17. TOTAL CLAIMED
AUTHORIZATION AND INVOICE FOR MEDICAL AND
HOSPITAL SERVICES
8. FEE SCHEDULE OR CONTRACT
12. AUTHORIZED BY (Name and Title)
11. FISCAL SYMBOLS
36
0160.001
SERVICE FURNISHED
YEAR
MONTH
DAY
$
2ND SA
$
CPF
ORIGINAL
OMB Number: 2900-0080
Estimated Burden: 2 minutes
VA FORM
FEB 2005 (R)
10-7078
DATE/INITIALS
$
1ST SA
ION PAT NO
TC & SC
LIQ AMT
PART IV - ACCOUNTING BLOCK
SlGNATURE AND TITLE DATE
REMARKS
$
AMOUNT DUE VOUCHER AUDITORDATE
AUDIT BLOCK
Payment of this will not cause payee to exceed maximum amount
allowed. Services have been furnished as authorized or medically
approved except as stated below.
ADMINISTRATIVE CERTIFICATION
PART III - FOR VA USE ONLY
15A. SOCIAL SECURITY NO
OR EMPLOYER ID NO
Individual or organization furnishing service,
enter billing date and amount claimed.
(Continue billing on back if necessary.)
16. BILLING DATE
(mm/dd/yyyy)
$
13. DATE(S)
OF SERVICE
14. DESCRIPTION OF SERVICE (If services furnished are identical to those authorized, enter
the remark "As Authorized Above" in this column. Otherwise, itemize services.)
15. FEE
CLAIMED
AMOUNT
9. AUTHORITY
PART II - INVOICE
9A. 10. ESTIMATED AMOUNT
1C. DATE OF ISSUE (Month, day, year)
1D. VETERAN'S NAME (First, middle initial, last)
1A. DATE OF ISSUE
1B. ISSUING OFFICE
(This is a mandatory field.)
(mm/dd/yyyy)
3. VETERAN'S CLAIM NUMBER2. NAME OF PHYSICIAN OR FACILITY
C-
This information is collected under the authority of Title 38 1703, 1725 and 1728. In accordance with section 3507 of the Paperwork Reduction Act of
1995, 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 individuals who must complete this invoice 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 medical treatment and provide a means to bill for
this service although private providers may also use local billing forms or UB (Uniform Billing) Forms 92. Submission of this form is voluntary and
failure to respond will have no impact on benefits to which you may 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
.
4. SOCIAL SECURITY NUMBER
FROM
(mm/dd/yyyy)
5. AUTHORIZATION VALID
TO
(mm/dd/yyyy)
PART I - SERVICES AUTHORIZED
6. SERVICES SHOWN BELOW AUTHORIZED FOR PERIOD INDICATED IN ITEM 5 ABOVE. (See special provisions on back of form.)
7. FEE
$
NOTE: Instructions are written for a multi-part form. Print additional copies as necessary.
