Fillable Printable VA Form 10-2478

VA Form 10-2478

VETERAN REQUEST FOR REFILL OF MEDICATIONS

AND/OR MEDICAL SUPPLIES

Instructions: This form is for your use in requesting additional medications or supplies. Mail in at least 14 days

before your supply is exhausted. Before mailing this form, please check it over to be sure all patient identification

blanks have been completed. Prescriptions more than six months old cannot be refilled.

PRESCRIPTION NUMBER

NAME(S) OF MEDICATION AND/OR MEDICAL SUPPLY

(Be sure to list only current prescriptions)

The information requested on this form is solicited under authority of Title 38, U. S. Code, Veterans' Benefits, and will be used to process your

prescription in the shortest time. Disclosure is voluntary. However, if information is not furnished the processing of of your prescription may

be delayed. Failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled.

CITY, STATE AND ZIP CODE

NUMBER AND STREET

NAME (Last, First, Middle Initial)

PATIENT'S SIGNATURE

TELEPHONE (Include area code)

SOCIAL SECURITY NO. DATE

PATIENT'S IDENTIFICATION (Print or Type)

VA FORM

JUL 2006 (R)

10-2478

EXISTING STOCK OF VA FORM 10-2478, MAY 1991, WILL BE USED.

Caution - Always carefully check all medications after receiving them. If any medication appears to be different from what you

have been taking, please immediately phone the Pharmacy( ) for clarification.

Please be sure that name and address are entered in the space to insure prompt delivery of medication.