the care they need, even in instances where prior approval was not secured.

QuestionAnswer
Form NameVa Form 10 583
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names10 583, 583 va 10, va 10 583 form, 583 form payment unauthorized

Form Preview Example

NOTE: Instructions are written for a multi-part form. Print additional copies as necessary.

OMB No: 2900-0080

Estimated Burden: 15 min.

CLAIM FOR PAYMENT OF COST OF

UNAUTHORIZED MEDICAL SERVICES

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. 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 15 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by calling the Health Benefits Contact Center at 1-877-222-8387.

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, United States Code, "Veterans Benefits," and will be used to assist us in determining your entitlement to reimbursement for services rendered. It will not be used for any other purpose. Disclosure is voluntary. However, failure to furnish the information will result in our inability to process your claim. Failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled. This form and relevant documents need to be sent to the VA Medical Facility where the Veteran is enrolled for medical care

PART I

1A. VETERAN'S NAME (Last, first, middle initial) (This is a mandatory field.)

1B. CLAIM NUMBER

1C. SOCIAL SECURITY NUMBER (Mandatory field.)

C-

1D. VETERAN'S ADDRESS (lnclude complete ZIP Code)

2A. NAME AND ADDRESS OF PERSON, FIRM OR INSTITUTION MAKING CLAIM (Leave blank if same as above)

2B. SOCIAL SECURITY NO. OR

 

EMPLOYEE IDENTIFICATION NO.

3.STATEMENT OF CIRCUMSTANCES UNDER WHICH THE SERVICES WERE RENDERED (Include diagnosis, symptoms, whether emergency existed, and reason VA facilities were not used)

 

4. AMOUNT CLAIMED

 

Attach bills or receipts showing services furnished, dates and charges

0.00

 

 

 

 

 

 

 

5.

COMPLETE A OR B AS APPROPRIATE

 

A. Amount charged does not exceed that charged the general

B. I certify that the amount claimed has been paid and

 

public for similar services. Payment has not been received.

reimbursement has not been received.

SIGNATURE AND TITLE OF PROVIDER OF SERVICE AND DATE

(mm/dd/yyyy)

SIGNATURE OF VETERAN OR REPRESENTATIVE AND DATE

(mm/dd/yyyy)

 

PART II - FOR VETERANS

 

 

 

AFFAIRS USE ONLY

6. ACTION

APPROVED

$

 

DISAPPROVED

 

 

 

 

7. SIGNATURE OF CHIEF, MEDICAL ADMINISTRATION SERVICE

CLAIM MEETS THE REQUIREMENT OF VA REGULATION

60806081

8. DATE

9. ADMINISTRATIVE VOUCHER NUMBER

VA FORM

10-583

DEC 2010

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step 1 to writing va 10583 form

The application will expect you to fill out the AMOUNT CLAIMED, Attach bills or receipts showing, A Amount charged does not exceed, B I certify that the amount, COMPLETE A OR B AS APPROPRIATE, SIGNATURE AND TITLE OF PROVIDER OF, SIGNATURE OF VETERAN OR, ACTION, APPROVED, PART II FOR VETERANS AFFAIRS USE, CLAIM MEETS THE REQUIREMENT OF VA, DISAPPROVED, SIGNATURE OF CHIEF MEDICAL, DATE, and ADMINISTRATIVE VOUCHER NUMBER segment.

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