VA 10-2850c PDF Template

[toc] In the United States, veteran benefits are controlled by the Department of Veteran Affairs. Veterans are eligible to receive healthcare benefits along with supplemental income for disabilities. For a healthcare professional to become certified to work with VA insurance, they need to be accepted into the VA healthcare system. There are a number of application forms that help accomplish this goal.

In general, the form 10-2850 is the piece of paperwork that healthcare professionals use to receive their authorization with the VA. 10-2850C specifically relates to healthcare professionals that have not been listed on other VA Form 10-2850s.

The form requires that the applicant give detailed information about themselves and their experience. Whatever information you provide will then be verified by the VA. You’ll be required to give personal information, references, work experience, and details about your education. When you fill out the form, specifics are more likely to grant you access than generalized statements.

The form broadly applies to any healthcare professional that wasn’t covered under other versions of the form. This might include:

Respiratory therapy technicians

Respiratory therapists

Physician’s assistants

Pharmacists

Physical therapists

Vocational nurses

Occupational therapists

Expanded-function dental auxiliaries

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If a health professional wants to be able to treat veteran patients using their VA health insurance, they must first receive official authorization from the VA. This application is the way that authorization is processed. There are a number of benefits to going through this channel. The pool of potential patients is widened for the healthcare professional, while the pool of potential healthcare professionals is widened for the patient.

The healthcare professional is the one responsible for filling out the form. They need to submit their completed form, along with any associated documentation, to their local Veterans Affairs office. You can fill out the complete PDF form online and then print it out to mail to the VA.

Anybody who doesn’t have VA authorization cannot bill the VA for their services. As such, veterans who use their VA health insurance won’t be able to access the services unless they pay out of pocket. This isn’t doable for most people.

The first thing you need to do is indicate the occupation you’re applying for. Put a check next to your profession. If you’re part of a healthcare profession not listed, check the Other box and write your occupation name.

Provide your name, starting with your last name. Then indicate whether this is an application for a specialty practice or general practice. You’ll need to give your present address, including city, state, zip code, and country. It’s best to provide two telephone numbers: one at which you can be reached professionally, and one at which you can be reached in your residence. Box 6 denotes your date of birth, Box 7 asks for your place of birth, and Box 8 is where you’ll record your Social Security number.

Box 9 will be used to explain your citizenship status. Are you a United States citizen? If not, use 9B to note which country you do currently have citizenship in. If you’ve ever filed to be appointed with the VA before, indicate your history in Box 10. Write in Box 11 to explain when the best time is to contact your current employer, and give your available employment date in Box 12.

If you were part of active military duty, Boxes 13A through 13E ask about your service. You’ll need to write the dates you served, the branch of service, and the type of discharge. If the discharge was anything other than honorable, you should explain on another sheet of paper.

The next part is about your licensure. You must list all states and territories in which you have ever held a license. Give the license number for that state, note whether you have a current registration, and write the expiration date of the registration. Check the boxes regarding any license restrictions in Box 15.

In Box 16A, you should write the name of the organization that certifies people for your particular occupation. You should also give the date of your most recently-issued certification or registration, along with your certification number. If action has ever been taken against your registration, you’ll need to indicate that on another sheet.

Explain whether you’ve ever had clinical privileges regarding any healthcare institution. Write the name of the most recent institution in which you held these clinical privileges.

If you’ve invested in liability insurance, you’ll need to note the carrier name, the dates the policy covers, the names of any prior carriers, and information about whether any carriers have previously cancelled your insurance.

The qualifications and professional experience sections allow you to give your educational and job history. The general information section is where you’ll write down any publications, journals, awards, and research grants that have been given to you. After that, you’ll need to give four references who can verify your professionalism within the last five years, without being related to you.

The last part is a series of yes/no questions, followed by your signature and the date. You will also need to sign an authorization for the release of your information.[pdf-embedder url=”https://cdn-prod-pdfsimpli-wpcontent.azureedge.net/pdfseoforms/pdf-20180219t134432z-001/pdf/va-form-10-2850a.pdf”]