Form VA Form 10-2570d VA Form 10-2570d Dental Record Authorization and Invoice for Outpatient S

NOTE: INSTRUCTIONS ARE WRITTEN FOR A MULTI-PART FORM. PRINT ADDITIONAL COPIES AS NECESSARY

DENTAL RECORD AUTHORIZATION AND
INVOICE FOR OUTPATIENT SERVICES
PART I - EXAMINATION PROCEDURE INSTRUCTIONS FOR THE PARTICIPATING FEE DENTIST
1. Examination Authorization. The Department of Veterans Affairs (VA) has authorized this veteran to choose a general practitioner
who will complete a thorough oral examination and treatment plan. The VA must be apprised of the veteran's current dental needs so as to
make a determination of the extent and type of treatment to be authorized. The allowable fees for radiographs and examination have been
indicated in Item 14 on page 3 of this form. The fee for radiographs is based on a full mouth series. This is a basic requirement when no
diagnostically usable radiograph record exists relating to a complete dentition. In a circumstance where depleted dentition or edentulous
status exists, the requirement for radiographs should be modified by the examining dentist. Any modification from a full mouth series
should be annotated by specifying the radiographs actually exposed. The fee will be adjusted, accordingly, by the VA. On subsequent
examinations, only radiographs necessary for proper diagnosis and treatment should be taken. Where pre-existing radiographs will serve to
satisfactorily augment a thorough clinical evaluation, the pre-printed entry in Item 9 should be crossed out and initiated by the examining
dentist.
WHEN IS ITEM 11 COMPLETED? WHICH ITEM AUTHORIZES TREATMENT?
2. Inappropriate selection of fee dentist. If you are a specialist, your practice is restricted to a specialty, or you are currently on active
military duty and engaged in part-time private practice, the veteran has made an inappropriate selection of a fee dentist. (VA is prohibited
from making payment of fees to a member of the military services.) Return this authorization and allied papers to the veteran and clarify
that a Civilian General Practice Dentist must be chosen for examination and treatment plan purposes. If the veteran needs assistance, the
Chief of Dental Service at the VA issuing office may be contacted.
3. Use of form. VA Form 10-2570d will serve for examination record, treatment recommendations, record of treatment and invoice for
services provided. If you receive the carbon-interleafed VA Form 10-2570d, please keep all copies together. Entries must be made with a
typewriter or ball point pen only. Use heavy pressure with a ball point pen. Inspect the last copy to see if all entries have been recorded
legibly. Supply all data requested in Items 2 through 5. Be certain to include your telephone number (including area code) in Item 2A.
4. Examination authorized. The examination authorization is your authority to proceed with radiographs and examination only. You
may not proceed with definitive dental care for your veteran patient. Payment will not be made for unauthorized treatment. The only
exception is for limited EMERGENCY dental care. To obviate an emergency situation, care which is needed at the time of the
examination (relief of pain, etc.) can be provided. However, the VA office (shown in Item 1) issuing this authorization must be notified of
the details and treatment within 15 days or there is no authority to make payment for these emergency services.
5. Dental examination. Chart all missing teeth in Item 6. Enter the date examination was conducted and radiographs were taken in
Item 10 opposite the appropriate pre-printed entries in Item 9. During the examination, take care to discuss options and not commit to any
specific treatment plan. If there are significant differences between what VA considers reasonable and appropriate and the proposed
treatment plan, VA may reexamine the veteran prior to treatment authorization to determine a treatment plan that provides a satisfactory
resolution of needs and is compatible with cost containment measures. List all treatment recommendations under Items 7, 8 and 9. Types
of abutments and pontics for fixed partial dentures must be stipulated and teeth to be clasped for removable partial dentures must be
specified. Enter your usual and customary fee for each line entry under Item 12. Enter statements in Item 13 (Remarks) which will further
clarify data under Item 9. Please identify specific teeth which the veteran states were extracted while he was in active military service.
Details as to appropriate dates and places of extractions are necessary to determine if replacements can be authorized. When all appropriate
entries have been completed, return the packet along with the patient's radiographs to the issuing office (shown in Item 1) for treatment
authorization.
6. Requirement to review radiographs. The VA outpatient dental care program operates under legal restriction and, with few exceptions,
only those dental conditions determined to be "service-incurred" may be corrected at Government expense. Therefore, it is necessary that
treatment recommendations and radiographs be returned to the issuing office (Item 1) for determination of the extent of allowable treatment
at VA expense and establishment of authorized fees for these services. Radiographs will be returned to you with the treatment
authorization and may be retained by you for your records.
7. Time limitation. There is a time limitation indicated in Item 19. Examination should be completed and findings returned by this date.
If veteran does not respond for examination, return the authorization to the issuing office. If there is a good reason an extension of time is
required, contact the issuing office (Item 1) for an extension of the time limitation.
8.

Payment for Services. Payment for examination and treatment will be made following completion or termination of treatment.

9. Precaution. There may be instances in which recently discharged veterans will report directly to your office requesting that certain
dental treatment initiated by the Military during service be completed at Government expense. While it is possible that such veterans, after
making application, may be determined eligible for treatment, VA will not be responsible for dental services provided prior to the date
treatment is appropriately authorized.

VA FORM
AUG 2006 (R)

10-2570d

DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA

Instructions

NOTE: INSTRUCTIONS ARE WRITTEN FOR A MULTI-PART FORM. PRINT ADDITIONAL COPIES AS NECESSARY

PART II - TREATMENT PROCEDURE INSTRUCTIONS FOR THE PARTICIPATING FEE DENTIST
1. Treatment Authorization. The Department of Veterans Affairs (VA) has authorized all dental treatment recommended under Item 9
which has not been lined out. The fees specified in Item 12 are approved unless changed in Item 14. Your acceptance of the treatment
authorization constitutes a contract to provide the authorized services for the approved fees, as payment in full. DO NOT request the
veteran to pay any difference between the fees authorized and your usual customary fees. If you are unable to provide the services for the
fees specified, the authorization should be promptly returned to the VA issuing office shown in Item 1. There is no objection to making
separate arrangements with the veteran for any needed service which legally the VA is unable to authorize.
2. Treatment. When services indicated under Item 9 have been provided, enter the date each service was completed under Item 10. This
dated entry in Item 10 will constitute a validation of the service provided by you and claim for payment of said service. When all treatment
has been completed, remove the third copy of the form for your records and return the remaining packet to the authorizing office for
payment. No separate invoice or letterhead is necessary. In order to avoid any misunderstanding concerning fraud, submission of the
completed form to the VA should not take place until all the treatment for which claim is being made has been provided.
3. Change in Treatment Plan by VA. The VA is the primary provider of dental care for VA beneficiaries and not a third-party carrier.
Treatment cases which are beyond the VA's capability to provide care in timely fashion are referred to fee dentists as alternate providers.
Consequently, there is need for consistency between the type and amount of care provided by the VA and that provided by private dentists.
If on review of your treatment plan, the VA disagrees with either of these factors, the Chief of Dental Service will contact you to discuss the
change or it will be noted on the VA Form 10-2570d as an altered plan prior to treatment authorization.
4. Change in Treatment plan by Fee Dentist. If circumstances necessitate a change in the treatment plan or if you disagree with the
approved treatment plan, it will be necessary to contact the Chief of Dental Service at the issuing VA office (shown in Item 1) for approval
of the change in the authorized services and fees prior to proceeding with the altered plan.
5. Spot check examinations. The VA routinely conducts a program of post-treatment clinical evaluations to assure satisfactory conclusion
of the care authorized in the veteran's behalf. Pre-treatment examinations are also employed, as indicated, to assure consistency and
appropriateness of planned treatment.
6. Time limitation for treatment. Treatment should be completed by the date shown in Item 28. If the patient does not respond for
appointment, return the authorization to the issuing VA office (shown in Item 1). If, for good reason, an extension of time is required,
please contact the same issuing office.
7. Restriction of Treatment. The VA outpatient dental care program operates under legal restrictions and, with few exceptions, only
those conditions having been determined by VA to be "service-incurred" may be corrected at government expense.
8. Referral of Treatment.
a. If you find it necessary to refer any part of the authorized plan to another General Practitioner you may do so if the other
dentist agrees to provide the care for the pre-authorized fees. The VA must be notified as to the identity of the other dentist and the
specific services to be provided. Your original authorization must be amended by you to reflect your altered participation as well as
the change to total fees which will be due to you.
b. If you find it necessary to refer any part of the authorized treatment to a Specialist you must first contact the Chief of Dental
Service at the issuing VA office (shown in Item 1) prior to any referral (except in a true emergency). The VA must: (1) concur in the
need for referral to a specialist; (2) confirm the specialty status of that individual; (3) negotiate with the specialist on appropriate fees
for the specific services to be provided; or (4) determine if these services should be provided by VA staff.
9. Incomplete treatment. If for reasons beyond your control, you are unable to complete treatment as authorized, you should return the
VA Form 10-2570d indicating the completed portions of treatment with an explanation of circumstances attached. If the patient has moved
and has contacted you, please include the new address. Undelivered prostheses should be forwarded to the issuing VA office (shown in
Item 1) along with your returned documents.
10. Questions concerning treatment or procedure. If any questions arise concerning dental care or procedures, contact the Chief of
Dental Service at the issuing VA office (shown in Item 1). Clarification and/or concurrence will provide for proper procedure sequences
and avoid undue problems.
11. Exclusion of dentists on active military duty. Dentists who are currently on active military duty and engaged in part-time private
practice may not participate as fee dentists in the treatment of authorized veteran beneficiaries. The Comptroller General's decision 505,
April 1, 1968 prohibits VA from making payments to members of the military service since, in their determination, it constitutes dual
compensation of the dentist by the Federal Government. If dental treatment is provided under these circumstances, neither the VA or the
veteran will be obligated for payment.
VA FORM
AUG 2006 (R)

10-2570d

DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA

Instructions

Any data typed after screen scrolls will not print.
NOTE: If completing this form manually, please press firmly using a ballpoint pen.

OMB Number: 2900-0335
Estimated burden: 20 min.

DENTAL RECORD AUTHORIZATION AND
INVOICE FOR OUTPATIENT SERVICES

Paperwork Reduction Act: This data collection is in accordance with the clearance requirements of 5 CFR Part 1320. 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 form
will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. This data is collected to authorize treatment, list
the dental needs and serve as an invoice for treatment provided. Response is voluntary and failure to respond will have no impact on any benefits to which you may be entitled.

1. ISSUING OFFICE: VA Medical Center
Fee Dentist: EXAMINATION AUTHORIZATION
DOES NOT allow for proceeding beyond diagnoses
and treatment plan. Complete all applicable items
2
through 13 and
return (with X-rays) for
TREATMENT AUTHORIZATION. Acceptance of
an authorized treatment case constitutes a contract
to provide the authorized services for the
approved fees, as payment in full. The patient
must not be requested to pay additional fees for those
services. Refer to attached instructions.

USE EXTRA PAGE FOR MORE SPACE.
7.

T
O
O
T
H

N
U
M
B
E
R

8.

S
U
R (MO,
F DO,
A MOD,
C etc.)
E
S

2. NAME, ADDRESS AND ZIP CODE OF FEE DENTIST

4. SSN OR IRS GROUP NUMBER
3. ARE YOU
NOW ON ACTIVE
MILITARY DUTY
YES
NO
4A. LICENSE NUMBER

2A. FEE DENTIST'S TELEPHONE
NUMBER
(999) 999-9999

5. SIGNATURE OF FEE DENTIST

Permanent

6. MARK OUT ANY MISSING TEETH
1

2

3

4

5

6

7

8

9

10

11

12

13

14

Primary
15

16

A

B

C

D

E

F

G

H

I

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T S R Q P O N M L
ENTER ONLY ONE TOOTH NUMBER, ONE PROCEDURE, ONE DATE OF SERVICE AND ONE FEE PER LINE
9. DESCRIPTION OF SERVICE
11. CODE NO.
12. USUAL &
10. DATE SERVICE
14. FEES
CUSTOMARY
PERFORMED
APPROVED
(List specific treatment recommendations in this column & indicate your usual &
FEE
customary fee in column 12)
BY VA
EXAMINATION (Indicate date)
LIST X-RAYS FIRST (Type & No.), THEN OTHER SERVICES

13. REMARKS: Include significant periodontal disease, soft tissue lesions, presence and serviceability of existing prostheses, pathogenicity of impacted teeth and statement
concerning teeth extracted while in service. Attach additional sheet if necessary.

NOTICE: Acceptance of this authorization and providing of such services or treatment
23. SERVICES NOT LINED OUT IN ITEM 9
subjects you, the provider of care, to the provisions of Public Law 93-579, the Privacy DENTAL ARE APPROVED
Act of 1974, to the extent of the records of the treatment of this veteran. VA pertinent REVIEW/ SIGNATURE OF CHIEF, DENTAL SERVICE OR
rules and regulations implementing this law are available on request at any VA facility. APPROVAL DESIGNEE
15. FISCAL SYMBOL

36

16. OB. NO. AND D.S.

17. VA REGULATION

24. FISCAL SYMBOL

$

27. AUTHORIZATION FOR

0160.001

36

18. AUTHORIZATION FOR: X-RAYS & EXAMINATION
19. EXPIRATION DATE
20. AUTHORIZING SIGNATURE AND DATE

(mm/dd/yyyy)

MEDICAL ADJUNCT CERTIFICATION
21. DENTAL
TREATMENT
IS

NECESSARY AS ADJUNCT TO MEDICAL DISABILITY OF:

25. OB. NO. AND D.S.

(mm/dd/yyyy)
26. VA REGULATION

0160.001

TREATMENT

$

30. TOTAL AMOUNT AUTHORIZED

$

28. EXPIRATION DATE 29. AUTHORIZING SIGNATURE AND DATE (mm/dd/yyyy)

32. THE SERVICES AND FEES LISTED ARE APPROVED EXCEPT:

IS NOT

22. CERTIFYING SIGNATURE AND DATE

(mm/dd/yyyy)
33A. DATE (mm/dd/yyyy)

33. SIGNATURE OF APPROVING OFFICIAL
31. PRINT OR TYPE BENEFICIARY'S NAME, IDENTIFICATION NUMBER, CURRENT
ADDRESS, ZIP CODE, AREA CODE AND TELEPHONE NUMBER

FOR FISCAL USE ONLY

(999) 999-9999

10-2570d

(mm/dd/yyyy)

34. APPROVED

35. VOUCHER AUDIT

36. DATE

STA. #

T/C & S/C

DATE (mm/dd/yyyy)

$

VA FORM
AUG 2006 (R)

DATE

CPF

PAT. #
LIQ. AMT.

$

1ST S/A

$

INITIALS
2ND S/A

$

DENTIST: NO PAYMENT WILL BE MADE UNLESS PRE-AUTHORIZED BY VA