Instructions are written for a multi-part paper form. Print additional copies as necessary.
OMB NUMBER: 2900-0080 Estimated Burden: 2 minutes
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 providers who must complete this form will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to authorize treatment and provide a means to bill for this service (private providers may, however, use any local billing form or UB (Uniform Billing) 92. Submission of this form is voluntary and failure to respond will have no adverse effect on benefits to which the provider might otherwise be entitled. Comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing the burden, may be addressed by calling the Health Benefits Contact Center at 1-877-222-8387.
AUTHORITY AND INVOICE FOR TRAVEL BY AMBULANCE OR OTHER HIRED VEHICLE
PART I - AUTHORIZATION FOR SERVICE
1. NAME AND ADDRESS OF BENEFICIARY (If authorization is issued to ambulance company or hired car owner) NAME AND ADDRESS OF BENEFICIARY OR COMPANY TO WHOM AUTHORIZATION IS ISSUED (See reverse for instructions) 2. SOCIAL SECURITY NUMBER 3. DATE AND HOUR AUTHORIZED TO REPORT (mm/dd/yyyy)
4. TRANSPORTATION IS AUTHORIZED BY AMBULANCE 4A. FROM OTHER HIRED VEHICLE
AND RETURN 5. RATES AUTHORIZED 6. CONTRACT NUMBER AND DATE (If applicable)
7. CONFIRMS PRIOR AUTHORIZATION (If applicable) DATED (mm/dd/yyyy)
8. NAME AND ADDRESS OF ISSUING OFFICE
10. FISCAL SYMBOLS
11. ESTIMATED COST OF TRAVEL
12. SIGNATURE AND TITLE OF AUTHORIZING OFFICIAL
13. DATE (mm/dd/yyyy)
PART II - INVOICE FOR SERVICE (See reverse for instructions)
14. SERVICE FURNISHED AMBULANCE OTHER HIRED VEHICLE 15. FROM 15A. TO AND RETURN YES NO
16. NAME AND ADDRESS OF PAYEE
17. ITEMIZATION OF CHARGES
18. TOTAL AMOUNT CLAIMED
19. SELECT STATEMENT BELOW THAT PERTAINS TO THE SERVICE AND CHECK THE APPROPRIATE BOX NO CONTRACT (The rate charged does not exceed the prevailing rate in the community) CONTRACT IN EFFECT (Service provided in accordance with current contract conditions)
PART III - STATEMENT BY VA OFFICIAL OR DESIGNEE
I CERTIFY THAT the service, as specified above, has been accomplished and is approved in accordance with authority issued therefore, or as otherwise shown in statement in remarks below, which is made a part hereof.
20. SIGNATURE AND TITLE OF VA OFFICIAL 21. DATE (mm/dd/yyyy)
PART IV - AUDIT BLOCK (For Finance use only)
22. AMOUNT DUE 23. DATE (mm/dd/yyyy) 24. VOUCHER AUDITOR
PART V - ACCOUNTING BLOCK
26. ION/PAT. NO. 27. TC&S/C 28. CPF 29. LlQ. AMT. 30A. 1ST S/A 30B. 2ND S/A
31. DATE & INITIALS
VA FORM 10-2511 JUNE 2007 (R)
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INSTRUCTIONS SECTION I - AUTHORIZATION FOR SERVICE (Instructions to Beneficiary)
a. If you cannot report on the date and hour specified in Item 3 on the face of the form, please notify the VA facility shown in Item 8 and return this form to that office. DO NOT REPORT UNTIL YOU RECEIVE ANOTHER AUTHORIZATION. (Use the blank space below to write to the VA facility shown in Item 8.) b. If you have moved to a city or town other than the one shown on the face of this form, enter your new address in the blank space below and indicate whether it is permanent or temporary. Return this form to the VA facility shown in Item 8 and DO NOT REPORT UNTIL YOU RECEIVE ANOTHER AUTHORIZATION c. If you are authorized to travel by hired vehicle instead of ambulance, the hired vehicle cannot be one which is the property of a relative or Government employee. For definition of a relative, see Section II b (2) below.
SECTION II - INVOICE FOR SERVICE (Instructions to Ambulance Company and/or Hired Car Operator)
a. Items 14 through 19, under Section II, must be completed by owner or authorized representative who is fully qualified to act on behalf of the company. In addition, the following information (if applicable) must be furnished. (1) If part or all of the charge is based on mileage, show the amount of flat fee and amount of mileage separately in Item 17. Also show the number of miles for which mileage is claimed. Note: A flat fee is an agreed upon charge for service rendered within a stated area. Where service is rendered solely on rate per mile times number of miles traveled, no additional fee is allowed. But, if the charge to the general public for like service includes both flat fee and mileage, payment therefore may be made if properly authorized by VA IN ADVANCE or if the charge is so stated in the terms of the contract. (2) Indicate the time the beneficiary was picked up and the time the destination was reached. (This should be shown only if there is a contract with VA which specifies different rates for day and night service.) b. The following instructions apply to companies or individuals who provide hired vehicle service (other than ambulance): (1) Travel must be performed by a usually travelled route. (2) A hired vehicle cannot be the property of a Government employee or a relative. A relative is a spouse, parent, son, daughter, brother, sister, uncle, aunt, niece, or nephew, by blood or marriage.
SECTION III - STATEMENT BY VA OFFICIAL OR DESIGNEE
Entries required are self-explanatory.
SECTION IV - AUDIT BLOCK
Entries are self explanatory. NOTE: USE THE BLANK SPACE BELOW FOR COMMUNICATING WITH THE ISSUING VA FACILITY SHOWN IN ITEM 8 ON THE FIRST PAGE OF THIS FORM.
VA FORM JUNE 2007 (R)
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