10-0003K-2
10-0003K-2
Employee Incentive Scholarship Program (EISP) Agreement
14 fillable fields
10-0003k
10-0003k
Employee Incentive Scholarship Program (EISP) Application
80 fillable fields
10-0102
10-0102
Career Development Application
47 fillable fields
10-0137
10-0137
VA Advance Directive: Durable Power of Attorney for Health Care and Living Will
80 fillable fields
10-0137A
10-0137A
What You Should Know About Advance Directives
1 fillable field
10-0143
10-0143
Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
8 fillable fields
10-0143a
10-0143a
Statement of Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973
8 fillable fields
10-0144a
10-0144a
Statement of Assurance of Compliance with Equal Opportunity Laws
9 fillable fields
10-0246
10-0246
Veteran Patient Statement
52 fillable fields
10-0376a
10-0376a
Credentials Transfer Brief
83 fillable fields
10-0379
10-0379
Ecclesiastical Endorsing Organization Request to Designate Ecclesiastical Endorsing Official
39 fillable fields
10-0383
10-0383
Catastrophically Disabled Veteran Evaluation and Approval
57 fillable fields
10-0388-1
10-0388-1
Documents and Information Required for State Home Construction and Acquisition Grants Initial Application
7 fillable fields
10-0388-10
10-0388-10
Certification of Compliance with Federal Requirements—State Home Construction Grant
6 fillable fields
10-0388-13
10-0388-13
Documents and Information Required for State Home Construction and Acquisition Grants—Post-Grant Requirements
7 fillable fields
10-0388-14
10-0388-14
Checklist of Major Requirements for State Home Construction/Acquisition Grants
90 fillable fields
10-0388-3
10-0388-3
State Home Construction Grant Program Space Program Analysis—Nursing Home & Domiciliary
75 fillable fields
10-0388-4
10-0388-4
State Home Construction Grant Program Space Analysis—Adult Day Health Care
53 fillable fields
10-0388-5
10-0388-5
Additional Documents and Information Required for State Home Construction and Acquisition Grants Application
7 fillable fields
10-0388-6
10-0388-6
Certification of State Matching Funds to Qualify for Group 1 on Priority List
9 fillable fields
10-0388-8
10-0388-8
Certification Regarding Drug-Free Workplace Requirements for Grantees Other Than Individuals
6 fillable fields
10-0398
10-0398
Research Protocol Safety Survey
627 fillable fields
10-0400
10-0400
Request for Veterans Service Organization (VSO) Access to Computer Patient Record System (CPRS) Read Only
8 fillable fields
10-0408
10-0408
VHA Fisher House Application
29 fillable fields
10-0430
10-0430
Application for Assistance for Hiring and Retaining Nurses at State Homes
23 fillable fields
10-0436
10-0436
Application for an Off-Site Tissue Banking Waiver at a Non-Profit or Academic Institution
74 fillable fields
10-0445
10-0445
Occupational and Environment Exposure History
137 fillable fields
10-0454
10-0454
Military Treatment Facility Referral to VA Liaison
55 fillable fields
10-0455a
10-0455a
Clinical Trial Inclusion/Enrollment Report
63 fillable fields
10-0460
10-0460
Request for Prescription Drugs from an Eligible Veteran in a State Home
76 fillable fields
10-0462
10-0462
Political Activities Fact Sheet and Certification
4 fillable fields
10-0491
10-0491
Academic Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
481 fillable fields
10-0491L
10-0491L
VA Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP) Agreement
12 fillable fields
10-0491c
10-0491c
Annual VA Employment or Deferment Verification—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
35 fillable fields
10-0491d
10-0491d
Education Program Completion Notice/Service Obligation Placement—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
15 fillable fields
10-0491e
10-0491e
Evaluation & Recommendation Form—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
17 fillable fields
10-0491f
10-0491f
Health Professional Scholarship Program (HPSP) Agreement
13 fillable fields
10-0491g
10-0491g
Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), & Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP)
118 fillable fields
10-0491h
10-0491h
Notice of Approaching Graduation—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
18 fillable fields
10-0491i
10-0491i
Notice of Change and/or Annual Academic Status—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
60 fillable fields
10-0491j
10-0491j
Request for Deferment for Advanced Education—Health Professional Scholarship Program (HPSP) & Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP)
24 fillable fields
10-0491k
10-0491k
VA Scholarship Offer Response—Health Professional Scholarship Program (HPSP), Visual Impairment and Orientation and Mobility Professionals Scholarship Program (VIOMPSP), Veterans Healing Veterans Medical Access and Education Scholarship Program (VHVMAESP)
35 fillable fields
10-0525
10-0525
Revocation of Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
9 fillable fields
10-0525a
10-0525a
Restriction of the Release of Individually-Identifiable Health Information Through eHEALTH Exchange
25 fillable fields
10-0527
10-0527
Request and Authorization to Release Protected Health Information to the Choice/PC3 Program
9 fillable fields
10-10065
10-10065
Ethics Consultation Feedback Tool
85 fillable fields
10-10068c
10-10068c
Camp Lejeune Family Member Program Information Update Form (VA Form 10-10068c)
60 fillable fields
10-10072
10-10072
Supportive Services for Veteran Families (SSVF) Program—Application for Supportive Services Grant
125 fillable fields
10-10072A
10-10072A
Supportive Services for Veteran Families (SSVF) Program—Participant Satisfaction Survey
191 fillable fields
10-10072B
10-10072B
Supportive Services for Veteran Families (SSVF) Program—Quarterly Grantee Performance Report
54 fillable fields
10-10072C
10-10072C
Supportive Services for Veteran Families (SSVF) Program—Renewal Application for Supportive Services Grant
53 fillable fields
10-10118
10-10118
Designee for Patient Personal Property
16 fillable fields
10-10143g
10-10143g
Non-VA Hospital Emergency Notification
31 fillable fields
10-10145
10-10145
Veterans Health Administration (VHA) Veterans Choice Program Provider Agreement
9 fillable fields
10-10152
10-10152
Reimbursement Request for Qualifying Adoption Expenses
50 fillable fields
10-10154
10-10154
Employee Incentive Scholarship Program—Mobility Agreement
14 fillable fields
10-10163
10-10163
Request for and Permission to Participate in Sharing Protected Health Information through Health Information Exchanges
9 fillable fields
10-10164
10-10164
Opt-Out of Sharing Protected Health Information Through Health Information Exchanges
9 fillable fields
10-10171
10-10171
Veterans Health Administration (VHA) Veterans Care Agreement
13 fillable fields
10-10172
10-10172
Community Care Provider—Request for Service
56 fillable fields
10-1023
10-1023
Information Regarding Possible Claim Against Third Party
27 fillable fields
10-1086
10-1086
Research Consent Form
7 fillable fields
10-10CG
10-10CG
Application for Comprehensive Assistance for Family Caregivers Program
87 fillable fields
10-10EC
10-10EC
Application for Extended Care Services
62 fillable fields
10-10EZ
10-10EZ
Instructions and Enrollment Application for Health Benefits
122 fillable fields
10-10EZR
10-10EZR
Health Benefits Update Form
99 fillable fields
10-10HS
10-10HS
Request for Hardship Determination
27 fillable fields
10-10M
10-10M
Medical Certificate
108 fillable fields
10-10SH
10-10SH
State Home Program Application for Veteran Care Medical Certification
159 fillable fields
10-10d
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fillable fields
10-1170
10-1170
Application for Furnishing Long-Term Care to Beneficiaries of Veteran Affairs
34 fillable fields
10-1223
10-1223
Report of Subcommittee on Human Studies
22 fillable fields
10-1245C
10-1245C
VA/Department of Defense Sharing Agreement
20 fillable fields
10-1313-1
10-1313-1
Merit Review Application
65 fillable fields
10-1313-13
10-1313-13
VHA Research & Development Letter of Intent Cover Page
46 fillable fields
10-1313-2
10-1313-2
Research and Development Program
6 fillable fields
10-1313-4
10-1313-4
Research and Development Program—Estimated Expenses
34 fillable fields
10-1313-5
10-1313-5
Research and Development Program—Investigator's Biographic Sketch
8 fillable fields
10-1313-6
10-1313-6
Research and Development Program—Investigator's Biographic Sketch
2 fillable fields
10-1314
10-1314
Health Services Research and Development Service Career Development Awardee—Annual Progress Report
126 fillable fields
10-1394
10-1394
Application for Adaptive Equipment—Motor Vehicle
41 fillable fields
10-2406
10-2406
Recommendation for Release of Patient in Home Other Than Patient's Own
73 fillable fields
10-2407
10-2407
Residential Care Home Program Sponsor Application
18 fillable fields
10-2409
10-2409
Patient's Agreement with Hospital in Relation to Home Other Than His Own
13 fillable fields
10-2410
10-2410
Agreement to Provide Home Care for Patient
13 fillable fields
10-2478
10-2478
Veterans Request for Refill of Medications and/or Medical Supplies
28 fillable fields
10-250
10-250
VHA Research Protocol Privacy Review Checklist
94 fillable fields
10-252
10-252
Authorization to Release Protected Health Information to State/Local Public Health Authorities
7 fillable fields
10-253
10-253
Ecclesiastical Endorsement for Veterans Affairs Chaplaincy
14 fillable fields
10-2553
10-2553
Certificate of Residency
7 fillable fields
10-259
10-259
Revocation of Authorization for Release of Release of Individually-Identifiable Health Information
15 fillable fields
10-2649A
10-2649A
Inter-Facility Transfer Form
82 fillable fields
10-2850d
10-2850d
Application for Health Professions Trainees
171 fillable fields
10-306
10-306
Request for Information (PCAFC Decisions)
11 fillable fields
10-307
10-307
Notice of Disagreement (PCAFC Decisions)
24 fillable fields
10-320
10-320
Veteran Reimbursement Claim Form
8 fillable fields
10-3203
10-3203
Consent for Production and Use of Verbal or Written Statements, Photographs, Digital Images, and/or Video or Audio Recordings by VA
35 fillable fields
10-3203a
10-3203a
Informed Consent and Authorization for Third Parties to Produce or Record Statements, Photographs, Digital Images, or Video or Audio Recordings
18 fillable fields
10-322
10-322
Clinical Determinations and Indications Question Submission Form (VA Form 10-322)
10 fillable fields
10-323
10-323
Veteran Repayment Plan (RPP) Agreement
23 fillable fields
10-334
10-334
VA Form - Tribal Documentation Form
14 fillable fields
10-3542
10-3542
Veteran/Beneficiary Claim for Reimbursement of Travel Expenses
26 fillable fields
10-3567
10-3567
State Home Inspection—Staffing Profile
370 fillable fields
10-390
10-390
VHA Fraud, Waste, and Abuse Complaint Form
37 fillable fields
10-493
10-493
TRICARE Affirmation
11 fillable fields
10-493b
10-493b
CHAMPVA Benefits Election Affirmation
10 fillable fields
10-5345
10-5345
Request for and Authorization to Release Health Information
61 fillable fields
10-5345a
10-5345a
Individuals' Request for a Copy of Their Own Health Information
43 fillable fields
10-5392
10-5392
Occasional Volunteer Time Sheet
120 fillable fields
10-5588
10-5588
State Home Report and Statement of Federal Aid Claimed
99 fillable fields
10-5588A
10-5588A
Claim for Payment for Nursing Home Care Provided to Veterans Awarded Retroactive Service Connection
80 fillable fields
10-6001a
10-6001a
Contract Progress Report
169 fillable fields
10-6056A
10-6056A
Lease
44 fillable fields
10-7055
10-7055
Application for Voluntary Service
25 fillable fields
10-7078
10-7078
Authorization and Invoice for Medical and Hospital Services
136 fillable fields
10-7959A
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fillable fields
10-7959C
10-7959C
CHAMPVA Other Health Insurance (OHI) Certification (VA Form 10-7959c)
51 fillable fields
10-7959D
10-7959D
CHAMPVA Potential Liability Claim
57 fillable fields
10-7959e
10-7959e
Claim for Miscellaneous Expenses
58 fillable fields
10-7959f-2
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)
15 fillable fields
10-8678
10-8678
Application for Annual Clothing Allowance (VA Form 10-8678)
31 fillable fields
10-9054
10-9054
Medical Education Affiliation Agreement Between VA and Institutions with Undergraduate Medical Education (UME)
29 fillable fields
10-9055
10-9055
Graduate Medical Education Affiliation Agreement between VA and Institutions Sponsoring Graduate Medical Education
29 fillable fields
FL-10-426
FL-10-426
Temporary Loan Follow-up Letter
4 fillable fields
VA1107
VA1107
Request for Repairs, and/or Accessories
20 fillable fields
VA2130
VA2130
Inspection Sheet—Prosthetic Dealer
189 fillable fields
VA2345
VA2345
Veteran’s Request for Prosthetic Socks
31 fillable fields
VA2346a
VA2346a
Request for Batteries and Accessories
12 fillable fields
VA2346b
VA2346b
Positive Airway Pressure (PAP) Devices and Supplies
22 fillable fields
VA2793
VA2793
Shop Data Sheet (Artificial Limbs)
73 fillable fields
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It holds 130 VA forms, such as 10-0003K-2, 10-0003k, and 10-0102.
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