10-7078 Authorization And Invoice For Medical And Hospital Servi

OMB Nunber: 2900-0080
Estimaled Burden: 2 minules

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

AUTHOR¡ZATION AND INVOICE FOR MEDICAL AND
HOSPITAL SERV¡CES

$$ o.purtment of Veterans Affairs

collection, including suggestions for reducing the burden, nay be addressed by calling the Health Benefits Conlact Cenler

PRIVACY

.TION: The infornration requested on this form

is solicited under authority of

^t

l-877-222-8387.

Title 38, U.S.C., Veterans

and

will

be used to

ofprocessing your application. The infornration you supply nray also be disclosed outside the VA as permitted by law or æ stated in the "Notices ofSystems ofVA
Records" 24VAl9, published in the Federal Register. Disclosure is voluntar, however, failure to furnish the information will result in our inability to process your request
and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.
1A, DATE OF ISSUE

1C. DATE OF ISSUE (Month, day, year)

18. tSSUtNG OFFTCE

þm/dd/yy.uy)
1D. VËTERAN'S NAME (First, middle initial,

2. NAME OF PHYSICIAN OR FACILITY

last)

Qhis is a nandarorylield.)

4. SOCIAL SECURITY NUMBER

3. VETERAN'S CLAIM NUMBER

c5. AUTHORIZATION VALID

FROM
tnn/tlú'.vyy)

TO
(múld/yy¡ry)

PART I . SERVICES AUTHORIZED
6. SERVICES SHO!\N BELOWAUTHORIZED FOR PERIOD INDICATED lN ITEM 5 ABOVE. (See spec¡al provisions on back of

8. FEE SCHEDULE OR CONTRACT

form.)

94.

9. AUTHORITY

7.FEE

10. ESTIMATED AMOUNT

12. AUTHORIZED BY (Name and Title)

11. FISCAL SYMBOLS

36

0160.001

PART II .INVOICE
r3. DATE(S)
OF SERVICE

MONTH OAY

14. DESCRIPTION OF SERVICE (lf services furnished are identical to those authorized, enter
the remark'As Authorized Above" in this column. Otherwise, itemize services.)

YEAR

SERVICE FURNISHEO

15A. SOCIAL SECURITY NO
OR EMPLOYER ID NO

lndividual or organization furnishing sery¡ce,
enter billing date and amount claimed.
(Continue billing on back if necessary.)

16. BILLING OAlÊ.

15. FEE

CLAIMED
AMOUNT

(nn/ddlywy)
17. TOTAL
CLAIMED

PART III . FOR VA USE ONLY
AUDIT BLOCK

ADMINISTRATIVE CERTIFICATION
Pavment of this will not cause pavee to exceed maximum amount allowed.
SeÍvices have been furnished äs authorized or medically approved except as
stated below.
SIGNATURE AND TITLE

DATE

AMOUNT DUE

DATE

VOUCHER AUDITOR

REMARKS

PART IV . ACCOUNTING BLOCK
ION PAT NO

TC&SC

ilâf9ffi 10-7078

CPF

LIQ

AMT

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$

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PART ll - INVOICE (Continued)
13. DATE(S)
OF SERVICE
MONTH

DAY

15. FEE CLAIMED
14. DESCRIPTION OF SERVICE
AMOUNT

YEAR

16. BILLING DATE

'

total in lTon front of form also.

I7A. TOTAL
CLAIMED

SPECIAL PROVISIONS: Acceptance of this authorization to render service is governed by the following:

*

ACCEPTANCE OF THIS AUTHORIZATION AND PROVIDING OF SUCH TREATMENT OR SERVICES SUBJECTS YOU, THE
PROVIDER OF CARE, TO THE PROVISIONS OF PUBLIC LAW 93-579, THE PRIVACY ACT OF 1974, TO THE EXTENT OF
THE RECORDS PERTAINING THE VA AUTHORIZED TREATMENT OR SERVICES OF THIS VETERAN.

In no event should charges be made to the VA in excess of

ú^

Fees or rates listed represent maxi¡num allowance for services specified.
usual and customary charges to the general public for similar services.

*

Payment by

*

Unless otherwise approved by VA, services are limited in type and extent to those shown on the authorization.
initiated for any reason, return a copy ofthe authorization to the issuing office with a briefexplanation.

VA

is payment in

full for authorized services rendered.

If

services are not

*

A copy of the Operative Report will be forwarded to the authorizing facility within I week following any nrajor surgery.

*

A copy of the hospital summary will be forwarded to the authorizing facility within l0 work days following the release of the patient
from the hospital.

All questions relat¡ng to this authorization should be referred to the issuing VA Facility.
,il

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10-7078

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