Forms
Commonly used forms for non-VA care include the following:- CMS-1500 (OMB NO. 0938-0999) Health Insurance Claim Form
- CMS-1450 (OMB NO. 0938-0997)Health Insurance Claim Form
- HCFA-1450 UB-92 (OMB NO. 0938-0279)Health Insurance Claim Form
- VA Form 10-583 - Claim for Payment of Cost of Unauthorized Medical Services
How to File a Claim
The following brochures provide additional information about non-VA care programs and services:Emergency Care in Non VA Facilities
