Veteran details
The Veteran's last and first name, the last 4 of the SSN, street address, city, state and zip code.
10-493
TRICARE Affirmation
- Agency
- VA
- Revision
- February 2016
- Fillable fields
- 11
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-493: TRICARE Affirmation
VA Form 10-493 is the U.S. Department of Veterans Affairs TRICARE Affirmation. A Veteran fills it in to elect to use TRICARE benefits for a visit or appointment at a VA medical facility. The form says the election is made at each episode of care, which it defines as the managed care provided by a health care facility or provider for a specific medical problem or behavioral condition or specific illness during a set time period.
The form is one page. It holds the Veteran's details, the election statement with the appointment date, the billing terms the Veteran agrees to and the patient's signature and date. 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 10-493
Episode of care
A paragraph explaining that an episode of care consists of all clinically related services for one patient for a discrete diagnostic condition from the onset of symptoms until treatment is complete.
Election statement
The Veteran's full name and the date of the appointment for which TRICARE benefits are elected.
Billing terms
Related ancillary services such as x-rays and laboratory are part of the episode of care and also billed to TRICARE. The Veteran is responsible for cost shares, co-pays and deductible amounts listed on the TRICARE Explanation of Benefits.
Payment and signature
The name of the medical treatment facility the cost shares are paid to, then the patient's signature and date.
How to fill in VA Form 10-493
- 1
Enter the Veteran's details
Fill in the name, last 4 of the SSN and the address at the top of the form.
- 2
Complete the election statement
Insert the Veteran's full name and the date of the appointment.
- 3
Read the billing terms
The form covers ancillary services, other health insurance, service-connected care and the cost shares, co-pays and deductibles.
- 4
Name the facility
Insert the name of the appropriate medical treatment facility that the cost shares, co-pays and deductible amounts are paid to.
- 5
Sign and date it
Sign the Patient's Signature line and enter the date.
Why fill Form 10-493 on indox
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- The official blank straight from the VA, not a copy someone retyped
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Filing and edition details
No address on the form
The form and VA's form page print no mailing address, fax number or email. The form says the VA medical facility where treatment is performed submits claims to TRICARE.
Each episode of care
The form says TRICARE benefits are elected at each episode of care.
Cost shares
The form says that when TRICARE is billed, cost shares, co-pays and deductible amounts cannot be waived and are paid in full to the named facility when the VA Patient Statement is received. The form does not list amounts.
Edition
The form is dated FEB 2016, which matches the revision date on VA's form page. No OMB control number is printed on it.
Related forms
Who uses VA Form 10-493?
The form is filled in by the Veteran and names the VA medical facility that bills TRICARE.
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Questions about Form 10-493
What is VA Form 10-493 used for?
A Veteran uses it to elect to use TRICARE benefits for an appointment at a VA medical facility.
How often is the TRICARE election made?
The form says it is made at each episode of care, which can be a short period of care, care on a continuous basis or a series of intervals with brief separations from care.
Are x-rays and lab work included?
The form says associated ancillary services related to the visit, such as x-rays and laboratory, are part of the episode of care and will also be billed to TRICARE.
What if I have other health insurance?
The form says VA bills the Other Health Insurance (OHI) as the primary insurance carrier, and then bills TRICARE as the secondary payer.
Is TRICARE billed for service-connected care?
The form says a dual-eligible (VA/Department of Defense) Veteran seeking care for a service-connected condition in a VA medical facility receives that care using Veteran's benefits, and TRICARE will not be billed.
Can cost shares be waived?
The form says that when TRICARE is billed, the cost shares, co-pays and deductible amounts cannot be waived.