Free VA Form 10-7959E - Claim for Miscellaneous Expenses- fillable - Federal

Department of Veterans Affairs
VA Health Administration Center

Claim for Miscellaneous Expenses

OMB Number: 2900-0578

Est. Burden: 6.5 minutes

1-888-820-1756

Attention: After reviewing the following, complete form in its entirety (print or typewritten only) and return with required documentation. Receipts must be provided with this form to ensure proper payment. Failure to provide the requested information will result in a delay or denial of reimbursement. If more space is needed, continue in the same format on a separate sheet. Note: This form is required for all claims for reimbursement of miscellaneous expenses related to the treatment of spina bifida and other covered birth defects and associated covered conditions. Regardless of the type of expense being claimed, completion of Sections I, II, and IV are mandatory. Completion of Section III is required only for claims involving travel. Reimbursement for approved expenses (including attendant travel/miscellaneous expenses) will be made payable to the beneficiary. Section I - Patient Information
Last Name First Name MI Social Security Number

Street Address

Date of Birth (mm/dd/yyyy)

City

State

ZIP Code

Telephone Number (include area code)

Last Name

First Name

Section II - Sponsor Information

MI

Social Security Number

Attach required receipts for expenses claimed (receipts for privately owned vehicle mileage [POV] excluded)

Section III - Travel Yes

Will the provider be billing for services? (Check one)
Date of Service (mm/dd/yyyy) Provider Tax ID Number

No
Provider signature certifying service on service date (type if electronic)

Certification of Medical Service (required for all travel claims)

Patient Travel Information
Mode of Travel

X

Airline Bus
Date(s) of travel (mm/dd/yyyy)

Taxi Train
City

POV (round trip) mileage

Other (specify)
Departure
State Time (e.g. 0815) City

Arrival
State Time (e.g. 0815)

Date(s) of travel (mm/dd/yyyy)
City

Departure
State Time (e.g. 0815) City

Arrival
State Time (e.g. 0815)

Last Name

First Name

Attendant Information

MI

Relationship to Patient

Patient/Attendant Miscellaneous Expenses

Lodging $

Other (parking, tolls, etc.) $


City VA FORM NOV 2008

Release of Medical Information: Signature in this section authorizes the patient's providers to release medical record documentation related to the services associated with this claim. This consent pertains to all medical records, including records related to treatment for psychological and psychiatric conditions, drug and alcohol abuse, acquired immune deficiency syndrome, human immunodeficiency virus infection, and sickle cell disease. Signature (type if electronic) Date I certify that the above information and attachments are correct and represent actual services, dates, and fees charged. (Sign and date on right.) If certification is signed by a person other than the patient, complete the information, signature and date.
First Name MI Relationship to Patient

Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, fictitious, or fraudulent statements or claims.

Section IV - Certification

Meals $

Last Name

Street Address

State

ZIP Code

Telephone Number (include area code)

10-7959e

Claim for Miscellaneous Expenses Appendix PRIVACY ACT: The authority for collection of the requested information on this form is 38 U.S.C. 501 and 1805 and 38 CFR 17.900 et seq. This information is required for all claims for reimbursement of miscellaneous expenses related to the health care benefits for children of qualifying veterans. You do not have to provide the requested information but if any or all of the requested information is not provided, it may delay or result in denial of your request for payment. 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". For example, information on this form may be disclosed to contractors, trading partners, health care providers and other suppliers of health care services to determine your eligibility for medical benefits and 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 6-1/2 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. Respondents should be aware that 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.

retain this portion for your records

Spina Bifida Health Care Program
VA Health Administration Center Spina Bifida Health Care Benefits PO Box 469065 Denver CO 80246-9065 Phone: Fax:
VA FORM NOV 2008

Children of Women Vietnam Veterans
VA Health Administration Center Children of Women Vietnam Veterans PO Box 469065 Denver CO 80246-9065 Phone: Fax: 1-888-820-1756 1-303-331-7807

1-888-820-1756 1-303-331-7807
10-7959e