Free VA Form 10-1245C - VA/Department of Defense Sharing Agreement (FILLABLE) - Federal


File Size: 207.3 kB
Pages: 2
Date: December 29, 2004
File Format: PDF
State: Federal
Category: Veterans Forms
Author: vhacohalleh
Word Count: 458 Words, 2,960 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.va.gov/vaforms/medical/pdf/vha-10-1245c-fill.pdf

Download VA Form 10-1245C - VA/Department of Defense Sharing Agreement (FILLABLE) ( 207.3 kB)


Preview VA Form 10-1245C - VA/Department of Defense Sharing Agreement (FILLABLE)
VA/DEPARTMENT OF DEFENSE SHARING AGREEMENT
INSTRUCTIONS

The instructions in this form are meant to be used as informal guidelines, and are not limited to the language herein expressed. Ultimately, proposed sharing agreements must adhere to the provisions outlined in section 38 USC8111 and the VA/DOD Health Care Resources Sharing Guidelines which are in the Memorandum of Understanding between VA and DOD, dated July 29, 1983. 1. 2. 3. 4. 5. 6. 7. 8. Before being submitted to the approving authorities, a proposed agreement must identify all health care resources to be shared and must be signed by both parties. If acquisition of additional resources is required, approval must be obtained for the additional resources from the resource provider, prior to submitting the proposal. The providing organization will prepare the appropriate invoice and send it to the receiving organization's office to be billed. Each agreement shall provide the method of reimbursement for all health care resource costs incurred by the providing Department or service region. Amendments to this agreement shall be submitted for approval as a new sharing agreement. This agreement will remain in force during the period stated unless terminated at the request of either party after thirty (30) days notice in writing. In the event of war or national emergency, this agreement may be terminated immediately upon written notice by the Department of Defense. Priority to Veterans. Provider reserves the right to deny provision of service to individuals where space or services is unavailable, or if provision of services to individuals would delay or deny care to eligible veterans. This agreement is subject to the availability of funds for the period after September 30 in succeeding fiscal years.

1. AGREEMENT NUMBER (LEAVE BLANK)

2. TYPE OF ACTION NEW AGREEMENT RENEWAL REPLACES: AMENDMENT AMENDS:

3. AGREEMENT PERIOD (MONTH/DAY/YEAR)

TO
5. DOD FACILITY (NAME/ADDRESS)

4. VA FACILITY (NAME/ADDRESS)

6. DIRECT PAYMENT TO (NAME/ADDRESS):

7. OFFICE TO BE BILLED (NAME/ADDRESS)/BILLING FREQUENCY

8. GENERAL PROVISIONS (TO BE INCLUDED IN ALL AGREEMENTS) a.

The authority for this agreement is Public Law 97-174, "Veterans Administration and Department of Defense Health Resources Sharing and Emergency Operations Act," 38 U.S.C. 8111 and the VA/DOD Health Care Resources Sharing Guidelines which are in the Memorandum of Understanding between VA and DOD, dated July 29, 1983.

9. OTHER PROVISIONS

VA FORM MAR 2004

10-1245c

SUPERCEDES VA FORM 10-1245c, June 1992, WHICH WILL NOT BE USED

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10A. SERVICES PROVIDED BY VA Service Number Estimated Value Of Shared Service

ADDITIONAL COMMENTS

10b. SERVICES PROVIDED BY DOD Service Number Estimated Value Of Shared Service

ADDITIONAL COMMENTS

11A. SIGNATURE OF AUTHORIZED VA OFFICIAL

11B. TITLE

11C. DATE

12A. SIGNATURE OF AUTHORIZED DOD OFFICIAL

12B. TITLE

12C. DATE

VA FORM 10-1245c

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