36C25619R0134-004.pdf

PDF 424 KB Posted Aug 26, 2019

Attached to: Nursing Home Services Gulfport, Mississippi
Solicitation number: 36C25619R0134
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 16

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36C25619R0134 VA FORM 10-7078- AUTHORIZATION AND INVOICE FOR MEDICAL AND HOSPITAL SERVICES.pdf

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File	Type	Posted
36C25620D0006-000.docx	DOCX document	Oct 7, 2019
36C25619R0134-001.docx	DOCX document	Aug 26, 2019
36C25619R0134-004.pdf	PDF	Aug 26, 2019
36C25619R0134-003.pdf	PDF	Aug 26, 2019
36C25619R0134-002.doc	DOC document	Aug 26, 2019
36C25619R0134-003.pdf	PDF	Aug 26, 2019
36C25619R0134-001.docx	DOCX document	Aug 26, 2019
36C25619R0134-002.doc	DOC document	Aug 26, 2019
36C25619R0134-000.docx	DOCX document	Aug 8, 2019
36C25619R0134-000.docx	DOCX document	Aug 8, 2019

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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 FURNISHEDYEARMONTH DAY

2ND SA $

CPF

ORIGINAL

OMB Number: 2900-0080 Estimated Burden: 2 minutes

VA FORM

FEB 2005 (R) 10-7078

DATE/INITIALS$1ST SAION 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

(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.

13. DATE(S)

OF SERVICE

AMOUNT

PART II - INVOICE (Continued)

15. FEE CLAIMED

14. DESCRIPTION OF SERVICE

MONTH DAY YEAR

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.

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:

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.

ORIGINALREVERSEVA FORM

JUN 2007

10-7078

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

0160.001

SERVICE FURNISHED

YEAR

MONTH

DAY

2ND SA

CPF

ORIGINAL

OMB Number: 2900-0080 Estimated Burden: 2 minutes

VA FORMFEB 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 AUDITOR

DATE

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. FEECLAIMED

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 NUMBER

2. 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

(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.

\\iaimain\apps1\Pam_Ward\Logos\Formlogo.jpg Department of Veterans Affairs

13. DATE(S)OF SERVICE

AMOUNT

PART II - INVOICE (Continued)

15. FEE CLAIMED

14. DESCRIPTION OF SERVICE

MONTH

DAY

YEAR

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:

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

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.

ORIGINAL

REVERSE

VA FORMJUN 2007

10-7078 u u Q:\19E1\FORMS\Form Flow Forms\awaiting OMB apvl\0080\vha-10-7078.xft Pam Ward 4-9-2003 1.0 Electronic Forms Department vha-10-7078

{CF3222A7-20FA-11D4-ABC1-00D0B71D6ABB}

IAI

10-7078

Service Date. Enter month, day, year. Line 1 of 23.:

1B. Enter Issuing Office.:

1C. Date of Issue. Enter month, day, year.:

1D. Veteran's Name. (First, middle initial, last) This is a mandatory field.:

2. Enter Name of Physician or Facility:

3. Enter Veteran's Claim Number. C-:

Enter Social Security Number. This is a mandatory field.:

Date From. Enter as MM/DD/YYYY.:

Date To. Enter as MM/DD/YYYY.:

Enter Services Authorized. Line 1 of 6.:

7. Enter Fee. Line 1 of 6:

Enter Services Authorized. Line 2 of 6.:

Enter Services Authorized. Line 3 of 6.:

Enter Services Authorized. Line 4 of 6.:

8. Enter FEE SCHEDULE OR CONTRACT:

9. Enter Authority.:

9. A.:

10. Enter Estimated Amount:

11. Enter Fiscal Symbols. 36:

12. AUTHORIZED BY Enter Name.:

12. AUTHORIZED BY Enter Title.:

Service Date. Enter month, day, year. Line 1 of 7.:

Enter Service Furnished. Line 1 of 7.:

Enter Amount. Line 2 of 7:

Service Date. Enter month, day, year. Line 2 of 7:

Enter Service Furnished. Line 2 of 7.:

Service Date. Enter month, day, year. Line 3 of 7:

Enter Service Furnished. Line 3 of 7.:

Enter Amount. Line 7 of 7:

Service Date. Enter month, day, year. Line 4 of 7:

Enter Service Furnished. Line 4 of 7.:

Service Date. Enter month, day, year. Line 5 of 7:

Enter Service Furnished. Line 5 of 7.:

Service Date. Enter month, day, year. Line 6 of 7:

Enter Service Furnished. Line 6 of 7.:

Service Date. Enter month, day, year. Line 7 of 7:

Enter Service Furnished. Line 7 of 7.:

15. A. Enter SOCIAL SECURITY NUMBER OR EMPLOYER ID NUMBER:

16. Billing Date. Enter as MM/DD/YYYY.:

17. Total Claimed. Enter Amount in Dollars.:

ion_pat_no:

tc_sc:

cpf:

liq:

amt:

first_sa:

second_sa:

date-initials:

amount:

Enter Service Furnished. Line 1 of 7.:

16. Billing Date. Enter as MM/DD/YYYY.:

auditor:

Enter Service Description. Line 1 of 23.:

Enter Amount in dollars. Line 1 of 23.:

Service Date. Enter month, day, year. Line 2 of 23.:

Enter Service Description. Line 2 of 23.:

Enter Amount in dollars. Line 2 of 23.:

Service Date. Enter month, day, year. Line 3 of 23.:

Enter Service Description. Line 3 of 23.:

Enter Amount in dollars. Line 3 of 23.:

Service Date. Enter month, day, year. Line 4 of 23.:

Enter Service Description. Line 4 of 23.:

Enter Amount in dollars. Line 4 of 23.:

Service Date. Enter month, day, year. Line 5 of 23.:

Enter Service Description. Line 5 of 23.:

Enter Amount in dollars. Line 5 of 23.:

Service Date. Enter month, day, year. Line 6 of 23.:

Enter Service Description. Line 6 of 23.:

Enter Amount in dollars. Line 6 of 23.:

Service Date. Enter month, day, year. Line 7 of 23.:

Enter Service Description. Line 7 of 23.:

Enter Amount in dollars. Line 7 of 23.:

Service Date. Enter month, day, year. Line 8 of 23.:

Enter Service Description. Line 8 of 23.:

Enter Amount in dollars. Line 8 of 23.:

Service Date. Enter month, day, year.Line 9 of 23.:

Enter Service Description. Line 9 of 23.:

Enter Amount in dollars. Line 9 of 23.:

Service Date. Enter month, day, year. Line 10 of 23.:

Enter Service Description. Line 10 of 23.:

Enter Amount in dollars. Line 10 of 23.:

Service Date. Enter month, day, year.Line 11 of 23.:

Enter Service Description. Line 11 of 23.:

Enter Amount in dollars. Line 11 of 23.:

Service Date. Enter month, day, year. Line 12 of 23.:

Enter Service Description. Line 12 of 23.:

Enter Amount in dollars. Line 12 of 23.:

Service Date. Enter month, day, year. Line 13 of 23.:

Enter Service Description. Line 13 of 23.:

Enter Amount in dollars. Line 13 of 23.:

Service Date. Enter month, day, year. Line 14 of 23.:

Enter Service Description. Line 14 of 23.:

Enter Amount in dollars. Line 14 of 23.:

Service Date. Enter month, day, year. Line 15 of 23.:

Enter Service Description. Line 15 of 23.:

Enter Amount in dollars. Line 15 of 23.:

Service Date. Enter month, day, year. Line 16 of 23.:

Enter Service Description. Line 16 of 23.:

Enter Amount in dollars. Line 16 of 23.:

Service Date. Enter month, day, year. Line 17 of 23.:

Enter Service Description. Line 17 of 23.:

Enter Amount in dollars. Line 17 of 23.:

Service Date. Enter month, day, year. Line 18 of 23.:

Enter Service Description. Line 18 of 23.:

Enter Amount in dollars. Line 18 of 23.:

Service Date. Enter month, day, year. Line 19 of 23.:

Enter Service Description. Line 19 of 23.:

Enter Amount in dollars. Line 19 of 23.:

Service Date. Enter month, day, year. Line 20 of 23.:

Enter Service Description. Line 20 of 23.:

Enter Amount in dollars. Line 20 of 23.:

Service Date. Enter month, day, year. Line 21 of 23.:

Enter Service Description. Line 21 of 23.:

Enter Amount in dollars. Line 21 of 23.:

Service Date. Enter month, day, year. Line 22 of 23:

Enter Service Description. Line 22 of 23.:

Enter Amount in dollars. Line 22 of 23.:

Service Date. Enter month, day, year. Line 23 of 23.:

Enter Service Description. Line 23 of 23.:

Enter Amount in dollars. Line 23 of 23.:

17. A. Total Claimed. Enter Amount in dollars.:

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