Fillable Printable VA Form 10-1245c
Fillable Printable VA Form 10-1245c
VA Form 10-1245c
VA FORM
APR 2011
10-1245c
Page 1 of 2
SUPERSEDES VA FORM 10-1245c, DEC 2010
VA/Department of Defense Sharing Agreement
INSTRUCTIONS:
1. A proposed agreement must include this form, signed by both parties and submitted to the approving authorities in each Department. Normally, agreements
will go into effect 46 days after receipt by the approving authorities provided no disapproval has been transmitted in writing to one or both parties signing the
agreement. Agreements will go into effect earlier than the 46-day period if approvals are obtained from both Departments' approving authorities. Agreements
may go into effect more than 46 days after receipt if a later date is indicated in Box 3.
2. If additional resources are required to implement an agreement, approval must be obtained from the Department providing the resources prior to submitting
the proposal.
3. The organization providing care should prepare a claim for services/care provided on an approved industry standard claim form (i.e. CMS 1500 / UB 04), if
possible. The form should be transmitted via the organization's Electronic Data Interface (EDI) to the receiving organization's office, or designee, to be
processed for billing. In cases where EDI is not available, claims may be printed and sent via secured mail. In some cases, the SF 1080 may still be used if
agreed to by both parties, primarily for non-medical services.
4. Rates should be established for all shared services and bills rendered for services provided. It is improper to exchange services without the preparation of
bills. Payments may be at the billed rate or offset against payments due.
5. Amendments to this agreement shall be submitted for approval as new sharing agreements. This agreement will remain in force during the period stated
unless terminated at the request of either party after thirty (30) days' notice in writing. To the extent that this agreement is so terminated, each party will be liable
only for payment in accordance with provisions of this agreement for resources provided prior to the effective date.
6. In the event of war or national emergency, this agreement may be terminated immediately upon written notice by either Department.
7. This agreement is subject to the availability of funds for the period after September 30 in succeeding fiscal years.
8. For further guidance see: VA-DoD Sharing Guidelines, dated October 31, 2008. For applicable Departmental policies for VA see: VHA Handbook 1660.4 “VA-
DoD Health Care Resources Sharing Handbook”: http://vaww.dodcoordination.va.gov For DoD see: DoD Instruction 6010.23, “DoD and VA Health Care
Resource Sharing Program”: http://www.tricare.osd.mil/DVPCO/default.cfm
1. AGREEMENT NUMBER (Leave blank)
2. TYPE OF ACTION (Check box)
New agreement
Renewal Replaces:
Amendment Amends:
3. AGREEMENT PERIOD
(Month/Year)
TO
4. VA FACILITY (Name/Address)
5. DOD FACILITY (Name /Address)
6. DIRECT PAYMENT TO: (Name/Address)
7. OFFICE TO BE BILLED/BILLING FREQUENCY (Name/Address)
8. GENERAL PROVISIONS: (To be included in all agreements)
a. Authorities for this agreement are “Department of Veterans Affairs and Department of Defense Health Resources Sharing and Emergency
Operations Act,” 38 U.S.C. 8111; and “Sharing of Health Care Resources with the Department of Veterans Affairs” 10 U.S.C. 1104.
b. Other provisions (if applicable)
(Continue on page 2)
VA FORM
APR 2011
10-1245c
Page 2 of 2
SUPERSEDES VA FORM 10-1245c, DEC 2010
9. DESCRIPTION OF SERVICES PROVIDED BY VA: NUMBER ESTIMATED COST
10. DESCRIPTION OF SERVICES PROVIDED BY DOD: NUMBER ESTIMATED COST
11. SIGNATURE OF VA MEDICAL CENTER DIRECTOR
12. SIGNATURE OF AUTHORIZED DEPARTMENT OF DEFENSE OFFICIAL
DATE
DATE
