Identifying fields and purpose
The VA medical center, Veterans Service Network, institution sponsoring GME education and ACGME number, and accrediting body, then a paragraph stating what the agreement establishes.
10-9055
Graduate Medical Education Affiliation Agreement between VA and Institutions Sponsoring Graduate Medical Education
- Agency
- VA
- Revision
- August 2018
- Fillable fields
- 29
- Pages
- 8
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-9055: Graduate Medical Education Affiliation Agreement
VA Form 10-9055 is the U.S. Department of Veterans Affairs Graduate Medical Education Affiliation Agreement between VA and Institutions Sponsoring Graduate Medical Education. The form says that, when duly executed and approved by VA, it establishes an affiliation between a VA medical center and an institution sponsoring graduate medical education programs, for the academic purposes of resident and fellow education.
It is an agreement between institutions, not an application for benefits. The form says the Sponsoring Institution, called the Affiliate, accepts primary responsibility for the integrated education programs conducted with VA, while the local VA medical center keeps full responsibility for the care of VA patients and the administration of its health care system. VA's page lists it under VHA.
The PDF is eight pages: identifying fields, background, responsibilities, terms, termination and a signature page. 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 10-9055
Background
Cites US Code 38 Section 7302 on VA's program of education and training of health personnel, and says the agreement forms the basis for more specific agreements between the parties.
Responsibilities A to G
Paired duties for the Affiliate and VA on accreditation standards, site director and faculty, program administration, orientation and supervision, policies, academic partnerships and the learning environment.
Terms of agreement
Control of VA facilities rests with VA and academic education with the institution. It covers nondiscrimination laws, liability under the Federal Tort Claims Act, and HIPAA rules for protected health information.
Termination
A blank for the end date, which the form says is no more than ten years in the future and expires on June 30th of that year, plus the ways the affiliation can be ended.
Signature page
Signature, date, name and title lines for the Affiliate, the VA medical center, the VA network and the VHA Office of Academic Affiliations.
How to complete VA Form 10-9055
- 1
Fill in the header
Select the VA medical center, Veterans Service Network and accrediting body, and enter the institution sponsoring GME education with its ACGME number.
- 2
Review the responsibilities and terms
Both parties read Responsibilities A to G and the Terms of Agreement, including the HIPAA commitments and the 24 hour breach reporting step the form lists.
- 3
Enter the end date
Insert the date the agreement stays in force until. The form says it is no more than ten years in the future and expires on June 30th of that year.
- 4
Collect the signatures
The Affiliate signs, then the VA Designated Education Officer, VA Medical Center Director and VA Network Director, then the Chief Academic Affiliations Officer.
Why fill Form 10-9055 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 it goes
Final approval
The last signature block belongs to the Office of Academic Affiliations (10AD2), Veterans Health Administration. The form prints no mailing address or submission method.
No online version
VA's page offers the form as a downloadable PDF only.
Renewal and ending it
The form says both parties monitor the expiration date and, if desirable, seek renewal in a timely fashion. It may be ended in writing by mutual consent, or by written notice from either party 6 months in advance of the next academic year.
Edition
The PDF footer reads VA FORM 10-9055, AUGUST 2018, and VA's page gives a form revision date of August 2018.
Related forms
Who completes VA Form 10-9055?
The signature page names the officials who sign for each party. Veterans do not file this form.
Official sources and the blank
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Questions about Form 10-9055
What is VA Form 10-9055 used for?
The form says it establishes an affiliation between a VA medical center and an institution sponsoring graduate medical education programs, for the academic purposes of resident and fellow education.
Do Veterans fill out VA Form 10-9055?
No. It is an agreement signed by officials of the sponsoring institution, the VA medical center, the VA network and the VHA Office of Academic Affiliations.
How long does the agreement last?
Until the date written in the Termination section. The form says that date is no more than ten years in the future and expires on June 30th of that year.
Can the affiliation be ended early?
The form says it may be terminated in writing at any time by mutual consent, or by written notice by either the Affiliate or VA 6 months in advance of the next academic year.
Does it cover telehealth to other VA medical centers?
The form says that if delivering care to other VA medical centers, such as by telehealth, is part of a rotation, it needs to be covered by an additional separate affiliation agreement.