Attachment 3 10-2520-fill PSC.pdf

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NAME AND ADDRESS OF FIRM OR DEALER

SECTION I - HCPCS REPAIR DATA

I certify that this invoice has been completed to show total charges;

that charges seem proper for work done; that these repairs were necessary and satisfactory

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 providers who must complete this form will average 4 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to provide a means of billing for repairs authorized by VA Form 10-2501, Prosthetic Service Card. Although you must submit a bill to receive reimbursement, return of this form is voluntary. Failure to respond will have no adverse effect on benefits to which you might otherwise be entitled.

OMB Number: 2900-0188 Estimated Burden: 4 minutes

VENDOR'S INVOICE NUMBER

PROSTHETIC SERVICE CARD INVOICE

TO

VETERANS AFFAIRS

VETERAN'S NAME (Last, first, middle initial) (mandatory)

FROM

VETERAN'S ADDRESS LAST 4 DIGITS OF SSN

(This is a mandatory field.)

NOTE: Payment will be deferred until these instructions are followed.

INSTRUCTIONS - Itemize separately actual amount and charges for material and parts used in rendering repairs, GIVING COMPLETE DESCRIPTION (DIMENSIONS, ETC.) OF MATERIAL USED, HCPCS AND/OR SPECIFIC ITEM REPAIRED. Labor charges will not be included in cost of material or parts, and are to be listed separately. Indicate in the spaces provided hereon the name, type, and age of the appliance repaired.

REPAIR DESCRIPTION CHARGES

DATE OF SERVICE TOTAL CHARGES

DATE DELIVERED

NAME OF APPLIANCE MANUFACTURER

WARNING - Any abuse of this system by the vendor through excessive charges for repairs or by the veteran in aiding or abetting such irregular activities may result in discontinuation of the program and invocation of criminal statutes for frauds against the Government.

TYPE OF APPLIANCE

SECTION II - CERTIFICATION OF VETERAN

SIGNATURE OF VETERAN

DATE

SECTION III - TO BE COMPLETED BY VA PROSTHETICS SERVICE

SIGNATURE AND TITLE

APPROVED FOR PURCHASE ORDER NUMBER

DATE

DATEVA FORM 10-2501 IS OF RECORD IN THIS CASE. PAYMENT AS CLAIMED IS

RECOMMENDED, WITH THE FOLLOWING EXCEPTIONS:

(DO NOT SIGN A BLANK FORM) (mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

HCPCS

10-2520JUN 2008

VA FORM

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine your eligibility/entitlement and reimbursement of individual claims, and identify your medical records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.

NAME AND ADDRESS OF FIRM OR DEALER

SECTION I - HCPCS REPAIR DATA

I certify that this invoice has been completed to show total charges; that charges seem proper for work done; that these repairs were necessary and satisfactory This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 providers who must complete this form will average 4 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to provide a means of billing for repairs authorized by VA Form 10-2501, Prosthetic Service Card. Although you must submit a bill to receive reimbursement, return of this form is voluntary. Failure to respond will have no adverse effect on benefits to which you might otherwise be entitled.

OMB Number: 2900-0188Estimated Burden: 4 minutes

VENDOR'S INVOICE NUMBER

PROSTHETIC SERVICE CARD INVOICE

TO

VETERANS AFFAIRS

VETERAN'S NAME (Last, first, middle initial) (mandatory)

FROM

VETERAN'S ADDRESS

LAST 4 DIGITS OF SSN

(This is a mandatory field.)

NOTE: Payment will be deferred until these instructions are followed.

INSTRUCTIONS - Itemize separately actual amount and charges for material and parts used in rendering repairs, GIVING COMPLETE DESCRIPTION (DIMENSIONS, ETC.) OF MATERIAL USED, HCPCS AND/OR SPECIFIC ITEM REPAIRED. Labor charges will not be included in cost of material or parts, and are to be listed separately. Indicate in the spaces provided hereon the name, type, and age of the appliance repaired.

REPAIR DESCRIPTION

CHARGES

DATE OF SERVICE

TOTAL CHARGES

DATE DELIVERED

NAME OF APPLIANCE MANUFACTURER

WARNING - Any abuse of this system by the vendor through excessive charges for repairs or by the veteran in aiding or abetting such irregular activities may result in discontinuation of the program and invocation of criminal statutes for frauds against the Government.

TYPE OF APPLIANCE

SECTION II - CERTIFICATION OF VETERAN

SIGNATURE OF VETERAN

DATE

SECTION III - TO BE COMPLETED BY VA PROSTHETICS SERVICE

SIGNATURE AND TITLE

APPROVED FOR

PURCHASE ORDER NUMBER

DATE

DATE

VA FORM 10-2501 IS OF RECORD IN THIS CASE. PAYMENT AS CLAIMED IS RECOMMENDED, WITH THE FOLLOWING EXCEPTIONS:

(DO NOT SIGN A BLANK FORM)

(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)

HCPCS

10-2520 10 - 10 S H

JUN 2008

V. A. FORM JULY 19 98

VA FORM

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine your eligibility/entitlement and reimbursement of individual claims, and identify your medical records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your request promptly and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.

Q:\19E1\FORMS\Form Flow Forms\awaiting OMB apvl\0188\10-2520\VHA-10-2520.xft Pam Ward 12-20-02 1.0 Electronic Forms Department

VHA-10-2520

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Melissa Hughes 10-2520

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