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Da pam 710-2-1 PDF 2023 Form: What You Should Know
The VA Form 10-2850D consists of the following information: 1. The Social Security number 2. Application for physicians, dentists, podiatrists, optometrists and chiropractors 3. The name and address, telephone number and fax number 4. A Statement of Intent to Operate a Practice. 5. A Statement of Purpose for the practice 6. The date of first services 7. An Application for Medical Exam 8. Information about location 9. Medical Examination Required. (must be completed by a licensed physician) 10. Information Required for Certification (must be completed by a licensed physician) 11. Examination Information Required for Certification (must be completed by a licensed physician) 2. The above information has been added to the form. The completed Form 10-2850D should be signed and returned to the Office of Veterans Service Support Services, in the following manner: (a) A copy of the completed form should be submitted to: (b) If you are the applicant, the applicant's signature must be marked with ink. If you are a health profession trainee, a copy of the completed form should be addressed to: (d) If you are the applicant, and you are not the applicant's spouse or dependent, the signature must be completed by an authorized person of the applicant (e) If you are a family member of the applicant, the signature of the applicant's spouse or dependent must be marked with ink. 3. If you are submitting copies of your medical exam: A signed medical exam must be submitted in duplicate along with the completed application. A completed medical exam must contain a diagnosis which indicates a significant need to perform medical examination. 4. A copy of any document evidencing that you have completed training in the health professions, and that you are currently working under the auspices of the VA in the practice of medicine may be submitted with the application to verify that you have satisfactorily fulfilled the medical competency and health professions training requirements. The medical exam should include a full and complete history; physical examination; mental examination; and diagnostic examination related to physical examination.
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