VA Form 10-10143g Non-VA Emergency Notification Guide

VA Form 10-10143g Non-VA Emergency Notification Guide – If you work at a non-VA hospital, emergency department, or community healthcare facility and treat Veterans, VA Form 10-10143g (Non-VA Hospital Emergency Notification) helps you quickly notify the Department of Veterans Affairs (VA) when a Veteran presents for emergent care. Timely notification supports care coordination, eligibility determinations, and potential VA payment for authorized emergency services under the Veterans Community Care Program.

This official fillable PDF form remains available on VA.gov and provides a structured way to submit the detailed case information VA requires. While VA now encourages faster digital options, the form continues to serve as a reliable method for facilities to document and report emergency episodes.

Download the official fillable VA Form 10-10143g here:
Download VA Form 10-10143g (Non-VA Hospital Emergency Notification Fillable PDF)

What Is VA Form 10-10143g?

VA Form 10-10143g is the official Non-VA Hospital Emergency Notification form used by community (non-VA) healthcare facilities. Its purpose is to notify VA when a Veteran receives emergency treatment outside the VA system. The form captures essential veteran identification, facility details, and clinical episode information needed for VA to evaluate coverage, coordinate care or transfers, and process related claims.

The form carries OMB Control Number 2900-0823 and was last revised in May 2020. Completing it typically takes about 10 minutes when the required information is readily available.

Who Should Use VA Form 10-10143g?

This form is designed for:

  • Non-VA hospital emergency departments and acute care facilities
  • Community providers treating Veterans under the Veterans Community Care Program (VCCP)
  • Billing, case management, or administrative staff responsible for VA notifications
  • Any facility that needs a standardized template to submit required emergency care details to VA

Veterans and their representatives can also help ensure notification occurs, though providers are in the best position to supply accurate clinical information.

The Critical 72-Hour Notification Deadline

VA requires notification of emergency care at non-VA facilities within 72 hours of the beginning of treatment. This deadline applies whether you use the form, the online portal, or the phone line.

Meeting this timeline helps VA:

  • Verify Veteran eligibility for coverage
  • Coordinate any necessary transfers to VA facilities
  • Authorize payment for qualifying emergency care
  • Support continuity of care after stabilization

Failure to notify VA in a timely manner for in-network care can prevent authorization and block claims processing through VA’s third-party administrators. Always notify as soon as possible after the Veteran presents.

Preferred Notification Methods vs. Using VA Form 10-10143g

VA currently recommends these faster options for most providers:

VA Form 10-10143g remains a valid official method. You can complete the fillable PDF and email it to [email protected]. The form’s fields closely match the information VA requests through the portal and phone, making it an excellent structured backup or supplementary tool.

Step-by-Step: How to Fill Out VA Form 10-10143g?

Download the fillable PDF and complete it digitally using Adobe Acrobat Reader or a compatible PDF editor for the cleanest results. Here is a field-by-field guide based on the current form layout:

Header Information

  • Today’s Date: Enter the date you are completing the form.

Veteran Information

  • Last Name, First Name
  • Date of Birth
  • Social Security Number (used by VA to identify records and administer benefits)

Home Address

  • Street, City, State, Zip

Other Insurance

  • Check Yes or No
  • If Yes, provide: Carrier name, Policy Number, and insurance address

Vendor (Facility) Information

  • Facility Name
  • Facility NPI (National Provider Identifier)
  • Facility Tax ID
  • Facility Phone Number

Facility Point of Contact (POC)

This is the person who will receive VA’s authorization decision and follow-up communications.

  • Full Name
  • Phone Number
  • Email Address

Facility Address

  • Street, City, State, Zip

Episode Information (Most Critical Section)

  • Date / Time of Emergency: When the Veteran presented for care
  • Mode of Arrival: (e.g., ambulance, walk-in, police, etc.)
  • Admitted? Check Yes or No
  • Discharge Date: If already discharged

One or more of the following is required:

  • Chief Complaint
  • Admit Diagnosis (DX)
  • Discharge Diagnosis (DX)

Provide as much accurate clinical detail as possible to support VA’s eligibility review.

What Happens After Submitting VA Form 10-10143g?

Once VA receives the notification:

  1. VA reviews the information for eligibility under applicable authorities (including prudent layperson standard and 72-hour rule).
  2. VA may coordinate care, arrange transfer to a VA facility when medically appropriate, or authorize continued community care.
  3. The designated POC receives the authorization decision.
  4. Claims processing can proceed for qualifying services.

Keep a copy of the completed form and confirmation of submission (email receipt or portal confirmation) for your records.

Eligibility Basics for VA Coverage of Non-VA Emergency Care

VA can cover emergency care at non-VA facilities when specific conditions are met. Key requirements generally include:

  • The Veteran is enrolled in VA health care or qualifies for an exemption
  • A VA or federal facility was not feasibly available
  • A prudent layperson would reasonably expect that delay in seeking care could endanger life, health, or safety
  • Timely notification to VA within 72 hours
  • The facility is in VA’s community care network (for authorized care)

Special rules apply for emergency mental health care, service-connected conditions, and certain other situations. Always refer to official VA guidance for the most current eligibility details.

Best Practices for Non-VA Hospitals and Emergency Departments

  • Train registration, case management, and billing staff to identify Veterans (VA health card, SSN, or self-report) and initiate notification immediately.
  • Use the fillable PDF or integrate similar data collection into your electronic health record workflow.
  • Designate a specific POC email and phone for VA communications and keep that information current on the form.
  • Document the date and time of notification and retain records for audit and claims support.
  • When in doubt, notify VA even if some fields are incomplete — VA will follow up for missing details.

How Veterans Can Help Ensure Proper Notification?

Veterans and family members should:

  • Carry their VA Health Identification Card and inform staff they want to use VA benefits.
  • Ask the provider or registration staff: “Have you notified VA about this emergency visit?”
  • If the facility seems unfamiliar with the process, provide the portal link or phone number: 844-724-7842.
  • Follow up with their VA medical center or the portal if they do not hear back within a reasonable time.

Frequently Asked Questions About VA Form 10-10143g

Is VA Form 10-10143g still required in 2026?

The form remains an official VA document and a valid way to submit required notification details via email. However, VA strongly encourages use of the Emergency Care Reporting Portal or the phone line for faster processing.

Can I submit the form if I don’t have all the information?

Yes. Provide what you have and VA will contact the appropriate parties to collect any missing details needed for eligibility and care coordination.

Who is responsible for notifying VA — the hospital or the Veteran?

Providers are in the best position and are preferred. However, Veterans or their representatives may also notify VA using the portal or phone if the facility does not complete notification.

Does using this form guarantee VA will pay for the emergency care?

No. The form supports the notification requirement, but payment depends on meeting all eligibility criteria under the applicable VA authority (authorized community care, unauthorized care for service-connected conditions, etc.).

What if the Veteran refuses transfer to a VA facility?

VA Form 10-8001 (Refusal of Transfer to VA Health Care Facility) may be used in those situations. The Veteran may become financially responsible for care beyond stabilization.

Additional Official Resources

Final Tips for Successful Use of VA Form 10-10143g

Complete the form as soon as the Veteran is stabilized and key information is available. Double-check that at least one clinical field (Chief Complaint, Admit DX, or Discharge DX) is populated. Send the completed form to the designated VA email and retain your sent copy with timestamp. When possible, also use the online portal for redundancy and faster VA acknowledgment.

By using VA Form 10-10143g correctly and promptly, non-VA facilities play a vital role in helping Veterans receive coordinated emergency care and protecting both the Veteran and the facility during the claims process.