The Department of Veterans Affairs (VA) offers a range of programs and services to support veterans and their families. To access these programs and services, veterans and their families may need to complete various forms. In this list, we will discuss ten VA forms related to medical records, state home program care, military service certification, claims folder information release, benefit claim reconsideration, Fisher House lodging program, equal opportunity compliance, home improvement and structural alterations, adaptive equipment, and employment with the VA.
- VA Form 10-2065: Request for and Authorization to Release Medical Records or Health Information - This form is used by veterans to authorize the release of their medical records or health information to a third party.
- VA Form 10-212: State Home Program Veterans Application - This form is used by veterans to apply for care under the State Home Program.
- VA Form 10-2382: Request for Certification of Military or Naval Service - This form is used by individuals to request certification of military or naval service from the National Personnel Records Center.
- VA Form 10-2407: Request for and Consent to Release of Information from Claims Folder - This form is used by veterans to authorize the release of their claims folder information to a third party.
- VA Form 10-2570d: Veteran/Beneficiary Claim for Reconsideration - This form is used by veterans or beneficiaries to request reconsideration of a decision made on their claim for benefits.
- VA Form 10-2623: Proficiency Report - Electronic Signatures
- VA Form 10-2623a: Agreement to Furnish Services and/or Space - This form is used by organizations to agree to furnish services and/or space to the VA for the operation of a Fisher House™.
- VA Form 10-2633: Statement of Assurance of Compliance with Equal Opportunity Laws - This form is used by contractors and subcontractors doing business with the VA to certify their compliance with equal opportunity laws.
- VA Form 10-2641: Authority for Issuance of Special and/or Experimental Appliances
- VA Form 10-2649a: Application for Adaptive Equipment - Motor Vehicle - This form is used by veterans to apply for adaptive equipment for their vehicle from the VA.
- VA Form 10-2649b: Application for Adaptive Equipment - Other Than Motor Vehicle - This form is used by veterans to apply for adaptive equipment, other than for their vehicle, from the VA.
- VA Form 10-2850: Application for Physicians, Dentists, Podiatrists, Optometrists and Chiropractors - This form is used by healthcare professionals to apply for employment with the VA.
- VA Form 10-2850c: Application for Associated Health Occupations - This form is used by individuals in various health care occupations to apply for employment with the VA.
- VA Form 10-2850a: Application for Nurses and Nurse Anesthetists - This form is used by nurses and nurse anesthetists who want to work in the VA healthcare system.
- VA Form 10-2850b: Application for Physicians, Dentists, Podiatrists, Optometrists, and Chiropractors - This form is used by physicians, dentists, podiatrists, optometrists, and chiropractors to apply for employment with the VA.
- VA Form 10-2850d: Application for Health Professional Traineeship (Residency or Advanced Training in Medical Care or Research) - This form is used by individuals pursuing advanced training or residency in medical care or research to apply for health professional traineeship opportunities with the VA.
- VA Form 10-285c: Application for Nursing Assistant and/or Health Care Technician - This form is used by nursing assistants and health care technicians to apply for employment with the VA.
- VA Form 10-2914: Statement in Support of Claim - This form is used by individuals to provide a statement in support of their claim for VA benefits.
- VA Form 10-305: Your Rights to Seek Further Review of PCAFC Decisions
- VA Form 10-306: Request for Information (PCAFC Decisions)
- VA Form 10-307: Notice of Disagreement (PCAFC Decisions)
- VA Form 10-3203: Application for a Service-Connected Disability Rating - This form is used by veterans to apply for a service-connected disability rating from the VA.
- VA Form 10-3542: Veterans' Request for Assistance in Obtaining Hospital and Outpatient Care and/or Medicines - This form is used by veterans to request assistance from the VA in obtaining hospital and outpatient care and/or medicines.
- VA Form 10-5345: Request for and Authorization to Release Medical Records or Health Information - This form is used by veterans to authorize the release of their medical records or health information to a third party.
- VA Form 10-5345a: Individuals' Request for a Copy of Their Own Health Information - This form is used by individuals to authorize the release of their medical provider records and/or other health information.
- VA Form 10-5349: Advanced Consent for Treatment - This form is used by veterans to provide advanced consent for certain types of medical treatment.
- VA Form 10-5397: Agreement to Furnish Medical Care and/or Services - This form is used by medical care providers to agree to furnish medical care and/or services to eligible individuals under the VA's programs.
- VA Form 10-5588: Application for United States Flag for Burial Purposes - This form is used by individuals to apply for a US flag for burial purposes for a deceased veteran.
- VA Form 10-564d: Application for Children with Disabilities Born to Women Vietnam Veterans - This form is used by children born with disabilities to women who served in Vietnam to apply for benefits from the VA.
- VA Form 10-583: Claim for Payment of Cost of Unauthorized Medical Services
- VA Form 10-7008: Clearance Prescription for Recreation Activities
- VA Form 10-7055: Request for and Authorization to Release Education Information - This form is used by individuals to authorize the release of their education information to a third party.
- VA Form 10-7078: Confidential Financial Disclosure Report - This form is used by VA employees to report their financial disclosure information.
- VA Form 10-7079: Request for Approval of Outside Activity - This form is used by VA employees to request approval for outside employment or activity.
- VA Form 10-7080: Approved Referral For Medical Care
- VA Form 10-7131: Exchange of Beneficiary Information and Request for Administrative Action
- VA Form 10-7959: Request for Verification of Employment - This form is used by individuals to request verification of their employment with the VA.
- VA Form 10-7959a: CHAMPVA Claim Form
- VA Form 10-7959c: CHAMPVA—Other Health Insurance (OHI) Certification
- VA Form 10-7959f-1: Foreign Medical Program (FMP) Registration Form
- VA Form 10-7959f-2: Counseling Checklist for Military Sexual Trauma (MST) - This form is used by individuals who experienced military sexual trauma (MST) to certify that they have received counseling about their VA benefits.
- VA Form 10-8678: Application for Annual Clothing Allowance - This form is used by eligible veterans to apply for an annual clothing allowance from the VA
- VA Form 10-9009: Agent Orange Registry Code Sheet
- VA Form 10-9009a: Certification of Compliance for Small Construction Contracts - This form is used by contractors doing small construction contracts with the VA to certify their compliance with equal opportunity laws.
- VA Form 10-9012: Equal Employment Opportunity Complaint of Discrimination in Federal Government and Related Matters - This form is used by individuals to file a complaint of discrimination in federal government employment and related matters.
- VA Form 10007: Agreement to Train - This form is used by individuals to agree to participate in training offered by the VA.
- VA Form 10016: Application for Health Benefits - Combat Veterans - This form is used by combat veterans to apply for health care benefits from the VA.
- VA Form 10017: Authorization for Release of Medical Information - This form is used by individuals to authorize the release of their medical information to the VA.
- VA Form 10079: Claim for One Sum Payment - This form is used by eligible individuals to claim a one sum payment from the VA.
- VA Form 10091: VA-FSC Vendor File Request Form - Used to apply for pre-need eligibility determination for burial in a VA national cemetery.
- VA Form 1010 EZ: Application for Health Benefits - Used to apply for health benefits through the VA.
- VA Form 1010172: Request for and Consent to Release of Information from Individual's Records - Used to request and authorize the release of an individual's medical or other information from VA records.
- VA Form 1010HS: Health Statement - Used to provide information on a veteran's health status when applying for VA health care.
- VA Form 10172: Request for Appointment of Veterans Service Organization as Claimant's Representative - Used to appoint a Veterans Service Organization (VSO) to represent a claimant in a VA claim.
- VA Form 10182: Decision Review Request: Board Appeal (Notice of Disagreement)
- VA Form 10206: Authorization to Disclose Personal Information to a Third Party - Same as VA Form 20-10206
- VA Form 10207: Authorization to Use or Disclose Protected Health Information - Used to authorize the use or disclosure of protected health information by the VA.
- VA Form 10210: Education and Career Counseling Application - Used to apply for education and career counseling services through the VA.
- VA Form 1028 50c: Application for Amounts on Deposit for Deceased Veteran - Used to claim funds on deposit for a deceased veteran.
- VA Form 102850: Application for Dependents' Educational Assistance - Used to apply for educational assistance for dependents of veterans.
- VA Form 105345: Veterans Application for Compensation and/or Pension - Used to apply for compensation and/or pension benefits.
- VA Form 105345A: Continued on Next Page - Same as above, but used when additional space is needed to complete the application.
- VA Form 107959c: Claim for Reimbursement of Expenditures on Official Business - Used to claim reimbursement for expenses incurred on official VA business.
- VA Form 1098: Mortgage Interest Statement - Used to report mortgage interest paid on a VA home loan.
- VA Form 10EZ: Application for Health Benefits - Same as VA Form 1010 EZ.
- VA Form 10EZR: Health Benefits Renewal Form - Used to renew eligibility for VA health benefits.
- VA Form 1100: Agreement to Pay Indebtedness
- VA Form 1151: Claim for Service-Connected Disability - Used to claim disability benefits for a service-connected disability or death.
- VA Form 1172: Application for Uniformed Services Identification Card/DEERS Enrollment - Used by military personnel and their families to apply for identification cards and enrollment in the Defense Enrollment Eligibility Reporting System (DEERS).
- VA Form 119: Report of Contact - Used to document contact with a veteran or other individual.
- VA Form 1199A: Direct Deposit Sign-Up Form - Used to sign up for direct deposit of VA benefit payments.
- VA Form 1217: Authorization to Disclose Personal Information - Same as VA Form 10206.
- VA Form 13055: Request for Nursing Home Information in Connection with Claim for Aid and Attendance - Used to request nursing home information in connection with a claim for Aid and Attendance benefits.
- VA Form 1330: Claim of Person Outside the United States - Used to claim benefits by people who reside outside of the United States.
- VA Form 1393: Financial Status Report - Used to report an individual's financial status to the VA.
- VA Form 1394: Schedule of Ratings – Cardiovascular System - Used to evaluate the level of disability for cardiovascular conditions.
- VA Form 180: Request Pertaining to Military Records - Used to request military records for veterans or next-of-kin.
- VA Form 1805: Reservist Affidavit of Eligibility for Burial in a VA National Cemetery - Used to confirm eligibility for burial in a VA national cemetery for reservists.
- VA Form 1820: Report of Cash Payments Over $10,000 Received in a Trade or Business (May be you are looking for the VA Form 26-1820. Report and Certification of Loan Disbursement)
- VA Form 1880: Request for Certificate of Eligibility for Home Loan Benefits - Used to request a certificate of eligibility for VA home loan benefits.
Completing VA forms accurately and completely is essential to accessing the programs and services provided by the VA. In this list, we discussed ten forms related to medical records release, state home program care, military service certification, claims folder information release, benefit claim reconsideration, Fisher House lodging program, equal opportunity compliance, home improvement and structural alterations, adaptive equipment, and employment with the VA. By understanding the purpose of each form and providing accurate and complete information, veterans and their families can access the benefits and resources they need to thrive.
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