Attachment D.2. - VHA-10-7078 Authorization Form 02.pdf

OMB Number: 2900-0080 Estimated Burden: 2 minutes

AUTHORIZATION AND INVOICE FOR MEDICAL AND

HOSPITAL SERVICES

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.

1A. DATE OF ISSUE

(mm/dd/yyyy)

1B. ISSUING OFFICE 1C. DATE OF ISSUE (Month, day, year)

1D. VETERAN'S NAME (First, middle initial, last) (This is a mandatory field.)

2. NAME OF PHYSICIAN OR FACILITY 3. VETERAN'S CLAIM NUMBER

C-

4. SOCIAL SECURITY NUMBER

FROM

(mm/dd/yyyy)

PART I - SERVICES AUTHORIZED

5. AUTHORIZATION VALID

TO

(mm/dd/yyyy)

7. FEE

6. SERVICES SHOWN BELOW AUTHORIZED FOR PERIOD INDICATED IN ITEM 5 ABOVE. (See special provisions on back of form.)

8. FEE SCHEDULE OR CONTRACT 9. AUTHORITY 9A. 10. ESTIMATED AMOUNT

11. FISCAL SYMBOLS

36 0160.001

12. AUTHORIZED BY (Name and Title)

13. DATE(S)

OF SERVICE

PART II - INVOICE

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

MONTH DAY YEAR SERVICE FURNISHED

AMOUNT

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)

17. TOTAL CLAIMED $

PART III - FOR VA USE ONLY

ADMINISTRATIVE CERTIFICATION AMOUNT DUE

AUDIT BLOCK

DATE VOUCHER AUDITOR

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.

SlGNATURE AND TITLE DATE

REMARKS

PART IV - ACCOUNTING BLOCK

ION PAT NO

VA FORM

FEB 2005 (R)

TC & SC

10-7078

CPF LIQ AMT 1ST SA

2ND SA

$ DATE/INITIALS

ORIGINAL

Attachment D.2. – VA Form 10-7078 Authorization Form 36C24924R0012

PART II - INVOICE (Continued)

13. DATE(S)

OF SERVICE

14. DESCRIPTION OF SERVICE

15. FEE CLAIMED

MONTH DAY YEAR AMOUNT

Please enter total shown in 17A. Enter this total in 17on front of form also.

16. BILLING DATE

17A. TOTAL CLAIMED

SPECIAL PROVISIONS: Acceptance of this authorization to render service is governed by the following:

ACCEPTANCE OF THIS AUTHORIZATION AND PROVIDING OF SUCH TREATMENT OR SERVICES SUBJECTS YOU,

* THE PROVIDER OF CARE, TO THE PROVISIONS OF PUBLIC LAW 93-579, THE PRIVACY ACT OF 1974, TO THE EXTENT OF THE RECORDS PERTAINING THE VA AUTHORIZED TREATMENT OR SERVICES OF THIS VETERAN.

Fees or rates listed represent maximum allowance for services specified. In no event should charges be made to the VA in excess of

* usual and customary charges to the general public for similar services.

* Payment by VA is payment in full for authorized services rendered.

Unless otherwise approved by VA, services are limited in type and extent to those shown on the authorization. If services are not

* initiated for any reason, return a copy of the authorization to the issuing office with a brief explanation.

* A copy of the Operative Report will be forwarded to the authorizing facility within 1 week following any major surgery.

* A copy of the hospital summary will be forwarded to the authorizing facility within 10 work days following the release of the patient from the hospital.

All questions relating to this authorization should be referred to the issuing VA Facility.

VA FORM

JUN 2007 10-7078 REVERSE ORIGINAL