Notification of ER or Observation Form - Spokane VA Medical Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering today’s date in the designated field at the top of the form.
3. Fill in the hospital name and fax number where indicated, ensuring accuracy for proper communication.
4. Provide the ER physician's name and phone number to facilitate follow-up if necessary.
5. Enter the date of service, followed by the veteran's name and Social Security Number (SSN) for identification purposes.
6. Detail the diagnosis clearly, as this information is crucial for processing claims.
7. Select the appropriate specialty by marking MED, SURG, PSYCH, REHAB, or OTHER as applicable.
8. If there is additional insurance information, provide it in the specified section to ensure comprehensive coverage.
9. The veteran or family member must sign at the bottom to authorize payment requests from VA.

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