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(*).

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