Online claiming provider agreement form (HW027)

Use this form to register for online claiming with us and the Department of Veterans' Affairs.

Download and complete the Online claiming provider agreement form.

This PDF is fillable. You can fill it out on your device, or print it and complete it by hand.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 10 December 2021