Va Form 10-0246 - Veteran Patient Statement

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VA
u.s.
Department
ofVeterans Affairs
STATEMENT QUESTIONS OR ADDRESS CHANGE?
Call
Methods of payment:
ONLINE:
BY MAIL:
to the address below
IN PERSON:
at any VA Medical Center
PAY BY PHONE: 1-888-827-4817
Statement reflects payments received by
ILOCAL VA'S MESSAGE
PATIENT NAME:
ACCOUNT NUMBER:
STATEMENT DATE·
I I I
I
*CREDIT CARD NUMBER
I I I I-I I
I
I
I-I
I
I
I I-I
*EXP. DATE
ACCOUNT NUMBER
STATEMENT DATE
MIM _IV IV
I
*CREDIT CARD TYPE
DAMERICAN D MASTER D DISCOVER D VISA
EXPRESS
CARD
ACCOUNT
PREVIOUS BALANCE
SUMMARY
DESCRIPTION
PAYING BY MAIL OR IN PERSON? DETACH THE COUPON BELOW. DO NOT INCLUDE ANY CORRESPONDENCE WITH PAYMENT.
PAYMENTS RECEIVED
NEW CHARGES
BALANCE
AMOUNT
BILLING REFERENCE
*SIGNATURE
BALANCE DUE BY
*PAYMENT AMOUNT
$
MAIL TO:
Pay By: Check, Money Order or Credit Card Payable to "VA". Include Account
VA FORM
10-0246 Veteran Patient Statement
Number. *If paying by Credit Card complete fields marked with an asterisk(*).
Jan 2013

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