Va form 10 0500-2026

1. Click ‘Get Form’ to open VA Form 10-0500 in our editor.
2. Begin by filling out the Submitter Information section. Provide your email, ensuring it uses PKI for internal use only.
3. Next, complete the Patient Information section. Fill in the patient's first and last name, address, city/state/zip, phone number, email, and social security number.
4. In the Provider’s Information section, enter the name of the business or facility along with its tax ID number and address.
5. For the Complaint Information section, indicate today’s date and describe the type of fraud, waste, or abuse. Include any relevant claim numbers and dates of service.
6. Attach any necessary documentation by selecting from the Documentation Checklist provided at the end of the form.
7. Once completed, save your changes and submit your form via U.S. Mail or fax it to Program Integrity at 303-398-5295.

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