VA Form 10-0500 Fraud, Waste and Abuse Complaint Form

Estimated Burden: 10 min.
OMB Number 2900-0770

VA

Department of Veterans Affairs

Program Integrity Fraud, Waste and Abuse Complaint Form

Form Instructions:
1. Fill out as much information as possible
2. Attach all relevant documents
3. Submit form to Program Integrity via U.S. Mail
or
4. Fax all associated documents to 303-398-5295

Mailing Address:
VA Purchased Care
Attn: Program Integrity
PO Box 461307
Denver, CO 80246

E-mail: INTERNAL USE ONLY
1. The e-mail must use PKI.
2. Attach the PDF file into e-mail
3. Forward all documents through
internal Outlook Mail Group
4. May utilize interoffice mail as well

Today’s Date
SUBMITTER’S INFORMATION

PATIENT’S INFORMATION-Complete as much as possible

First & Last Name

First & Last Name

Address

Address

City/State/Zip

City/State/Zip
58

Country

Country

Phone

Phone

E-mail

Social Security #

Select One

Program Type

58

PROVIDER’S INFORMATION
Name of Business/Facility/Practice
Tax ID Number

NPI Number

Address

City/State/Zip
Country

58

COMPLAINT INFORMATION
Program Type

Does a claim exist?

Type of Fraud, Waste, or Abuse
Provide a list of all parties involved.

Please provide a detailed description of the suspected fraud, waste or abuse. If, possible, include claim number(s), date(s) of
service and a history of what happened. (Please attach additional pages if needed.)

Documentation Check List (Please select all documents included in this submission)

Total Page Count

Complaint

Bill(s)

EOB(s)

Policy Refer.

Invoice(s)

PPR Screen

FBCS Screen

Sponsor/Patient Info.

VA FORM
DEC 2012

10-0500

Print Form

Medical Docs.
Other

Correspondence

Program Integrity Fraud, Waste and Abuse Complaint Form
PRIVACY ACT INFORMATION: The authority for collection of the requested information on this form is 38 U.S.C. 501 and
1781. The purpose of collecting this information is to adjudicate and process fraud, waste and abuse cases for VA
Purchased Care Program. You do not have to provide the requested information but if any or all of the requested information
is not provided, it may significantly delay processing of your request. Failure to furnish the requested information will have
no adverse impact on any other VA benefit to which you may be entitled. The responses you submit are considered
confidential and may be disclosed outside VA only if the disclosure is authorized under the Privacy Act, including the routine
uses identified in the VA system of records 54VA16, titled "Health Administration Center Civilian Health and Medical
Program Records -VA", 23VA16, titled “Non-VA Fee Basis Records -VA, as set forth in the Compilation of Privacy Act
Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html. For example, information on this
form may be disclosed to VAOIG, FBI, health care providers and other law enforcement agencies involved in actions related
to or affected by health care services rendered, medical benefits or payment for services. Disclosure of Social Security
number(s) of those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary.
Social Security numbers will be used in the administration of veterans benefits, in the identification of veterans or persons
claiming or receiving VA benefits and their records and may be used for other purposes where authorized by Title 38,
U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
PAPERWORK REDUCTION ACT: This information collection is in accordance with the clearance requirements of Section
3507 of the Paperwork Reduction Act of 1995. Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed and completing and reviewing the collection of information. Comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by
calling the Purchased Care Programs Help Line, 1-877-466-7124. Respondents should be aware that notwithstanding any
other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does
not display a currently valid OMB control number. The purpose of this data collection is to provide a mechanism for the
creation of fraud, waste and abuse CHAMPVA or Non-VA Care program complaint inquiry cases.

VA FORM
DEC 2012

10-0500