10-0003K-2
Employee Incentive Scholarship Program (EISP) Agreement
14 fields, 2 pages
10-0003k
Employee Incentive Scholarship Program (EISP) Application
80 fields, 3 pages
10-0102
Career Development Application
47 fields, 2 pages
10-0137
VA Advance Directive: Durable Power of Attorney for Health Care and Living Will
80 fields, 6 pages
10-0137A
What You Should Know About Advance Directives
1 field, 2 pages
10-0143
Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
8 fields, 2 pages
10-0143a
Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973
8 fields, 1 page
10-0144a
Statement of Assurance of Compliance with Equal Opportunity Laws
9 fields, 1 page
10-0246
Veteran Patient Statement
52 fields, 1 page
10-0376a
Credentials Transfer Brief
83 fields, 2 pages
10-0379
Ecclesiastical Endorsing Organization Request to Designate Ecclesiastical Endorsing Official
39 fields, 3 pages
10-0383
Catastrophically Disabled Veteran Evaluation and Approval
57 fields, 2 pages
10-0388-1
Documents and Information Required for State Home Construction and Acquisition Grants Initial Application
7 fields, 2 pages
10-0388-10
Certification of Compliance with Federal Requirements—State Home Construction Grant
6 fields, 1 page
10-0388-13
Documents and Information Required for State Home Construction and Acquisition Grants—Post-Grant Requirements
7 fields, 1 page
10-0388-14
Checklist of Major Requirements for State Home Construction/Acquisition Grants
90 fields, 2 pages
10-0388-3
State Home Construction Grant Program Space Program Analysis—Nursing Home & Domiciliary
75 fields, 2 pages
10-0388-4
State Home Construction Grant Program Space Analysis—Adult Day Health Care
53 fields, 2 pages
10-0388-5
Additional Documents and Information Required for State Home Construction and Acquisition Grants Application
7 fields, 2 pages
10-0388-6
Certification of State Matching Funds to Qualify for Group 1 on Priority List
9 fields, 1 page
10-0388-8
Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
6 fields, 1 page
10-0398
Research Protocol Safety Survey
627 fields, 12 pages
10-0400
Request for Veterans Service Organization (VSO) Access to Computer Patient Record System (CPRS) Read Only
8 fields, 1 page
10-0408
VHA Fisher House Application
29 fields, 3 pages
10-0430
Application for Assistance for Hiring and Retaining Nurses at State Homes
23 fields, 2 pages
10-0436
Application for an Off-Site Tissue Banking Waiver at a Non-Profit or Academic Institution
74 fields, 7 pages
10-0445
Occupational and Environment Exposure History
137 fields, 3 pages
10-0454
Military Treatment Facility Referral to VA Liaison
55 fields, 2 pages
10-0455a
Clinical Trial Inclusion/Enrollment Report
63 fields, 1 page
10-0460
Request for Prescription Drugs from an Eligible Veteran in a State Home
76 fields, 3 pages
10-0462
Political Activities Fact Sheet and Certification
4 fields, 1 page
10-0491
Academic Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
481 fields, 7 pages
10-0491L
VA Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) Agreement
12 fields, 3 pages
10-0491c
Annual VA Employment or Deferment Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
35 fields, 1 page
10-0491d
Education Program Completion Notice/Service Obligation Placement—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
15 fields, 1 page
10-0491e
Evaluation & Recommendation Form—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
17 fields, 2 pages
10-0491f
Health Professional Scholarship Program (HPSP) Agreement
13 fields, 4 pages
10-0491g
Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), & Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP)
118 fields, 7 pages
10-0491h
Notice of Approaching Graduation—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
18 fields, 1 page
10-0491i
Notice of Change and/or Annual Academic Status—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
60 fields, 2 pages
10-0491j
Request for Deferment for Advanced Education—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
24 fields, 1 page
10-0491k
VA Scholarship Offer Response—Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP)
35 fields, 1 page
10-0525
Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
9 fields, 1 page
10-0525a
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
25 fields, 2 pages
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fields, 1 page
10-10065
Ethics Consultation Feedback Tool
85 fields, 1 page
10-10068c
Camp Lejeune Family Member Program Information Update Form (VA Form 10-10068c)
60 fields, 2 pages
10-10072
Supportive Services for Veteran Families (SSVF) Program—Application for Supportive Services Grant
125 fields, 10 pages
10-10072A
Supportive Services for Veteran Families (SSVF) Program—Participant Satisfaction Survey
191 fields, 3 pages
10-10072B
Supportive Services for Veteran Families (SSVF) Program—Quarterly Grantee Performance Report
54 fields, 3 pages
10-10072C
Supportive Services for Veteran Families (SSVF) Program—Renewal Application for Supportive Services Grant
53 fields, 14 pages
10-10118
Designee for Patient Personal Property
16 fields, 1 page
10-10143g
Non-VA Hospital Emergency Notification
31 fields, 1 page
10-10145
Veterans Health Administration (VHA) Veterans Choice Program Provider Agreement
9 fields, 6 pages
10-10152
Reimbursement Request for Qualifying Adoption Expenses
50 fields, 5 pages
10-10154
Employee Incentive Scholarship Program—Mobility Agreement
14 fields, 1 page
10-10163
Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges
9 fields, 1 page
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fields, 1 page
10-10171
Veterans Health Administration (VHA) Veterans Care Agreement
13 fields, 16 pages
10-10172
Community Care Provider—Request for Service
56 fields, 2 pages
10-1023
Information Regarding Possible Claim Against Third Party
27 fields, 1 page
10-1086
Research Consent Form
7 fields, 1 page
10-10CG
Application for Comprehensive Assistance for Family Caregivers Program
87 fields, 6 pages
10-10EC
Application for Extended Care Services
62 fields, 4 pages
10-10EZ
Instructions and Enrollment Application for Health Benefits
122 fields, 6 pages
10-10EZR
Health Benefits Update Form
99 fields, 5 pages
10-10HS
Request for Hardship Determination
27 fields, 2 pages
10-10M
Medical Certificate
108 fields, 3 pages
10-10SH
State Home Program Application for Veteran Care Medical Certification
159 fields, 6 pages
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fields, 3 pages
10-1170
Application for Furnishing Long-Term Care to Beneficiaries of Veteran Affairs
34 fields, 2 pages
10-1223
Report of Subcommittee on Human Studies
22 fields, 1 page
10-1245C
VA/Department of Defense Sharing Agreement
20 fields, 2 pages
10-1313-1
Merit Review Application
65 fields, 1 page
10-1313-13
VHA Research & Development Letter of Intent Cover Page
46 fields, 1 page
10-1313-2
Research and Development Program
6 fields, 1 page
10-1313-4
Research and Development Program—Estimated Expenses
34 fields, 1 page
10-1313-5
Research and Development Program—Investigator's Biographic Sketch
8 fields, 1 page
10-1313-6
Research and Development Program—Investigator's Biographic Sketch
2 fields, 1 page
10-1314
Health Services Research and Development Service Career Development Awardee—Annual Progress Report
126 fields, 2 pages
10-1394
Application for Adaptive Equipment—Motor Vehicle
41 fields, 2 pages
10-2406
Recommendation for Release of Patient in Home Other Than Patient's Own
73 fields, 2 pages
10-2407
Residential Care Home Program Sponsor Application
18 fields, 1 page
10-2409
Patient's Agreement with Hospital in Relation to Home Other Than His Own
13 fields, 1 page
10-2410
Agreement to Provide Home Care for Patient
13 fields, 1 page
10-2478
Veterans Request for Refill of Medications and/or Medical Supplies
28 fields, 1 page
10-250
VHA Research Protocol Privacy Review Checklist
94 fields, 5 pages
10-252
Authorization to Release Protected Health Information to State/Local Public Health Authorities
7 fields, 1 page
10-253
Ecclesiastical Endorsement for Veterans Affairs Chaplaincy
14 fields, 2 pages
10-2553
Certificate of Residency
7 fields, 1 page
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
15 fields, 1 page
10-2649A
Inter-Facility Transfer Form
82 fields, 3 pages
10-2850d
Application for Health Professions Trainees
171 fields, 4 pages
10-306
Request for Information (PCAFC Decisions)
11 fields, 2 pages
10-307
Notice of Disagreement (PCAFC Decisions)
24 fields, 3 pages
10-320
Veteran Reimbursement Claim Form
8 fields, 2 pages
10-3203
Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/or Video or Audio Recordings by VA
35 fields, 2 pages
10-3203a
Informed Consent and Authorization for Third Parties to Produce or Record Statements, Photographs, Digital Images, or Video or Audio Recordings
18 fields, 1 page
10-322
Clinical Determinations and Indications Question Submission Form (VA Form 10-322)
10 fields, 1 page
10-323
Veteran Repayment Plan (RPP) Agreement
23 fields, 2 pages
10-334
VA Form - Tribal Documentation Form
14 fields, 1 page
10-3542
Veteran/Beneficiary Claim for Reimbursement of Travel Expenses
26 fields, 2 pages
10-3567
State Home Inspection—Staffing Profile
370 fields, 4 pages
10-390
VHA Fraud, Waste, and Abuse Complaint Form
37 fields, 2 pages
10-493
TRICARE Affirmation
11 fields, 1 page
10-493b
CHAMPVA Benefits Election Affirmation
10 fields, 1 page
10-5345
Request for and Authorization to Release Health Information
61 fields, 2 pages
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fields, 1 page
10-5392
Occasional Volunteer Time Sheet
120 fields, 1 page
10-5588
State Home Report and Statement of Federal Aid Claimed
99 fields, 5 pages
10-5588A
Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive Service Connection
80 fields, 2 pages
10-6001a
Contract Progress Report
169 fields, 3 pages
10-6056A
Lease
44 fields, 5 pages
10-7055
Application for Voluntary Service
25 fields, 2 pages
10-7078
Authorization and Invoice for Medical and Hospital Services
136 fields, 2 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fields, 2 pages
10-7959D
CHAMPVA Potential Liability Claim
57 fields, 2 pages
10-7959e
Claim for Miscellaneous Expenses
58 fields, 2 pages
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)
15 fields, 2 pages
10-8678
Application for Annual Clothing Allowance (VA Form 10-8678)
31 fields, 1 page
10-9054
Medical Education Affiliation Agreement Between VA and Institutions with Undergraduate Medical Education (UME)
29 fields, 8 pages
10-9055
Graduate Medical Education Affiliation Agreement between VA and Institutions Sponsoring Graduate Medical Education
29 fields, 8 pages
FL-10-426
Temporary Loan Follow-up Letter
4 fields, 1 page
VA1107
Request for Repairs, and/or Accessories
20 fields, 1 page
VA2130
Inspection Sheet—Prosthetic Dealer
189 fields, 2 pages
VA2345
Veteran’s Request for Prosthetic Socks
31 fields, 1 page
VA2346a
Request for Batteries and Accessories
12 fields, 1 page
VA2346b
Positive Airway Pressure (PAP) Devices and Supplies
22 fields, 1 page
VA2793
Shop Data Sheet (Artificial Limbs)
73 fields, 2 pages
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It holds 130 VA forms, such as 10-0003K-2, 10-0003k, and 10-0102.
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