10-2421 Prosthetic Authorization For Items Or Services

OMB Number: 2900-0188
Estimated Burden: 4 minutes
Expiration Date: xx/xx/xxxx

PROSTHETIC AUTHORIZATION FOR ITEMS OR SERVICES
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 form is used as an authorization and invoice for direct procurement of new prosthetic appliances or services. Although the service provider 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 the provider 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.

1. NAME AND ADDRESS OF VENDOR

2. NAME AND ADDRESS OF VA FACILITY

3. VETERAN'S NAME (Last, First, Middle Initial) (This is a mandatory field.)

4. DATE OF AUTHORIZATION (mm/dd/yyyy)

5. VETERAN'S ADDRESS

6. DATE REQUIRED (mm/dd/yyyy)
9. AUTHORITY FOR ISSUANCE
CFR 17.115
8. SOCIAL SECURITY NUMBER
(mandatory)

7. CLAIM NUMBER
10. STATISTICAL DATA

CHARGE MEDICAL APPROPRIATION (Specify AMIS Line Number below)
11. FOB POINT

SC
NSC

IP
A&A

OP

50%

INITIAL
REPEAT

12. DISCOUNT TERMS

13. DELIVERY TIME

14. DELIVER TO:

15. DESCRIPTION OF ITEMS OR SERVICES AUTHORIZED
QUANTITY
ORDERED

DESCRIPTION/NOMENCLATURE

ITEM NUMBER

UNIT

UNIT PRICE

AMOUNT

$

ORIGINAL COPY AND COMMERCIAL INVOICE MUST BE SUBMITTED
TO THE VAMC PROSTHETIC ACTIVITY LISTED ABOVE
16. CONTRACT NUMBER (If any)
17. SIGNATURE AND TITLE OF REQUESTING OFFICIAL

18. DATE (mm/dd/yyyy)

TOTAL

19. SIGNATURE AND TITLE OF
CONTRACTING/ACCOUNTABLE OFFICER

$

20. DATE (mm/dd/yyyy)

ORDER AND RECEIPT ACTION
21. ORDER NUMBER

22. DATE OF ORDER

23. DATE ITEM RECEIVED

24. DATE DELIVERED

25. The articles or services listed have been received, or rendered ordered and in the quantity and
quality specified originally or as shown by authenticated changes, except as noted.

SIGNATURE OF VETERAN OR VA OFFICIAL
APPROVED FOR

VOUCHER AUDIT BLOCK (For use by VA Facility only)
DATE

VOUCHER AUDITOR

$
ACCT. SYMBOL

VA FORM
DEC 2010

10-2421

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TERMS AND CONDITIONS
52.252-02 - CLAUSES INCORPORATED BY REFERENCE (Jun 88)
This contract incorporates one or more clauses by reference, with the same force and effect as if they were
given in full text. Upon request, the Contracting Officer will make their full text available.
FEDERAL ACQUISITION REGULATION (48 CFR CHAPTER I) CLAUSES
Officials Not to Benefit (Apr 84)
Gratuities (Apr 84)
Covenant Against Contingent Fees (Apr 84)
Restrictions on Subcontractor Sales to the Government (Jul 85)
Anti-Kickback Procedures (Oct 88)
Variations in Quantity (Apr 84)
Convict Labor (Apr 84)
Contract Work Hours and Safety Standards Act --Overtime Compensation (General)(Mar 86)
Equal Opportunity (Apr 84)
Affirmative Action for Handicapped Workers (Apr 84)
Buy America Act -- Supplies (Jan 89)
Restrictions on Contracting with Sanctioned Persons (May 89)
Payments (Apr 84)
Discounts for Prompt Payment (Apr 89)
Prompt Payment (Apr 89)
Disputes (Apr 84)
Changes -- Fixed Price (Aug 87)
Termination for Convenience of the Government (Fixed Price) (Short Form) (Apr 84)
Default (Fixed-Price Supply and Service) (Apr 84)
SHIPPING INSTRUCTIONS NUMBER 1
1. The following shall apply when the Order specified "f.o.b. origin, transportation prepaid, with transportation
costs to be included as a separate item on the invoice":
a. Consistent with the terms of the contract, pack, mark and prepare shipment in conformance with carrier
requirements to protect the personal property and assure assessment of the lowest applicable transportation charge.
b. Add transportation cost as a separate item on your invoice. Insurance charges will not be paid unless the
Order specifically requires that the shipment be insured. If shipment is made by other than parcel post, the invoice
must bear the following certification: "The invoiced transportation charges paid and evidence of such payment will
be furnished upon the Government's request."
c. Do not prepay transportation charges on this order if such charges exceed $100.00. Ship collect and annotate
the commercial bill of lading "To be converted to Government Bill of Lading". These instructions do not apply if
order in question is placed against a Federal Supply Schedule contract that authorizes prepayment or transportation
charges regardless of cost.
SHIPPING INSTRUCTIONS NUMBER 2
2. The following shall apply when the Order specifies f.o.b. origin, ship by parcel post:
52.203-01
52.203-03
52.203-05
52.203-06
52.203-07
52.212-09
52.222-03
52.222-04
52.222-26
52.222-36
52.225-03
52.225-13
52.232-01
52.232-08
52.232-25
52.233-01
52.243-01
52.249-01
52.249-8

a. The contractor shall forward the shipment by parcel post using the VA Form 3017 provided with the Order as
an address label and postage.
b. The Post Office Department Certificate of Mailing, Form POD 3817, (also provided with the Order), is to be
receipted by the sending post office and returned to the VA ordering office as evidence that shipment was mailed.
Vendors need not affix postage to the certificate of mailing (POD 3817). It will be accepted for mailing without
postage when presented at the post office together with the package bearing the indicia mail label (VA Form 3017).

VA FORM
DEC 2010

10-2421

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