36C24118Q0304-00001004.pdf

FORM 10-5565B

DEPT OF VETERANS AFFAIRS

READJUSTMENT COUNSELING SERVICES

CONTRACT SERVICES AUTHORIZATION

Copies: ______ Veteran ______ Contract Service Provider ______ Originating Office Client File

VA FORM 10-5565B

1. Contractor Information

A. Contract Service Provider Readjustment Counseling B. 4 Digit Provider # ________

Contractor: _____________________________________________

C. Address of Contract Service Provider (Number, Street, City, State, Zip, Tel #)

Street Address: ___________________

City: ____________________ State: _____ Zip: _________ Phone: _______________

2. Veteran Information

D. Name of Veteran and Vet Ctr Client # (Last, First MI) Client # for Billing: _______

Last Name:____________________, First: _______________, MI: ________

E. This Veteran has been determined to be eligible for readjustment counseling. Only the following services have been authorized from __________ to __________.

# Sessions Auth.

1. Individual readjustment counseling

2. Marriage and family readjustment counseling

3. Group readjustment counseling

The number of sessions displayed above indicate the TOTAL NUMBER of sessions authorized for THIS QUARTER to date.

F. I have informed the veteran of the following:

1. He/she is eligible for readjustment counseling beginning on this date: _____________ or extended to this date:

2. He/she is entitled to no more than 1 visit per week for which the Department of Veterans Affairs will provide remuneration.

3. He/she has been advised of his/her potential for financial responsibility for services should his/her eligibility not be substantiated.

3. Referral Information

G. This veteran is being referred to you for readjustment counseling: You will initiate care for:

Ongoing care

3 authorized initial assessment visits. Additional visits may be authorized after submission of an initial treatment plan

Reassessment evaluation

Note: This contract service provider may request an increase in the number of visits to 2 per week by contacting the authorizing offical shown below.

H. This authorization is from: Vet Center I. Vet Center or Facility #

J. Authorization Official:

TL/COR Signature: ____________________________ Date: ___________ Telephone: ________________