VA Form 10-2520 Prosthetic Service Card Invoice

OMB Number: 2900-0188
Estimated Burden: 4 minutes

PROSTHETIC SERVICE CARD INVOICE

VENDOR'S INVOICE NUMBER

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.
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.
VETERANS AFFAIRS

NAME AND ADDRESS OF FIRM OR DEALER

TO

FROM

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

VETERAN'S ADDRESS

LAST 4 DIGITS OF SSN
(This is a mandatory field.)

TYPE OF APPLIANCE

NAME OF APPLIANCE MANUFACTURER

DATE DELIVERED

SECTION I - HCPCS REPAIR DATA
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.

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

DATE OF SERVICE

HCPCS

TOTAL CHARGES

(mm/dd/yyyy)

CHARGES

$

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.

SECTION II - CERTIFICATION OF VETERAN
I certify that this invoice has been completed to show total charges; SIGNATURE OF VETERAN (DO NOT SIGN A BLANK FORM)
that charges seem proper for work done; that these repairs were
necessary and satisfactory

DATE

(mm/dd/yyyy)

DATE

(mm/dd/yyyy)

DATE

(mm/dd/yyyy)

SECTION III - TO BE COMPLETED BY VA PROSTHETICS SERVICE

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

None
APPROVED FOR

VA FORM
JUN 2008

10-2520

SIGNATURE AND TITLE

See Reverse
PURCHASE ORDER NUMBER