10-2511 Authority And Invoice For Travel By Ambulance Or Other H

form. Print additional

lnstructions are written for a m

l$

o"p.rtment of Veterans Affairs

BY AMBULANCE OR OTHER HIRED VEHICLE

reducing the burden, may be addressed by calling the Health Benefits Contact Center ât l-877-222-8387.

furnish the information will have no adverse effect on any other benefìts to which you nray be entitled.

PART I . AUTHORIZATION FOR SERVICE
SOCIAL SECURITY NUMBER

. NAME AND ADDRESS OF EENEFICIARY (lf authorization is issued to ambulance company or hired car owner)

3. DATE AND HOUR AUTHORIZED TO REPORT þnnitd:yyyy¡

IAME AND ADDRESS OF BENEFICIARY OR COMPANY TO WHOM AUTHORIZATION IS ISSUED
(See reverse for instructions)

4. TRANSPORTATION IS AUTHORIZED BY

AMBULANCE

OTHER HIREDVEHICLE

IA. FROM

B. TO

AND
6. CONTRACT NUMBER ANO DATE (lf applicable)

. RATES AUTHORIZEÞ

RETURN

YES

NO

7. CONFIRMS PRIOR AUTHORIZATION (lf applicable) DATED -

(nnkkl/yyry)
I. NAME AND AODRESS OF ISSUING OFFICE

10. FISCAL SYMBOTS

). AUTHORITY

1. ESTIMATED COST OF TRAVEL

3.DATE (nnrdd/yyyy)

12. SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL

PART ll - INVOICE FOR SERVICE (See rever€e for instructions)
14. SERVICE FURNISHED

AMBULANCE

15. FROM

rsA. TO

OTHER HIRED VEHICLE

AND

RETURN YES

NO

6. NAME AND ADDRESS OF PAYEE

18, TOTAL AMOUNT CLAIMED

7. ITEMIZATION OF CHARGES

19. SELECT STATEMENT BELOW THAT PERTAINS TO THE SERVICE AND CHECK THE APPROPRIATE BOX

NO CONTRACT (The rate charged does not exceed the prevailing rate in the commun¡ty)
CONTRACT lN EFFECT (Service prov¡ded in accordance w¡th current contract conditions)

PART III . STATEMENT BY VA OFFICIAL OR DESIGNEE
CERTIFY THAT the service, as specified above, has been accornplished and is approved in accordance with authority issued therefore, or as otherwise showrt in statenrent in
enrarks below, which is ntade a part hereof.
1. DATE (nn'ddtyyy)

IO. SIGNATURE AND TITLE OF VA OFFICIAL

PART
12.

AMOUNT DUE

13.

lv -AUDIT BLOCK lFor Flnanco use only)

DATE (nnakkU¡yyy)

14.

VOUCHER AUDITOR

I5. REMARKS

PART V . ACCOUNTING BLOCK
16.

vA

toN/PAT. NO.

7. TC&S/C

FoRM ,,0-2511

JAN 201

1

18.

CPF

¿9, LIO. AMT.

I
"^ I

31. DATE & INITIALS

;:î"^

ls

;1,""

Is
Page 1 of 2

INSTRUCTIONS

SECTION I - AUTHORIZATION FOR SERVICE (Instructions to Beneficiary)
a, If you cannot report on the date and hour specified in Item 3 on the face of the form, please notify the VA facility shown in
Item 8 and return this form to that office. DO NOT REPORT UNTIL YOU RECEIVE ANOTHER AUTHORIZATION'
(Use the blank space below to write to the VA facility shown in Item 8.)
b. If you have moved to a city or town other than the one shown on the face of this form, enter your ne\il address in the blank
space below and indicate whether it is permanent or temporary. Return this form to the VA facility shown in Item 8 and

DO NOT REPORT UNTIL YOU RECEIVE ANOTHER AUTHORIZATION
c. If you are authorized to travel by hired vehicle instead of ambulance, the hired vehicle cannot be one which is the properly
of a relative or Government employee. For definition of a relative, see Section II b (2) below.

SECTION II - INVOICE FOR SERVICE (Instructions to Ambulance Company and/or Hired Car Operator)
a. Items l4 through 19, under Section II, must be completed by owner or authorized representative who is fully qualified to act
on behalf of the company. In addition, the following information (if applicable) rnust be furnished.

(l) If part or all of the charge is based

on mileage, show the amount of flat fee and amount of mileage separately in Item 17.
Also show the number of miles for which mileage is claimed. Note: A flat fee is an agreed upon charge for service rendered
within a stated area. Where service is rendered solely on rate per mile times number of miles traveled, no additional fee is
allowed, But, if the charge to the general public for like service includes both flat fee and mileage, payment therefore rnay
be made if properly authorized by VA IN ADVANCE or if the charge is so stated in the terms of the contract.
(2) Indicate the time the beneficiary was picked up and the time the destination was reached. (This should be shown only if
there is a contract with VA which specifies different rates for day and night service.)
b. The following instructions apply to companies or individuals who provide hired vehicle service (other than ambulance):

(l)

Travel must be performed by a usually travelled route.
(2) A hired vehicle cannot be the property of a Government employee or a relative. A relative is a spouse, parent, son,
daughter, brother, sister, uncle, aunt, niece, or nephew, by blood or marriage.

SECTION

III.

STATEMENT BY VA OFFICIAL OR DESIGNEE

Entries required are self-explanatory.

SECTION IV - AUDIT BÍ.,OCK
Entries are self explanatory.

NOTE: USE THE BLANK SPACE BELOW FOR COMMUNICATING WITH THE ISSUING VA FACILITY SHOWN
IN ITEM 8 ON THE FIRST PAGE OF THIS FORM.

vA

FoRM

JAN 201

1

10-2511

Page2 of 2