Va Form 10-7959e - Claim For Miscellaneous Expenses
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2OMB Number: 2900-0219
Est. Burden: 10 minutes
Claim for Miscellaneous Expenses
Department of Veterans Affairs
VA Health Administration Center
1-888-820-1756
Attention: After reviewing the following information, complete the form in its entirety (print or type only) and return with the
required documentation. Receipts must be provided with this form to ensure proper payment. Failure to provide the requested
information will result in a delay or denial of reimbursement. If more space is needed, continue in the same format on a
separate sheet.
Note: This form is required for all claims for reimbursement of miscellaneous expenses related to the treatment of spina
bifida and other covered birth defects and associated covered conditions. Regardless of the type of expense being claimed,
completion of Sections I, II, and IV are mandatory. Completion of Section III is required only for claims involving travel.
Reimbursement for approved expenses (including attendant travel/miscellaneous expenses) will be made payable to
the beneficiary.
Section I - Patient Information
Last Name
First Name
MI
Social Security Number
Street Address
Date of Birth (mm/dd/yyyy)
City
State
ZIP Code
Telephone Number (include area code)
Section II - Sponsor Information
Last Name
Social Security Number
First Name
MI
Section III - Travel
Attach required receipts for expenses claimed (receipts for privately owned vehicle mileage [POV] excluded)
Will the provider be billing for services? (Check one)
Yes
No
Certification of Medical Service (required for all travel claims)
Date of Service (mm/dd/yyyy) Provider Tax ID Number
Provider signature certifying service on service date (type if electronic)
X
Patient Travel Information
Mode of Travel
444
Taxi
Airline
POV (round trip) mileage
44444
Bus
Train
Other (specify)
Date(s) of travel (mm/dd/yyyy)
Departure
Arrival
City
State
Time (e.g. 0815)
City
State
Time (e.g. 0815)
Date(s) of travel (mm/dd/yyyy)
Departure
Arrival
Time (e.g. 0815)
Time (e.g. 0815)
City
State
City
State
Attendant Information
Last Name
First Name
MI
Relationship to Patient
Patient/Attendant Miscellaneous Expenses
Lodging $
Other (parking, tolls, etc.) $
Meals $
Section IV - Certification
Federal Laws (18 USC 287 and 1001) provide for criminal penalties for knowingly submitting or making any false, fictitious, or fraudulent statements or claims.
Release of Medical Information: Signature in this section authorizes the patient's providers to release medical record documentation related to the
services associated with this claim. This consent pertains to all medical records, including records related to treatment for psychological and psychiatric
conditions, drug and alcohol abuse, acquired immune deficiency syndrome, human immunodeficiency virus infection, and sickle cell disease.
4
I certify that the above information and attachments are correct
Signature (type if electronic)
Date
and represent actual services, dates, and fees charged. (Sign and
date on right.) If certification is signed by a person other than the
patient, complete the information, signature and date.
Last Name
First Name
MI
Relationship to Patient
Street Address
City
State
ZIP Code
Telephone Number (include area code)
VA FORM
10-7959e
MAY 2010
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