VA Form 10-2850

VA Form 20-2850 is better known as an Application for Physicians but also includes, dentists, podiatrists, optometrists, and chiropractors. This form is used to verify the credentials and qualifications of applying medical professional and collects personal information such as their license information, along with their full name, address, social security number, and citizenship information. The Department of Veterans Affairs will use all of this collected information to ensure that the individual is qualified to work in the Veterans Health Administration. It is important to complete the document in its entirety, furnishing all required spaces to ensure that the application is processed as quickly as possible by the Department.

Table of Contents

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What is a VA Form 10 2850?

This form is used by the United States Department of Veterans Affairs. The VA Form 20-2850 is known as an Application for Physicians, Dentists, Podiatrists, Optometrists, and Chiropractors (OMB No. 2900-0205). The form is used to verify the qualifications of one of these parties to determine if they can be a member of the Veterans Health Administration.
This form will require detailed information about the medical professional who is applying for recognition. They will need to list their personal and contact information, including full name, address, citizenship information, and social security number. In the following sections, the applicant will need to detail their licensing information. The Department of Veterans Affairs will verify this information to ensure the professional is qualified to join the Veterans Health Administration.

Most Common Uses

This form is commonly used by physicians, dentists, podiatrists, optometrists, and chiropractors who would like to become members of the Veterans Health Administration.

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Components of a VA Form 10 2850

A VA Form 10-2850 contains the following sections:

• Personal Information
• Active Military Duty
• Licensure, DEA/State Certification, Specialty Boards and Clinical Privileges
• Professional Liability Insurance
• Pre Professional Education
• Professional Education
• Residency Training and Fellowships Subsequent to Graduation from Professional School
• Teaching and/or Research Associations and Appointments with Professional Schools
• Visiting Staff Hospital Appointments
• Professional Experience
• General Information
• Signature
• Authorization for Release of Information

How to complete a VA Form 10 2850 (Step by Step)

To complete a VA Form 10-2850, you will need to provide the following information:

• Personal Information
  • Name
  • Application for: general practice or specialty
  • Address
  • Phone number
  • Whether location is a residence or business
  • Date of birth
  • Place of birth
  • Social security number
  • Citizenship status
  • Country of citizenship
  • Whether you have ever filed an application for appointment in the VA
  • Name of office where filed
  • Date filed
  • Whether VA may make an inquiry with your present employer
  • Date available for employment
  • Date from
  • Date to
  • Serial or service number
  • Branch of service
  • Type of discharge
  • List of all states/territories/commonwealths of the U.S. or District of Columbia where you are or have ever been licensed
  • License number
  • Whether your registration is current
  • Expiration date
  • Whether you have pending or have ever had any license revoked, suspended, denied, restricted, limited, or issued/placed in a probationary status or voluntarily relinquished
  • Number of current or most recent DEA certificate and/or state license/permit to prescribe controlled substances.
  • Date of expiration
  • Whether you have ever had a DEA certificate or state license/permit revoked, suspended, limited, restricted in any way or voluntarily relinquished
  • Whether you are certified by an American specialty board
  • Date
  • Special certifications
  • Date
  • List and details of all certifications other than an American specialty board
  • Whether you currently have or have ever had clinical privileges at a health care institution or agency
  • Name and address of current or most recent privileges held
  • Whether any of your staff appointments or clinical privileges have ever been denied, revoked, suspended, reduced, limited, not renewed, or voluntarily relinquished
  • Present professional liability insurance carrier
  • Date coverage began
  • Names of prior carriers
  • Dates of coverage
  • Whether any carrier has ever cancelled, denied, or refused to renew your coverage
  • Name of school
  • Address
  • Major
  • Years attended
  • Graduation month and year
  • Degree
  • Name of school
  • Address
  • Years attended
  • Graduation month and year
  • Degree
  • Name of hospital or institution
  • Address
  • Specialty
  • PG level
  • Completed month and year
  • Number of months
  • Institution
  • Address
  • Position
  • Dates of program
  • Institution
  • Address
  • Position
  • Dates
  • Employer
  • Address
  • Position
  • Whether it was full time
  • Part-time average hours per week
  • Dates employed
  • Names under which you were employed if different than the one given in application
  • List of all professional publications, scientific papers, honore, awards, research grants, fellowships
  • References
  • Whether you receive or have a pending application for retirement or retainer pay, pension, or other compensation
  • Whether the VA employs any of your relatives
  • Whether you are now or have ever been involved in an administrative, professional or judicial proceeding in which malpractice was alleged in the past 5 years
  • Whether you have been discharged from a position in the last five years
  • Whether you have resigned or retired from a position after being notified you would be disciplined or discharged or after questions about your competence were raised
  • Whether you have ever been convicted, forfeited collateral, or are now under charges for any felony or firearms or explosives offense against the law
  • Whether you have been convicted, imprisoned, or probation or parole, or forfeited collateral, or are now under charges for any offense against the law in the past 7 years
  • Whether you have been convicted by general court-martial while in military service
  • Whether you received non-judicial punishment while you were in the military service as a physician, dentist, podiatrist, optometrist, or chiropractor
  • Whether you are delinquent on any federal debt
  • Indication if you authorize the VA to conduct an inquiry by contacting your previous employers, current employer, educational institutions, state licensing boards, professional liability insurance carriers, national practitioner data bank, American Medical Association, Federation of State Medical Boards, other professional organizations and/or persons, agencies, organizations or institutions listed by me as references, and any other source the VA deems appropriate
  • Authorization for release of related documents and records to the VA
  • Release from liability those who provide information to the VA in good faith response to such inquiries
  • Authorization for VA to disclose identifying information to those persons and organizations to make such inquiries
  • Signature
  • Date

  Related Forms

  This form is similar to the following VA Forms:

  • VA Form 10-2850a Application for Nurses and Nurse Anesthetists
  • VA Form 10-2850b Application for Residents
  • VA Form 10-2850c Application for Associated Health Occupations
  • VA Form 10-2850d Application for Health Professions Trainees

  If you need additional space to answer a question, attach a separate sheet of paper and refer to the number of the item being answered by number.
  

  Paperwork Reduction Act and Privacy Act Notice

  The U.S. Department of Veterans Affairs is conducting this information collection to determine your qualifications for employment. It has authority to do so under Title 38, United States Code, Chapters 73 and 74. OMB Number 2900-0205.
  The information provided on the form may be released without your prior consent to another U.S. government, state, or local agency, to the National Practitioner Data Bank which is administered by the Department of Health and Human Services, to State licensing boards, and other appropriate organizations or agencies.
  Disclosure of your social security information is necessary to obtain the employment benefits that you are applying for. The VA is authorized to ask you for your SSN under Executive Order 9397, dated November 22, 1943.