DVA claim generator
Provider Data
Servicing Provider ID:*
Service Type:*
Select
General
Specialist
Payee Provider ID:
Claim Data
Hospital Indicator:*
Select
No
Yes
Treatment Location Code:*
Select
Home Visit
Hospital
Rooms
Claim Certified Ind:
Yes
Claim Certified Date:*
Accepted Disability Ind:*
Select
No
Yes
Accepted Disability Text:
Invoice Number:
Batch ID
Patient Data
First Name:*
Last Name:*
Veteran File Number:*
Gender:*
Select
Female
Male
DOB:*
Referral Data
Referral Provider Number:
Referral Date:
Referral Period Type:
Select
Standard
Non Standard
Indefinite
Referral Override Type:
Select
Emergency
Hospital
Lost
Not required
Service Data 1
Item Number:*
Service Date:*
Service Time:
Service Charge:*
Service Text:
Duplicate Service:
LSP Number:
Multiple Procedures:
Self Deemed:
Equipment ID:
After Care Override Ind:
Distance (KMs):
Add Service
Create XML