**§17.1004 Filing claims.**

\(a\) A claimant for payment or reimbursement under 38 U.S.C. 1725 must
be the entity that furnished the treatment, the veteran who paid for the
treatment, or the person or organization that paid for such treatment on
behalf of the veteran.

\(b\) To obtain payment or reimbursement for emergency treatment under
38 U.S.C. 1725, a claimant must submit to the VA medical facility of
jurisdiction a completed standard billing form (such as a UB92 or a HCFA
1500). Where the form used does not contain a false claims notice, the
completed form must also be accompanied by a signed, written statement
declaring that "I hereby certify that this claim meets all of the
conditions for payment by VA for emergency medical services under 38 CFR
17.1002 (except for paragraph (e)) and 17.1003. I am aware that 38
U.S.C. 6102(b) provides that one who obtains payment without being
entitled to it and with intent to defraud the United States shall be
fined in accordance with title 18, United States Code, or imprisoned not
more than one year, or both."

**Note to §17.1004(b):** These regulations regarding payment or
reimbursement for emergency services for nonservice-connected conditions
in non-VA facilities also can be found on the internet at
*http://www.va.gov/health/elig*.

\(c\) Notwithstanding the provisions of paragraph (b) of this section,
no specific form is required for a claimant (or duly authorized
representative) to claim payment or reimbursement for emergency
transportation charges under 38 U.S.C. 1725. The claimant need only
submit a signed and dated request for such payment or reimbursement to
the VA medical facility of jurisdiction, together with a bill showing
the services provided and charges for which the veteran is personally
liable and a signed statement explaining who requested such
transportation services and why they were necessary.

\(d\) To receive payment or reimbursement for emergency services, a
claimant must file a claim within 90 days after the latest of the
following:

> \(1\) July 19, 2001.
>
> \(2\) The date that the veteran was discharged from the facility that
> furnished the emergency treatment;
>
> \(3\) The date of death, but only if the death occurred during
> transportation to a facility for emergency treatment or if the death
> occurred during the stay in the facility that included the provision
> of the emergency treatment; or
>
> \(4\) The date the veteran finally exhausted, without success, action
> to obtain payment or reimbursement for the treatment from a third
> party.

\(e\) If after reviewing a claim the decisionmaker determines that
additional information is needed to make a determination regarding the
claim, such official will contact the claimant in writing and request
additional information. The additional information must be submitted to
the decisionmaker within 30 days of receipt of the request or the claim
will be treated as abandoned, except that if the claimant within the
30-day period requests in writing additional time, the time period for
submission of the information may be extended as reasonably necessary
for the requested information to be obtained. (Authority: 38 U.S.C.
1725)

\[66 FR 36470, July 12, 2001, as amended at 68 FR 3404, Jan. 24, 2003\]

**Supplement *Highlights* reference**: 14(1)