U.S. Department of Veterans Affairs - Veterans Health Administration
This FillingPDF page is associated with the U.S. Department of Veterans Affairs - Veterans Health Administration. It contains information associated with the agency.
U.S. Department of Veterans Affairs - Veterans Health Administration forms
- 10-4236a · VA-VHACertificate of Reciprocity
Certificate of Reciprocity (10-4236a) is a U.S. government resource issued by U.S. Department of Veterans Affairs - Veterans Health Administration. VA Form 10-4236a, Certificate of Reciprocity, records a personnel-vetting eligibility determination for a named employee, including the sensitivity or public-trust level of the position, the underlying investigation tier and date, and a reference to applicable reinvestigation rules. The form identifies itself as a memorandum for the employee’s official personnel folder.
1 page - 10-0403a · VA-VHAData Use Agreement
VA Form 10-0403a is the Data Use Agreement of the Veterans Health Administration (VHA), U.S. Department of Veterans Affairs, in which a data requestor initials the terms for using VHA data. Fill out the PDF online on FillingPDF and download or print it.
1 page - 10-10d · VA-VHAForm 10-10d, Application for CHAMPVA Benefits
VA Form 10-10d is the Veterans Health Administration application for CHAMPVA health care benefits for spouses, children and survivors of eligible veterans. Fill it out online and download or print the completed PDF.
3 pages - 10-10EZ · VA-VHAForm 10-10EZ, Instructions and Enrollment Application for Health Benefits
VA Form 10-10EZ is the Veterans Health Administration application Veterans use to apply for enrollment in VA health care. Fill out the form online on FillingPDF and download or print the completed PDF.
6 pages - 10-306 · VA-VHAForm 10-306, Request for Information (PCAFC Decisions)
VA Form 10-306 is the Veterans Health Administration request for information about decisions on PCAFC applications and participation. Fill out the fillable PDF online on FillingPDF, then download or print it to mail to VA.
2 pages - 10-5018 · VA-VHAForm 10-5018, Petty Cash Receipt
VA Form 10-5018, Petty Cash Receipt, is a Veterans Canteen Service form issued by the VA Veterans Health Administration to record a petty cash payment. Fill it out online on FillingPDF and download or print the completed PDF.
1 page - 10-7959a · VA-VHAForm 10-7959A, CHAMPVA Claim Form
VA Form 10-7959a, the CHAMPVA Claim Form, is issued by the VA Veterans Health Administration for beneficiary reimbursement claims. Fill out the form online on FillingPDF and download or print the completed PDF.
2 pages - 10-7959c · VA-VHAForm 10-7959C, CHAMPVA—Other Health Insurance (OHI) Certification
VA Form 10-7959c is the CHAMPVA Other Health Insurance (OHI) Certification from the Veterans Health Administration. Fill it out online on FillingPDF and download or print the completed PDF to report your other health insurance.
2 pages - FL 10-212 · VA-VHAForm FL 10-212, Request for Medical Records
VA Form FL 10-212 is the Veterans Health Administration authorization for a health care entity to release a patient's medical records to VA. Fill out the PDF online on FillingPDF and download or print the completed form.
1 page - 10-9050 · VA-VHAHealth Care Personnel Influenza Vaccination Form
Health Care Personnel Influenza Vaccination Form (10-9050) is a U.S. government resource issued by U.S. Department of Veterans Affairs - Veterans Health Administration. VA Form 10-9050 is the Seasonal Influenza Vaccination Program form for Veterans Health Administration health care personnel. It documents one of three routes: receiving the seasonal influenza vaccine, requesting a medical exception or requesting a religious exception. The June 2026 form includes instructions for supporting evidence and signatures.
1 page - 10-0137 · VA-VHAVA Advance Directive: Durable Power of Attorney for Health Care and Living Will
VA Advance Directive: Durable Power of Attorney for Health Care and Living Will (10-0137) is a U.S. government resource issued by U.S. Department of Veterans Affairs - Veterans Health Administration. VA Form 10-0137 is the VA Advance Directive: Durable Power of Attorney for Health Care and Living Will. Veterans can use it to designate health care decision-makers and describe preferences for medical, mental-health, long-term and other care if they are later unable to decide for themselves. It combines a health care power of attorney and a living will.
6 pages - 10-10M · VA-VHAVA Form 10-10M, Medical Certificate
VA Form 10-10M, Medical Certificate, is a Veterans Health Administration form that records a patient's arrival, vital signs, history and physical, diagnostic impressions, plan and discharge instructions. Fill it out online on FillingPDF and download or print the PDF.
3 pages - 10-320 · VA-VHAVeteran Reimbursement Claim Form
Veteran Reimbursement Claim Form (10-320) is a U.S. government resource issued by U.S. Department of Veterans Affairs - Veterans Health Administration. VA Form 10-320 is the Veteran Reimbursement Claim Form. It is used to claim eligible out-of-pocket emergency prescription expenses at pharmacies outside the VA network and out-of-pocket expenses for unauthorized emergency care at non-VA facilities. The form separates claimant details, itemized evidence and a signed explanation of why VA care was not used.
2 pages - 10-304 · VA-VHAWaiver Statement
Waiver Statement (10-304) is a U.S. government resource issued by U.S. Department of Veterans Affairs - Veterans Health Administration. VA Form 10-304, Waiver Statement, is a veteran statement requesting waiver of government indebtedness for health-care copayment charges. The form requests the veteran’s identification and an explanation of changed circumstances. It expressly warns that a waiver may be partial and does not cover future copayments.
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About the U.S. Department of Veterans Affairs - Veterans Health Administration
This is the FillingPDF page for the U.S. Department of Veterans Affairs - Veterans Health Administration. It presents information associated with the agency.