Prosthetic Service Card, VA Form 10-2501

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PROSTHETIC SERVICE CARD

VETERANS AFFAIRS -

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VETERAN’S LAST NAME - FIRST NAME - MIDDLE INITIAL
PATIENT ID #

DATE OF BIRTH

DATE CARD ISSUED

REPAIR COST NOT TO EXCEED

SIGNATURE OF VETERAN

WHEN USING CARD VETERAN MUST PRESENT PICTURE I.D.

THIS CARD DOES NOT ENTITLE BEARER TO NEW APPLIANCES
VA FORM
SEP 2009

10-2501

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The veteran described hereon may obtain repairs or replacement parts for each of the
following listed items or veterinary treatment for their guide dog, at a cost not to exceed
the amount indicated above from any repair shop or veterinarian in U.S.A. or Puerto Rico.
ITEM/SERVICE:
SERIAL #:
MISC.
INFORMATION:

For payment, forward original invoice signed by the veteran to the VA
Office listed below:
NOTE: INVOICE MUST CONFORM TO THE SAMPLE ON THE
REVERSE OF THIS FORM. VA FORM 10-2520, PROSTHETIC
SERVICE CARD INVOICE, (AVAILABLE FROM VA) MAY BE USED.
PREFERRED PAYMENT WILL BE CREDIT CARD.
LOCATION OF VA OFFICE

PROTHESTICS OFFICAL

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FRONT OF 10-2501

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BACK OF 10-2501

SAMPLE INVOICE
COMPANY NAME
Company Address
Veteran's Name:
Last 4 of SSN:
Date of Service:
QTY

DESCRIPTION

SERIAL #

HCPCS

UNIT PRICE CHARGES

REPAIRS TO (Specify item)
REPLACE (Specify
Components)

0.00

0.00

LABOR-HR

0.00

0.00

$0.00
I certify that these repairs were necessary and have been
satisfactorily made.

Veteran’s signature

{

IMPORTANT: Invoices will not be paid unless veteran’s
name, last four of social security number, serial number
and the certification shown above are clearly written or
typed on the face of the company’s standard invoice.
VA FORM
SEP 2009

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10-2501
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