HomeVA ProstheticsVA Handbook 1173.1 - Prosthetics EligibilityBasic Records and Forms

1.9. Basic Records and Forms

a. VA Form 10-1394 , Application for Adaptive Equipment-Motor Vehicle. A standardized document that authorizes the necessary equipment or adaptations for ingress, egress, and safe operation of an automobile or other conveyance.

b. VA Form 10-2319 (ADP), Record of Prosthetic Service. A form that will be created as a consolidated record of prosthetic services furnished to all beneficiaries. This form serves as the basic document of reference, and features screens of information. It will be initially prepared by the Prosthetic Program with PSA responsibility for wherever the veteran resides. The screens are:

(1) Screen 1 - Patient Demographics. Screen 1 contains the veteran's name, address, patient identification number (SSN), next of kin, prosthetic disability code(s), and veteran's eligibility (rating).

(2) Screen 2 - Clinic Enrollments/Correspondence. Screen 2 contains information about the veteran's hospital admissions and discharges, clinic enrollments, pending appointments, and correspondence. NOTE: One may create or view a letter to the veteran through this screen.

(3) Screen 3 - Entitlement Information. Screen 3 contains PSC information, Clothing Allowance, Automobile Adaptive Equipment, and Loaned Equipment data.

(4) Screen 4 - Appliance Transactions. Screen 4 contains all information regarding new appliances and repairs. Inquiries to individual transactions may be found on the sub-screen for each item.

(5) Screen 5 - Automobile Adaptive Equipment. Screen 5 contains all information concerning each vehicle and modifications under the adaptive equipment program. This screen should only be used for beneficiaries who are eligible under Pub. L. 91-666, Pub. L. 96-466, or Pub. L. 97-66.

(6) Screen 6 - Critical Comment. Screen 6 allows for entry of information that may be important to providing service to the beneficiary.

(7) Screen 7 - Add/Edit Disability Code. Screen 7enables the user to record a disability code to the record of prosthetic services.

(8) Screen 8 - Home Oxygen Program. Screen 8 contains all information concerning prescribed delivery systems, supplies, and associated costs.

c. VA Form 10-2341, Stump Sock Record. A document used to establish entitlement to receive stump sock from DDC at the beneficiary's request.

d. VA Form 2345, Veteran's Request For Stump Socks. A document used by the beneficiary to request replacement stump socks from DDC, when VA Form 10-2341 has been established.

e. VA Form 2346, Veteran's Request For Hearing Aid Batteries. A document used by the beneficiary to request batteries from the DDC.

f. VA Form 10-2421, ADP Prosthetic Authorization for Items or Services. A procurement document used to purchase new items and services for individual beneficiaries, to include the repair of same.

g. VA Form 10-2431, Request for Prosthetic Services. This is a physician's authorization, either manual or electronic, to provide a prosthetic item and service.

h. VA Form 10-2501, Prosthetic Service Card (PSC). This is a debit-card issued to eligible beneficiaries authorizing repairs for artificial limbs, wheelchairs, braces, and aids for the blind. This card is limited to repairs.

i. VA Form 10-2520, Prosthetic Service Card Invoice. This form is generated by a vendor for those PSC repairs which do not exceed the monetary limit.

j. VA Form 10-2529-3, Request and Receipt for Prosthetic Appliances or Services. A document used to obtain orthotics, prosthetics, restorations, and footwear from other VA facilities.

k. VA Form 10-2641, Authority for Issuance of Special and/or Experimental Appliances. A document requesting written authority to provide items designated for mandatory approval, high cost items, non-contract items, and for the purpose of advising VHA Headquarters, PSAS SHG of unusual field facility requests.

l. VA Form 10-2914, Prescription and Authorization for Eyeglasses. A procurement document for the purpose of prescribing and purchasing corrective lenses and frames.

m. VA Form Letter 10-55, Authority to Exceed Repair Costs of Prosthetic Appliances. A letter of authorization forwarded to a provider of PSC repairs, when the cost of that repair exceeds the limit authorized by the PSC. The letter should accompany the associated invoice.

n. VA Form 21-8678, Application for Annual Clothing Allowance. A form completed by the veteran or health care professional in which veteran's disability and prosthetic appliance is described and justification provided to request an annual clothing allowance.

o. VA Form 21-8679, Eligibility Determination for Clothing Allowance. A form used to enter appropriate eligibility information and document clothing allowance decisions made by the appropriate VA official.


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