Community Care

Forms for VHA Office of Integrated Veteran Care Programs

Forms on this site are available in several formats. Fillable Portable Document Formats can be completed online, edited, saved and printed. Other forms are blank, printable forms which need to be completed offline and mailed. Please visit the VA Forms page to search for a specific VA form.

Portable Document Format (PDF) is a file format that requires the use of Adobe Reader software to open them on your computer.

On this page

• CHAMPVA
• Camp Lejeune
• Children of Women Vietnam Veterans
• Spina Bifida
• Meds by Mail
• Foreign Medical Program
• Forms for Providers

Authorization for Release of Medical Records

• Request For and Authorization To Release Medical Records, VA Form 10-5345 (Fillable PDF)
  NOTE: Only use this form for one time release of information.

Care in the Community

• Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF)

Claim for Miscellaneous Expenses

• Claim for Miscellaneous Expenses, VA Form 10-7959e (Fillable PDF)
  NOTE: This form is not for provider use.
• Reclamo de Gastos Misceláneos, Forma S10-7959e (PDF Rellenable)
  NOTA: Este formulario no es para uso del proveedor.

CHAMPVA

• CHAMPVA Application for Benefits, VA Form 10-10d (Fillable PDF)
• CHAMPVA Claim Form, VA Form 10-7959a (Fillable PDF)
  NOTE: This form is not for provider use.
• CHAMPVA Other Health Insurance (OHI) Certification, VA Form 10-7959c (Fillable PDF)
• CHAMPVA School Enrollment Certification Letter (Fillable PDF)

Solicitudes Para Beneficios de CHAMPVA en Espanol

• Aplicación a los Beneficios CHAMPVA, Forma S10-10d (PDF Rellenable)
• Formulario de Reclamo CHAMPVA, Forma S10-7959a (PDF Rellenable)
  NOTA: Este formulario no es para uso del proveedor.
• Certificacion CHAMPVA de Otros Seguros de Salud, Forma S10-7959c (PDF Rellenable)

Camp Lejeune Family Member Program (CLFMP)

• Camp Lejeune Family Member Program Application, VA Form 10-10068 (Fillable PDF)

Children of Women Vietnam Veterans (CWVV)

• Application for Benefits for a Qualifying Veteran's Child Born with Disabilities, VA Form 21-0304 (Fillable PDF)
  for Children of Women Vietnam Veterans Born with Certain Birth Defects–38 U.S.Code 1815

Spina Bifida Health Care Benefits Program (SBHCBP)

• Application for Benefits for a Qualifying Veteran's Child Born with Disabilities, VA Form 21-0304 (Fillable PDF)
  for Spina Bifida Benefits Eligibility

Meds by Mail

• Meds by Mail Prescription Order Form, VA Form 10-0426 (Fillable PDF)
• Formulario De Pedido Para Medicinas por Correo, Forma S10-0426 (PDF Rellenable)

Foreign Medical Program (FMP)

• FMP Registration Form, VA Form 10-7959f-1 (Fillable PDF)
• FMP Claim Cover Sheet, VA Form 10-7959f-2 (Fillable PDF)

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