VA Form 10-2850a

Fill out
Export or Print
Download your fillable VA Form 10-2850a in  PDF
VA Form 10-2850a

The VA Form 10-2850a issued by the Department of Veteran Affairs (or VA) is a legal record that certain medical care workers create and sign if they want to cure veterans in the United States. This document is also called the “Application for Nurses and Nurse Anesthetists.”

Veterans in the US have specific insurance, and each applicant approved by the department can render services under this insurance. Each such application contains the following info:

  • Applicant’s personal information;
  • Education details;
  • Work experience info;
  • References (people who can prove that the applicant is qualified enough);
  • Applicant’s rewards, scientific papers, and other achievements;
  • Other data that might be vital for the department.

Every submitted application is attentively checked, and the more experienced the applicant is, the more chances they have. So, if you need to apply, gather all the info about your professional merit and include it in the document.

Who Must Use the Form

The form must be used by either nurse anesthetists or nurses willing to work with veterans who use the department’s health insurance.

If everything is fine with the application, and the specialist who has applied has provided truthful details, their application will probably be approved; they will join the Veterans Health Administration and may be able to participate in veterans’ curation.

Other VA Forms

Need other VA PDF forms? Check out the list below to see what you could fill in and edit with FormsPal. Additionally, remember that it is easy to upload, fill out, and edit any PDF at FormsPal.

How to Fill Out the Template

While many legal forms in the United States are simple to fill out, many signatories feel unconfident and face a lack of instructions. We are here to help: just use our comprehensive guidelines below to fill out the VA Form 10-2850a correctly.

Basically, the form provides the Department with personal details about yourself and your career. You have to be honest when creating the form because all data you insert will be further checked by public authorities.

  • Obtain the Relevant Template

With our user-friendly form-building software, you can get the needed template at a glance. You can download the form on the official VA website, but why surfing on the internet and opening additional tabs if you can find the form right here? So, we recommend downloading the checked and approved file on our website.

  • Read the Instructions

VA has provided applicants with some instructions regarding the form’s completion. You can either write the info using your pen or print the information using your laptop. Also, you might notice a lack of space when adding some specific data: in this case, you can take a separate blank paper and write the necessary details there the way the instructions propose.

  • Give Your Basic Details

The template begins with the applicant’s introduction. Write your full name, what you are applying for (either general practice or specialty), current address, and phone number (with an area code). If you have residence or business phone numbers, add them below.

Then, enter your birth date and place. Put your social security number (or SSN) and state if you are a citizen of the United States. If not, insert the country in the blank field nearby.

step 3 give your basic details filling out a va form 10 2850a

  • Reveal If You Have Ever Filed Such Applications Before

After inserting your data, you should answer if you have ever applied to VA with such a form. If the answer is “yes,” specify where and when you have filed the document.

The department may need to check your info with your current employer. Indicate when it is possible and when you will be available for employment.

step 4 reveal if you have ever filed such applications before filling out a va form 10 2850a

  • Describe Your Active Duty (in Military)

If you are currently in service, enter the terms, serial (or service) number, branch, and discharge type (either “honorable” or “other”; if “other,” you may use a separate sheet to explain more here if needed).

step 5 describe your active duty (in military) filling out a va form 10 2850a

  • Add the Registration Info

You might be registered as a specialist in various states or territories. In this section, you have to list all such territories and write your registration number and expiration dates for each place you enter. If the offered blank lines are not enough for you, use an additional blank sheet.

step 6 add the registration info filling out a va form 10 2850a

  • Describe Your Registration in Detail

Then, you will see several clarifying questions that require a bit more details about your registration. You need to answer either by marking the blank box or writing responses on an additional sheet (depending upon the answer you give).

The first question obliges you to tell if you are fully registered in all listed territories or not. If not, you have to provide details. Then, answer if any of your registration certificates have ever been canceled or restricted (again, if yes, you have to explain the circumstances); if you have ever had registration on practices that are not used anymore.

Finally, describe if you have or used to have any clinical privileges, adding a name of the institution that provides (or provided) them (if applicable). Remember that if you mark the answer which requires additional info, you have to add it to the additional blank sheet.

step 7 describe your registration in detail filling out a va form 10 2850a

  • Complete the Following Section If You Are a Nurse Anesthetist

The next part of the form is for nurse anesthetists only. Answer if you are certified by CCNA (or the Council on Certification of Nurse Anesthetists), indicate the most recent certification (or re-certification) date and your ID number in AANA (or the American Association of Nurse Anesthetists). If your AANA certification has ever been canceled, you must specify why (again, on a separate blank paper).

step 8 complete the following section if you are a nurse anesthetist filling out a va form 10 2850a

  • Pass the Form to the Facility Director or Designee

The following section must be completed by the facility director or responsible designee. Pass the template to them. They should verify the data you have added above, sign the document, add their title, and put the current date.

step 9 pass the form to the facility director or designee filling out a va form 10 2850a

  • Tell about Your Insurance

Next, you must describe your professional liability insurance. Write your insurance’s current and previous carrier along with the terms when insurance is valid. If any carrier has ever revoked your insurance, explain why on a separate paper.

step 10 tell about your insurance filling out a va form 10 2850a

  • Describe Your Education

Then, you have to list places where you have studied and gotten a degree. You shall start with basic nursing education. For each location, write its name and address, program length, the date when you finished your studies, and what you have received (a diploma or a degree). If the suggested blank lines are not sufficient for all your schools, use an additional paper.

Any additional education should be described below the basic education chart. Again, you should add the name and address for each; besides, write the major, termination date, degree, and credits.

After enumerating all the locations, you must answer the question about your professional biography or send an existing copy if you have one. If some places of your studies (or additional and professional education) are not included in your bio, you should also send the missing diplomas and certificates with the form.

step 11 describe your education filling out a va form 10 2850a

  • List Your Workplaces

As you may guess, your work experience is vital for the department. If possible, you have to enter at least three employers and their details. For each entry, insert the entity’s name, address, your position there, dates of your employment, and the name of your chief (director). Mark whether you have been working full-time or part-time.

step 12 list your workplaces filling out a va form 10 2850a

  • Give More General Details

If you have ever used other names than the one, you have stated in the first section, list such names here. Then, you can add all your professional publications, awards, and other achievements. This field does not contain much space, so you can continue writing on a separate paper.

step 13 give more general details filling out a va form 10 2850a

  • Add References

One way to check your data for the department is to use references you provide. There must be four references, and all people you indicate should not be your blood relatives or spouses. They also have to be specialists and have enough qualifications to estimate your skills.

For each person, provide their name, address, phone number, and job (position and entity).

step 14 add references filling out a va form 10 2850a

  • Answer the Questions

After you have added your references, there will be a list of 10 various questions you have to reply to. They are “yes” or “no” questions; depending on your answer, you should or should not explain details on an additional paper.

Read each question attentively and answer honestly. If you cheat and the department discovers it, your application will be considered void, and you will be penalized.

step 15.1 answer the questions filling out a va form 10 2850a
step 15.2 answer the questions filling out a va form 10 2850a

  • Sign the Document

With your signature, you verify that every single detail you have provided is accurate. Check everything once again; if the added data is correct, sign the document and add the signing date next to your signature.

step 16 sign the document filling out a va form 10 2850a

  • Let VA Check Your Information

By filling out the following page, you must allow the department to check all data you have inserted. Mark all boxes with ticks, sign below to express your consent and add the date again.

step 17 let va check your information filling out a va form 10 2850a
After the document is ready, you have to submit it to the VA office located in your area. The department’s official website will advise on all the locations.