Section I: Submitter information
Item 1, a confidential or anonymous complaint, then name, address, telephone and email in Items 2 to 5, and the submitter type in Item 6.
10-390
VHA Fraud, Waste, and Abuse Complaint Form
- Agency
- VA
- Revision
- October 2024
- Fillable fields
- 37
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-390: VHA Fraud, Waste, and Abuse Complaint Form
VA Form 10-390 is the Veterans Health Administration (VHA) Fraud, Waste, and Abuse Complaint Form. VA's form page says to use it to report potential health-care fraud, waste, or abuse in VA programs. The form defines fraud as the intentional misrepresentation of information to gain undeserved payment for a claim, waste as spending federal healthcare dollars on services that are unnecessary, and abuse as a questionable practice inconsistent with accepted medical or business policies.
The form is two pages: Section I for the submitter, Section II for the Veteran, patient or beneficiary, Section III for the provider and Section IV for the complaint itself. It is sent by email or secure fax. 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 10-390
Section II: Veteran, patient or beneficiary
A box for I do not know any patient information, a box for same information as submitter, then name, address, telephone and email in Items 9 to 12.
Section III: Provider information
A box for I do not know any provider information, then the name of the provider, business, facility or practice, the provider NPI if known and the address.
Section IV: Program and type
Item 17 names the program, such as CHAMPVA, VA Community Care, the Foreign Medical Program, the Camp Lejeune Family Member Program, State Veteran Homes or a VA Medical Center. Item 18 asks about a related medical claim and Item 19 the type of fraud, waste or abuse.
Section IV: Details and attachments
Item 20 lists all parties involved, Item 21 holds a detailed description and history with any claim numbers and dates of service, and Item 22 covers attachments, copies only.
Privacy Act and burden notices
Page 2 explains how the information is used and shared, and estimates an average of 10 minutes per respondent, per year.
Most sections open with the note Complete as much as possible.
How to file VA Form 10-390
- 1
Choose confidential or anonymous
Select how to submit the complaint in Item 1. The form explains when a confidential submitter's identity may still be disclosed outside VA.
- 2
Fill in what you know
Complete as much of Sections I to III as possible. Check the boxes in Items 7 and 13 if no patient or provider information is known.
- 3
Describe the complaint
Pick the program and the type of fraud, waste or abuse, list the parties involved and write a detailed description and history of what happened, with claim numbers and dates of service if available.
- 4
Attach copies
Item 22 says multiple attachments may be sent, copies only, such as complaints, bills, EOBs and correspondence.
- 5
Email or fax it
Send the form by email to [email protected] or by secure fax to 303-398-5295. The form asks that emailed complaints not include sensitive information like Social Security Number or bank account information.
Why fill Form 10-390 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
[email protected]. The form says not to include sensitive information like Social Security Number or bank account information when submitting by email.
Secure fax
303-398-5295.
Phone
The form says you may also call the VHA Integrity and Compliance Helpline: 866-842-4357 (VHA-HELP).
Not the burden address
Comments on the burden estimate go to [email protected], and the form says not to send a completed VA Form 10-390 to that address.
Edition
The current edition is dated OCT 2024. It carries OMB Control No. 2900-0944, which expires 10/31/2027.
Related forms
10-10d
Application for CHAMPVA Benefits (VA Form 10-10d)
73 fields, 3 pages
10-7959A
CHAMPVA Claim Form (VA Form 10-7959a)
42 fields, 2 pages
10-7959f-2
Foreign Medical Program (FMP) Claim Cover Sheet (VA Form 10-7959f-2)
15 fields, 2 pages
10-10068
Camp Lejeune Family Member Program Application
84 fields, 3 pages
Who uses VA Form 10-390?
Item 6 of the form lists who the submitter can be.
Official sources and the blank
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Questions about Form 10-390
What is VA Form 10-390 used for?
VA's form page says to use it to report potential health-care fraud, waste, or abuse in VA programs.
Can I submit the complaint anonymously?
Item 1 offers an anonymous option. The form says an anonymous submitter is not required to give a name, patient name or contact information, but withholding it could limit the review.
Is a confidential complaint kept private?
The form says the information is confidential and may be disclosed outside VA only if authorized under the Privacy Act. It lists cases where identity may still be disclosed, such as a referral to law enforcement.
How do I send VA Form 10-390?
By email to [email protected] or by secure fax to 303-398-5295. The form also lists the VHA Integrity and Compliance Helpline, 866-842-4357 (VHA-HELP).
What can I attach?
Item 22 says multiple attachments may be submitted, copies only. Its examples are complaints, bills, EOBs and correspondence.
Who may see the information?
The Privacy Act notice says information on the form may be disclosed to VA OIG, the FBI and other law enforcement agencies involved in actions related to health care services, medical benefits or payment for services.
Can I file it without knowing the patient or provider?
Yes. Item 7 is a box for I do not know any patient information and Item 13 a box for I do not know any provider information.