This is where to find your VA ONLINE: www.pay.gov account ...
[Pages:1]This is where to find your VA account number.
PATIENT NAME: ACCOUNT NUMBER: STATEMENT DATE:
ACCOUNT SUMMARY
DESCRIPTION
PREVIOUS BALANCE
PAYMENTS RECEIVED
STATEMENT QUESTIONS OR ADDRESS CHANGE?
Call
Methods of payment: ONLINE: BY MAIL: IN PERSON: PAY BY PHONE:
to the address below at the VA Medical Center 1-888-827-4817
Statement reflects payments received by LOCAL VA'S MESSAGE.
NEW CHARGES
BALANCE
AMOUNT
BILLING REFERENCE
PAYING BY MAIL OR IN PERSON? DETACH THE COUPON BELOW. DO NOT INCLUDE ANY CORRESPONDENCE WITH PAYMENT.
*CREDIT CARD NUMBER
*EXP. DATE
M M
Y
Y
ACCOUNT NUMBER
STATEMENT DATE
v
* *CREDIT CARD TYPE
AMERICAN EXPRESS
MASTER CARD
*SIGNATURE
DISCOVER
VISA
BALANCE DUE BY
AMOUNT DUE
*PAYMENT AMOUNT
$
MAIL TO:
VA FORM 10-0246 Veteran Patient Statement
Jan 2013
Pay By: Check, Money Order or Credit Card Payable to "VA". Include Account Number. *If paying by Credit Card complete fields marked with an asterisk(*).
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- department of veterans affairs medication copayments
- co payment application for seniors
- co payments for medicaid services
- copayment requirements by priority group
- state of connecticut emergency room copayment
- a guide to federal government ach payments
- colorado indigent care program client copayment table
- this is where to find your va online account
Related searches
- where to advertise your business
- where to find financial statements
- where to find stock news
- where to find analyst reports
- where to put your money now
- where to put your savings
- where to find minecraft saves
- where to find loose tea
- where to find minecraft world files
- where to invest your money in retirement
- where to find financial reports
- where to market your business