VA Form 10-314, REQUEST FOR PAYMENT OF 
BOWEL AND BLADDER SERVICES

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OMB Control No. 2900-0924
Respondent Burden: 10 Minutes
Expiration Date: XX/XX/20XX

REQUEST FOR PAYMENT OF
BOWEL AND BLADDER SERVICES
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is 2900-0924, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 10
minutes per person, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA
Reports Clearance Officer at [email protected]. Please refer to OMB Control Number 2900-0924 in any correspondence. Do not send you completed VA Form 10-314 to this email address.
PRIVACY ACT INFORMATION: Information on this form is collected in accordance with the System of Records Notice 23VA10NB3 Non-VA Care (Fee) Records-VA (FR:
Thursday, July 30, 2015). Category: Records maintained in the system include veterans seeking healthcare services under title 38 U.S.C. Chapter 17. Authority: 38 USC Veteran Benefits.
Purpose: Records may be used to establish, determine, and monitor eligibility to receive VA benefits and for authorizing and paying Non-VA healthcare services furnished to veterans and
beneficiaries. Routine Use: Relevant identifying and medical treatment information may be disclosed to a Federal agency or non-VA healthcare provider or institution, including their
billing or collection agent, when VA refers a patient for treatment or medical services, or authorizes a patient to obtain non-VA medical services and the information is needed by the
Federal agency or non-VA institution or provider to perform the services, or for VA to obtain sufficient information in order to consider or make payment for health care services, to
evaluate the services rendered, or to determine the need for additional services. Disclosure: Voluntary. Failure to furnish the requested information will have no adverse impact on VA
benefits.
Information on this form is collected in accordance with the System of Records Notice 186VA10D Community Care (CC) Provider Profile Management System (PPMS)-VA (FR Monday,
January 25, 2021). Category: VA health care providers and Non-VA health care providers. Authority: Public Law 104-191; 5 U.S.C. 301; 38 U.S. Code Sec. 1703; 45 Code of Federal
Regulations (CFR) part 164; and 4 CFR 103. Purpose: Records may be used to establish, determine, and monitor eligibility to receive VA benefits and for authorizing and paying NonVA healthcare services furnished to veterans and beneficiaries. Routine Use: Relevant identifying and medical treatment information may be disclosed to a Federal agency or non-VA
healthcare provider or institution, including their billing or collection agent, when VA refers a patient for treatment or medical services, or authorizes a patient to obtain non-VA medical
services and the information is needed by the Federal agency or non-VA institution or provider to perform the services, or for VA to obtain sufficient information in order to consider or
make payment for health care services, to evaluate the services rendered, or to determine the need for additional services. Disclosure: Voluntary. Failure to furnish the requested
information will have no adverse impact on VA benefits.
VETERAN'S NAME (First & Last):

VETERAN FULL ICN*:
MONTH/YEAR INVOICED (MM/YYYY):

PROVIDER NAME:
PROVIDER ADDRESS:

PROVIDER TIN NUMBER:

PROVIDER PHONE NUMBER: ((999) 999-9999)
PROVIDER NPI:

REFERRAL NUMBER*:

BOWEL AND BLADDER CARE PROVIDED (For dates and time noted below)
DATE

HOURS

MINUTES

DATE

1st

17th

2nd

18th

3rd

19th

4th

20th

5th

21st

6th

22nd

7th

23rd

8th

24th

9th

25th

10th

26th

11th

27th

12th

28th

13th

29th

14th

30th

15th

31st

HOURS

MINUTES

16th

I hereby certify, this is a true account of time spent providing bowel and/or bladder care to the above-named Veteran. By the signature below, Provider
acknowledges that any materially false, fictitious, or fraudulent statement or representation, made knowingly, is punishable by a fine and/or imprisonment pursuant
to 18 U.S.C. §§ 287 and 1001.
DATE (MM/DD/YYYY):

PROVIDER SIGNATURE:

*See VA Referral Form 10-7080
This form is intended for use by Individual B&B Providers certified through the VA's Spinal Cord Injuries and Disorders Program.
VA FORM
XXX 20XX

10-314

YOU MAY REPRODUCE THIS FORM

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INSTRUCTIONS
VETERAN'S NAME (First & Last): Enter the full first and last name of the Veteran who received the services.
PROVIDER NAME: Enter the full name of the provider/caregiver who provided these services.
PROVIDER ADDRESS: Enter the address of the provider/caregiver.
VETERAN FULL ICN: Enter the Veteran's full 17 alpha-numeric Integrated Control Number (ICN). The ICN number can
be found on the Approved Referral for Medical Care (VA Form 10-7080), issued by the referring VA medical center.
Example ICN: 123456789V123456
MONTH/YEAR INVOICED (MM/YYYY): Enter the month and year the services were provided, using the MM/YYYY
format. For example, if the services were provided in January 2026, enter “01/2026.”
PROVIDER PHONE NUMBER: Enter the phone number of the provider/caregiver.
PROVIDER TAX IDENTIFICATION NUMBER (TIN)/SOCIAL SECURITY NUMBER: Enter your 9-digit legal identification
number registered with the IRS.
PROVIDER NPI: Enter the provider/caregiver's 10-digit National Provider Identification Number (NPI).
REFERRAL NUMBER: Enter the alpha-numeric referral number from the Approved Referral for Medical Care (VA Form
10-7080), issued by the referring VA medical center. Example referral number: VA0123456789
BOWEL AND BLADDER CARE PROVIDED (For dates and time noted below): For each date services were provided,
enter the number of hours and/or minutes in the appropriate boxes. Use actual hours and minutes only. For example, if
services were provided for 1 hour and 30 minutes daily, enter “1” under hours and “30” under minutes. Use “8” for 8
minutes, “50” for 50 minutes, etc. Do not use lines, arrows, quotation marks, or other symbols to indicate repeated times
from day to day (each day must be filled out individually). Leave boxes blank for any days when no services were
provided.
PROVIDER SIGNATURE: The provider/caregiver must sign the form.
DATE (MM/DD/YYYY): Enter the date when form was signed, using the MM/DD/YYYY format. For example, if the form
was signed January 22, 2026, enter “01/22/2026.”
For information on where to submit your claim visit:
https://www.va.gov/COMMUNITYCARE/revenue-ops/BowelAndBladder-Claims.asp

VA FORM 10-314, XXX 20XX

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