Cover block and background
Selections for the VA medical center, Veterans Service Network and accrediting body, the institution's name, and a background section citing US Code 38 Section 7302.
10-9054
Medical Education Affiliation Agreement Between VA and Institutions with Undergraduate Medical Education (UME)
- Agency
- VA
- Revision
- August 2018
- Fillable fields
- 29
- Pages
- 8
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-9054: Medical Education Affiliation Agreement (UME)
VA Form 10-9054 is the Medical Education Affiliation Agreement Between VA and Institutions with Undergraduate Medical Education (UME), covering the undergraduate programs of allopathic and osteopathic colleges (schools) of medicine. The agreement says that, when duly executed and approved by VA, it establishes an affiliation between the VA medical center and the institution for the academic purpose of education. Its signers are officials of the institution, the VA medical center and network, and the VHA Office of Academic Affiliations.
The eight pages hold a cover block naming the VA medical center, Veterans Service Network, institution and accrediting body, then the background, the responsibilities of each party, the terms of agreement, termination and the signature pages.
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What's in VA Form 10-9054
Responsibilities A to C
Accreditation standards (LCME or COCA for the institution, The Joint Commission for VA), site director and faculty, and administration and setting of the medical education program.
Responsibilities D to G
Orientation, resources and supervision, program policies including Directive 1400.09, academic partnerships through the VA Affiliation Partnership Council, and the learning environment.
Terms of agreement
Civil rights laws, liability under the Federal Employees Liability Reform and Tort Compensation Act and the Federal Tort Claims Act, and HIPAA and HITECH duties, including reporting a possible PHI breach within 24 hours of discovery.
Termination
An end date no more than ten years in the future that expires on June 30th of that year, and the ways either party may end the agreement earlier.
Signature pages
Signature, date, name and title lines for the institution, the VA medical center and network, and the VHA Office of Academic Affiliations, plus the institution's full legal name.
How VA Form 10-9054 is completed
- 1
Fill in the cover block
Select the VA medical center, Veterans Service Network and accrediting body, and enter the institution, school or college.
- 2
Review the responsibilities
Sections A to G set out what the institution and VA each do, from accreditation to the learning environment.
- 3
Insert the end date
The termination section asks for a date no more than ten years in the future that expires on June 30th of that year.
- 4
Institution signs
The institution's signer adds a signature, date, name, title and the institution's full legal name.
- 5
VA signs
The VA medical center and network officials sign, then the Chief Academic Affiliations Officer or Designee for the VHA Office of Academic Affiliations.
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Approval, scope and renewal
Approval
The agreement says it establishes the affiliation when duly executed and approved by the Department of Veterans Affairs.
Facility specific
The agreement says delivering care to other VA medical centers, such as by telehealth, is not covered by it, and that a separate affiliation agreement or other approval may be needed.
Renewal
It says both parties are expected to monitor the termination date and, if desirable, seek to renew it in a timely fashion to avoid any lapse in the agreement.
Edition
The edition is dated AUGUST 2018 on every page, the same revision date VA's form page lists.
Related forms
Who completes VA Form 10-9054?
The agreement is between a VA medical center and an institution. The signature pages name who signs for each side.
Official sources and the blank
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Questions about Form 10-9054
What is VA Form 10-9054?
It is the Medical Education Affiliation Agreement Between VA and Institutions with Undergraduate Medical Education (UME), which establishes an affiliation between a VA medical center and an institution for the academic purpose of education.
Who signs VA Form 10-9054?
The institution's Dean, College of Medicine, Senior Associate, or Vice Dean of Medical Education; the VA Designated Education Officer or Associate Chief of Staff in Education; the VA Medical Center Director; the VA Network Director or equivalent; and the Chief Academic Affiliations Officer or Designee.
How long does the agreement last?
The agreement is in force until a date inserted in the termination section, which the form says is no more than ten years in the future and expires on June 30th of that year.
How can the agreement be ended early?
The form says it may be terminated in writing at any time by mutual consent with due consideration of patient care and educational commitments, or by written notice by either party 6 months in advance of the next training experience.
Which accrediting bodies does it name?
For the institution, the Liaison Committee for Medical Education (LCME) or the Commission on Osteopathic College Accreditation (COCA) of the American Osteopathic Association. For VA, The Joint Commission and/or other hospital or clinic accrediting entities as appropriate.
Does it cover telehealth to other VA medical centers?
No. The agreement says delivering care to other VA medical centers, such as by telehealth, would not be covered, and that a separate affiliation agreement or other approval may be needed as affiliation agreements are facility specific.