Form 10-583 CLAIM FOR PAYMENT OF COST OF UNAUTHORIZED MEDICAL SERVIC

NOTE: lnstructions are wr¡tten for a multi-part

OMB No: 2900-0080
Estimated Burden: l5 min.

form. Print additional cop¡es as necessary.

CLAIM FOR PAYMENT OF COST OF
UNAUTHORIZED MEDICAL SERVICES

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The Paperwork Reduction Act of 1995 requires us to notifr 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 l5 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 l-877-222-8387.

PRMCY 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. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Noticès of Systems
VA Records" 24VAl9, published in the Federal Register. 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.

PART
A. VETERAN'S NAME (Last, tirst, m¡ddle ¡n¡tial) fihis

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