Fillable Printable VA Form 10-0246
Fillable Printable VA Form 10-0246
VA Form 10-0246
VA
u.s.
Department
of
Veterans Affairs
STATEMENT
QUESTIONS
OR
ADDRESS
CHANGE?
Call
Methods
of
payment:
ONLINE:
www.pay.gov
BY
MAIL:
to
the address
below
IN
PERSON:
at any
VA
Medical Center
PAY
BY
PHONE:
1-888-827-4817
Statement
reflects
payments
received
by
ILOCAL VA'S MESSAGE
PATIENT NAME:
ACCOUNT NUMBER:
STATEMENT DATE·
I I I I
*CREDIT
CARD
NUMBER
I I I
I-I
I I I
I-I
I I I
I-I
*EXP.
DATE
ACCOUNT
NUMBER
STATEMENT
DATE
MIM
_IV
IV
I
*CREDIT
CARD
TYPE
DAMERICAN
D
MASTER
D
DISCOVER
D
VISA
EXPRESS
CARD
ACCOUNT
PREVIOUS
BALANCE
SUMMARY
DESCRIPTION
PAYING
BY
MAIL
OR
IN
PERSON?
DETACH
THE
COUPON
BELOW.
DO
NOT
INCLUDE
ANY
CORRESPONDENCE
WITH
PAYMENT.
PAYMENTS
RECEIVED
NEW
CHARGES
BALANCE
AMOUNT BILLING
REFERENCE
*SIGNATURE
BALANCE
DUE
BY
*PAYMENT
AMOUNT
$
MAIL TO:
Pay
By:
Check,
Money
Order
or
Credit
Card Payable
to
"VA".
Include
Account
VA
FORM
10-0246
Veteran
Patient
Statement
Number.
*If
paying by
Credit
Card
complete
fields
marked
with
an
asterisk(*).
Jan
2013
