Heading and today's date
The heading says to complete the form within 72 hours of the beginning of treatment and gives the return email. The form then asks for today's date.
10-10143g
Non-VA Hospital Emergency Notification
- Agency
- VA
- Revision
- May 2020
- Fillable fields
- 31
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10143g: Non-VA Hospital Emergency Notification
VA Form 10-10143g is the U.S. Department of Veterans Affairs Non-VA Hospital Emergency Notification. VA's form page says non-VA health care facilities can fill out and return this form to VA when a Veteran presents emergently at the facility. It is a facility form, not a Veterans benefit application.
The form is one page. Its heading says it is to be completed within 72 hours of the beginning of treatment and returned to [email protected]. It has blocks for Veteran information, vendor information, other insurance and episode information, plus a Paperwork Reduction Act and Privacy Act notice that cites 38 U.S.C. Section 1703, the Veterans Community Care Program.
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 10-10143g
Veteran information
Last name, first name, date of birth, Social Security number and home address with street, city, state and ZIP.
Other insurance
A yes or no choice, then the carrier and the policy number.
Vendor information
Facility name, facility NPI, facility tax ID and phone number, the facility point of contact to whom the VA decision will be sent, and the facility address.
Episode information
Date and time of the emergency, mode of arrival, whether the Veteran was admitted and the discharge date, plus chief complaint, admit diagnosis and discharge diagnosis, of which the form says one or more is required.
Privacy and burden notice
It estimates an average of 10 minutes to complete and says that leaving out information may result in a delay or denial of health care benefits under the Veterans Community Care Program.
How to complete VA Form 10-10143g
- 1
Start within 72 hours
The form says it is to be completed within 72 hours of the beginning of treatment.
- 2
Enter the Veteran's details
Fill in the Veteran information, home address and any other insurance.
- 3
Enter the facility's details
Add the facility name, NPI, tax ID, phone, address and the point of contact who will receive VA's decision.
- 4
Describe the episode
Enter the date and time of the emergency, mode of arrival, admission and discharge details, and at least one of chief complaint, admit diagnosis or discharge diagnosis.
- 5
Email it to VA
Return the completed form to [email protected].
Why fill Form 10-10143g 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
Where to send it
Return to
[email protected], as printed on the form.
Timing
The form says it is to be completed within 72 hours of the beginning of treatment.
VA's decision
The form says the VA decision is sent to the facility point of contact named in the vendor information block.
Edition
The PDF footer reads VA FORM MAY 2020 10-10143g, matching the May 2020 revision date on VA's page. It carries OMB Control Number 2900-0823 and a burden of 10 minutes.
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10-10172
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10-7078
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Who uses VA Form 10-10143g?
VA's page and the form say who completes it and who receives it.
Official sources and the blank
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Questions about Form 10-10143g
Who fills out VA Form 10-10143g?
VA's page says non-VA health care facilities can fill out and return this form to VA when a Veteran presents emergently at the facility.
When is VA Form 10-10143g due?
The form's heading says it is to be completed within 72 hours of the beginning of treatment.
Where is the form sent?
The form says to return it to [email protected].
Which diagnosis fields are required?
The episode information block says one or more of the following is required: chief complaint, admit diagnosis and discharge diagnosis.
Who receives VA's decision?
The facility point of contact listed under vendor information. The form labels it the facility POC to whom VA decision will be sent.