Va Form 10-7078 - Authorization And Invoice For Medical And Hospital Services

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OMB Number: 2900-0080

NOTE: Instructions are written for a multi-part form. Print additional copies as necessary.

Estimated Burden: 2 minutes

AUTHORIZATION AND INVOICE FOR MEDICAL AND

HOSPITAL SERVICES

This information is collected under the authority of Title 38 1703, 1725 and 1728. In accordance with section 3507 of the Paperwork Reduction Act of

1995, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We

anticipate that the time expended by all individuals who must complete this invoice will average 2 minutes. This includes the time it will take to read

instructions, gather the necessary facts and fill out the form. The purpose of this form is to authorize medical treatment and provide a means to bill for

this service although private providers may also use local billing forms or UB (Uniform Billing) Forms 92. Submission of this form is voluntary and

failure to respond will have no impact on benefits to which you may be entitled. Comments regarding this burden estimate or any other aspect of this

collection, including suggestions for reducing the burden, may be addressed by calling the Health Benefits Contact Center at 1-877-222-8387

1C. DATE OF ISSUE (Month, day, year)

1A. DATE OF ISSUE

1B. ISSUING OFFICE

(mm/dd/yyyy)

(This is a mandatory field.)

1D. VETERAN'S NAME (First, middle initial, last)

4. SOCIAL SECURITY NUMBER

2. NAME OF PHYSICIAN OR FACILITY

3. VETERAN'S CLAIM NUMBER