To submit this form, address it to the VA Medical Facility where the veteran is enrolled for medical care. Include all required documentation and ensure it is sent via a secure method, such as certified mail or fax. It is advisable to keep copies of everything submitted for your records.

There are no specific recurring dates; however, it is advised to keep track of any changes in VA regulations that could affect your submission. Always check for updates to procedures in 2024 and 2025.

The primary purpose of this form is to allow veterans to request reimbursement for medical expenses incurred outside of authorized VA facilities. This process ensures that veterans can receive necessary care without financial burden. Proper completion and submission of the form are vital for successful claims processing.

• 1. Veteran's Name: Mandatory field requiring the veteran's full name.
• 2. Claim Number: Identification number associated with the claim.
• 3. Social Security Number: Required for verification and identification purposes.
• 4. Veteran's Address: Complete address including ZIP Code.
• 5. Claimant Information: Details about the person or institution making the claim.
• 6. Statement of Circumstances: Description of services rendered including diagnosis and reasons for non-usage of VA facilities.
• 7. Amount Claimed: Total amount that the veteran is requesting reimbursement for.
• 8. Provider Signature: Signature and date from the provider of service.
• 9. Veteran's Signature: Signature and date from the veteran or their representative.

Failing to submit the form correctly can lead to delays in reimbursement or denial of the claim. It is essential to provide accurate information and include all required documentation to prevent issues.

• Delays in Processing: Incomplete forms can result in extended waiting times for reimbursement.
• Denial of Claim: Incorrect or missing information may lead to a complete rejection of the claim.
• Inability to Recoup Costs: Failure to submit may prevent veterans from recovering out-of-pocket expenses.

• 1. Emergency Treatments: Any urgent care received without prior VA authorization.
• 2. Specialist Consultations: Medical services provided by specialists outside the VA network.
• 3. Hospitalization Costs: Costs incurred during hospitalization in a non-VA hospital.
• 4. Outpatient Services: Any outpatient treatments received from non-VA providers.
• 5. Prescriptions: Cost of medications purchased without VA prescription approval.