Claim ID: Veteran Name: Claim Type: Billing Provider Name: Status: Service Provider Name:
Amount Billed: Service Date From: Description of Service: Service Date To:
Payment Information Payment Type: Authorization or Check #: Payment Date (mm/dd/yyyy): Amount VA Will Pay ($$.cc):
Adjustment #1 Amount ($$.cc): Group: Reason:
Adjustment #2 Amount ($$.cc): Group: Reason:
Remittance Remark:
* required fields