Form 10-10143f Community Care Document Cover Sheet

OMB Control Number: 2900-0823
Burden: 5 Minutes

Community Care Document Cover Sheet
Purpose
To allow for the submission of paper documents in support of a claim for emergency care rendered in the community when not accompanied by a paper Health Care Claim Form (Documents may
include but are not limited to: Emergency Room Reports, Discharge Summaries, Transportation Trip Sheets, Explanation of Benefits).
Note: This coversheet is to be used exclusively for the submission of medical documentation for unauthorized emergent services. Documentation for care referred and authorized by VA
should be submitted back to the VA as part of the care coordination process.

Paperwork Reduction and Privacy Act Information
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of
1995. 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 5 minutes. This includes the time it will take to read instructions, gather the necessary facts, and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1703 to accompany documents submitted to the Veterans Community Care Program.
Information you supply may be verified from initial submission forward through a computer matching program. VA may disclose the information that you put on the form, as permitted by law. VA may
make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the VHA Notice of Privacy Practices. Providing the requested
information is voluntary, but if any or all of the requested information is not provided, it may result in a delay or denial of your health care benefits under the Veterans Community Care Program. Failure
to furnish the information will not have any effect on any other benefits to which you may be entitled. If you provide VA with your Social Security Number, VA will use it to administer your VA benefits.
VA also may use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes authorized or required by law.

Instructions
All fields must be filled out completely and properly. Incomplete or incorrectly submitted information may result in the inability to match documentation to claims and a return to sender.

Provider Information

837 Transaction Information

Nine digit tax identification number. No dashes. No spaces.

Nine digit social security number. No dashes. No spaces.

Ten digit national provider identification number.

Patient Name (Last, First, MI)

Unique alpha-numeric number assigned by the provider. Located in field 3a on the CMS 1450/UB-04 and field
26 on the CMS 1500/HCFA.

Statement From Date

Statement To Date

Unique Paperwork ID from the 837 transaction submittal.
Learn more about filing electronically by visiting: www.va.gov/communitycare

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VA FORM
MAR 2020

10-10143f