Payment methods panel
Online at www.pay.gov, by mail to the address below, in person at any VA Medical Center, and pay by phone at 1-888-827-4817, with a Call line for statement questions or an address change.
10-0246
Veteran Patient Statement
- Agency
- VA
- Revision
- January 2013
- Fillable fields
- 52
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-0246: Veteran Patient Statement
VA Form 10-0246 is the U.S. Department of Veterans Affairs Veteran Patient Statement. It is a one page account statement for a patient. It shows the patient name, account number and statement date, an account summary of the previous balance, payments received, new charges and balance, and a table of charges with a description, amount and billing reference for each.
The bottom of the page is a payment coupon. The form says to detach the coupon when paying by mail or in person, and not to include any correspondence with the payment. It lists payment online at www.pay.gov, by mail, in person at any VA Medical Center and by phone at 1-888-827-4817.
The statement fields, such as the account summary and the local VA's message, describe the account. The coupon fields marked with an asterisk are the ones the form asks a credit card payer to complete. VA's page lists the form under VHA. You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-0246
Patient details
Patient name, account number, statement date, the date through which payments received are reflected, and the local VA's message.
Account summary
Previous balance, payments received, new charges and balance.
Charges table
A description, amount and billing reference for each item on the statement.
Payment coupon
Credit card number, expiration date (MM YY), account number, statement date, credit card type (American Express, Master Card, Discover or Visa), signature, Mail to address, balance due by date and payment amount.
Payment terms
The footer says to pay by check, money order or credit card payable to VA and to include the account number.
How to pay with VA Form 10-0246
- 1
Review the statement
Check the account summary and the charges table, and note the balance due by date on the coupon.
- 2
Choose a payment method
The form lists online at www.pay.gov, by mail, in person at any VA Medical Center, or by phone at 1-888-827-4817.
- 3
Complete the coupon
For a credit card payment, fill in the fields marked with an asterisk. For a check or money order, the footer says to make it payable to VA and include the account number.
- 4
Detach and send it
When paying by mail or in person, detach the coupon. The form says not to include any correspondence with the payment.
Why fill Form 10-0246 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Paying and getting help
Online
www.pay.gov, as listed on the form.
By phone
1-888-827-4817, the pay by phone number printed on the form.
By mail or in person
By mail to the address on the coupon's Mail to line, or in person at any VA Medical Center. The blank PDF leaves the Mail to address empty.
Questions or address change
The form has a Call line for statement questions or an address change. The blank PDF does not print a number on that line.
Edition
The footer reads VA FORM JAN 2013 10-0246, matching the January 2013 revision date on VA's form page.
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Who uses VA Form 10-0246?
The form is a statement for a Veteran patient's account. It names these parties and uses.
Official sources and the blank
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Questions about Form 10-0246
What is VA Form 10-0246?
It is the Veteran Patient Statement: an account statement showing the previous balance, payments received, new charges and balance, with a payment coupon at the bottom.
How can the balance on the statement be paid?
The form lists online at www.pay.gov, by mail, in person at any VA Medical Center, or by phone at 1-888-827-4817.
Which fields are filled in to pay by credit card?
The form says to complete the fields marked with an asterisk: credit card number, expiration date, credit card type, signature and payment amount.
Who is a check made payable to?
The footer says to pay by check, money order or credit card payable to VA and to include the account number.
Can a letter go in with the payment?
The form says not to include any correspondence with the payment.
Which number is for statement questions?
The form has a Call line for statement questions or an address change. The blank PDF does not print a number on that line. The pay by phone number printed on the form is 1-888-827-4817.