Form 10-10143g Non-VA Hospital Emergency Notification

OMB Control Number: 2900-0823
Burden: 10 Minutes

NON-VA HOSPITAL EMERGENCY NOTIFICATION
(TO BE COMPLETED WITHIN 72 HOURS OF THE BEGINNING OF TREATMENT)
COMPLETE AND RETURN THIS FORM WHEN A VETERAN PRESENTS EMERGENTLY TO YOUR FACILITY
RETURN TO: [email protected]

PAPERWORK REDUCTION ACT AND PRIVACY ACT INFORMATION
The Paperwork Reduction Act of 1995 requires us to notify 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 10 minutes. This includes the time it will take
to read instructions, gather the necessary facts, and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1703, the Veterans Community Care Program, when
a veteran presents emergently at your facility. Information you supply may be verified from initial submission forward through a computer matching program. VA
may disclose the information that you put on the form, as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy
Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested information is voluntary, but if any or all of the
requested information is not provided, it may result in a delay or denial of your health care benefits under the Veterans Community Care Program. Failure to
furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA with your Social Security Number, VA will use
it to administer your VA benefits. VA also may use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for
other purposes authorized or required by law.

Today’s Date:

VETERAN INFORMATION

VENDOR INFORMATION

Last Name:

Facility Name:

First Name:

Facility NPI:

Date of Birth:

Facility Tax ID:

Social Security Number:

Facility Phone #:

HOME ADDRESS

FACILITY POC TO WHOM VA DECISION WILL BE SENT

Street:

Full Name:

City:

Phone #:

State:

Zip:

OTHER INSURANCE
Yes

Email:
FACILITY ADDRESS

No

Street:

Carrier:

City:

Policy #:

State:

Zip:

EPISODE INFORMATION
Date / Time of Emergency:

ONE OR MORE OF THE FOLLOWING IS REQUIRED

Mode of Arrival:

Chief Complaint:

Admitted?

Yes

Discharge Date:
VA FORM
MAY 2020

10-10143g

No

Admit DX:
Discharge DX?