Fillable Printable VA Form 10-493a
Fillable Printable VA Form 10-493a
VA Form 10-493a
DEPARTMENT OF VETERANS AFFAIRS
TRICARE For Life Affirmation
Please fill in the section below if you elect to use your TRICARE For Life benefits for this visit/appointment. In order to utilize your
TRICARE For Life benefits, you must elect to use them at each "episode of care." An "episode of care" is defined as the managed
care provided by a health care facility or provider for a specific medical problem or behavioral condition or specific illness during a
set time period. An episode of care can be a short period of care or care on a continuous basis or it may consist of a series of
intervals marked by one or more brief separations from care. An episode of care consists of all clinically related services for one
patient for a discrete diagnostic condition from the onset of symptoms until treatment is complete.
I
(Insert Veteran's Full Name)
agree and elect to use my TRICARE benefits for an appointment
on
(Insert Date)
. I understand that any associated ancillary services (such as x-rays, laboratory, etc.) related
to this visit are considered to be a part of this “episode of care” and will also be billed to TRICARE For Life. I understand that
the US Department of Veterans Affairs (VA) medical facility where treatment is performed will submit claims on my behalf to
TRICARE For Life and that I am responsible for any cost shares, co-pays, and deductible amounts, which are listed on the
TRICARE For Life Explanation of Benefits. I also understand that if I have Other Health Insurance (OHI), VA will bill my OHI,
(i.e., Medigap, as my primary insurance carrier, and then bill TRICARE For Life as my secondary payer. I further understand
that:
• If I am a dual-eligible (VA/Department of Defense) Veteran seeking care for a service-connected condition in a
VA medical facility, I must receive that care using my Veteran’s benefits and TRICARE For Life will not be billed.
When TRICARE For Life is billed the cost shares, co-pays and deductible amounts cannot be waived and it becomes my responsibility to pay
such cost shares, co-pays, and deductible amounts in full to
(Insert Name of the Appropriate Medical Treatment Facility)
when I receive the VA Patient Statement.
Patient's Signature Date
10-493a
FEB 2016
Veteran's Last, First Name:Last 4 SSN:
Street Address:
City:State:Zip Code:
