Can this form be e-signed?

Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; ensure the signer demonstrates intent and consent and that records are retained.

Is a HIPAA BAA required?

If the platform or vendor will access, store, or transmit protected health information (PHI), execute a Business Associate Agreement (BAA) to comply with HIPAA privacy and security requirements.

Who is authorized to sign?

Typically the referring VA clinician or delegated official; signatures must match documented authority and credentials in the clinician's record.

How do I correct an error?

If unsigned, correct and reissue the form. If already signed, create an amended plan and include a clear audit trail showing the correction and reason.

Are notarization or witnesses required?

Most clinical authorizations do not require notarization, but state rules differ; consult local statute and the plan's legal counsel if notarization is requested.

How long must I keep the record?

Follow HIPAA's six-year baseline (45 CFR §164.530(j)), IRS retention where applicable, and any state-specific longer retention periods; retain until statute of limitations and audit windows close.

Electronic Signature
Templates
Healthcare
Healthcare Non-VA Care Plan

Healthcare Non-VA Care Plan

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Healthcare Non-VA Care Plan

Patient Information

Patient Name: Date of Birth: Gender: Address: Primary Phone: Emergency Contact (Name, Relationship, Phone):

Insurance and Billing

Insurance Provider: Policy / ID Number: Group Number (if applicable): Subscriber Name (if different):

Referring VA Provider

Referring VA Clinician / Provider: VA Facility / Location: VA Contact Phone/Ext:

Authorized Non-VA Provider / Facility

Non-VA Provider / Facility Name: Provider Type / Specialty: Provider Address & Phone:

Plan of Care — Clinical Order

Primary Diagnosis / Problem List:

Secondary Diagnosis / Comorbidities:

Services Requested / Clinical Goals:

Expected Start Date:

Expected End Date / Review Date:

Frequency / Duration: Estimated Total Charges:

Clinical Considerations, Risks & Benefits

The non-VA services described above are provided by independent non-VA entities and are not VA medical staff activities. Expected benefits, clinical risks, and alternatives are discussed with the patient and documented in the medical record. Non-VA providers may employ different standards of care. VA is authorizing the service described above for the purpose stated and retains responsibility for oversight and coordination of care as documented herein.

Patient Clinical Notes / Special Precautions:

Care Coordination & Responsibilities

The following responsibilities apply to each party. VA will maintain the medical record and coordinate communication with the authorized non-VA provider. The non-VA provider will report clinical status, adverse events, and discharge summaries to the referring VA provider in a timely manner. The patient is responsible for attending appointments and notifying VA of any changes in condition.

Coordination Instructions / Follow-up Requirements:

Authorization & Privacy

By signing below the patient authorizes disclosure of protected health information to the non-VA provider and to the VA personnel responsible for care coordination, limited to information necessary to provide, bill, and manage the authorized services. This authorization also permits the non-VA provider to release reports and invoices to the referring VA clinician for payment and clinical oversight.

Records / Information to be Shared:

I authorize the release and exchange of the specified records between VA and the non-VA provider for the purposes stated above.

Authorization Expiration Date:

Cost, Payment & Liability

Authorization of care does not guarantee payment. Payment responsibility is determined by VA criteria, insurance coverage, and the non-VA provider's billing policies. The patient remains responsible for any charges not covered by VA or other payers, including copayments or services deemed not covered. The non-VA provider is an independent contractor and not an agent of VA; liability for non-VA care resides with the non-VA provider in accordance with applicable law.

VA is expected to assume primary payment responsibility for authorized services.

Patient acknowledges potential financial responsibility for uncovered charges.

Other Payment Notes:

Rights, Withdrawal & Termination

The patient has the right to refuse or withdraw consent for non-VA care at any time. Withdrawal of authorization may result in termination of services and requires communication to the referring VA provider and the non-VA provider. VA reserves the right to modify or revoke authorization based on clinical need, eligibility, or program rules.

I acknowledge my right to refuse or withdraw this authorization and understand potential consequences.

HIPAA Privacy Acknowledgment

By signing this Care Plan, the patient acknowledges receipt of information regarding the use and disclosure of protected health information necessary for the provision and coordination of care. The patient understands that disclosures will be limited to the minimum necessary to accomplish the stated purpose.

I acknowledge the HIPAA privacy terms described above and consent to necessary disclosures for treatment, payment, and healthcare operations related to this plan.

Medical History Summary

Current Medications: Allergies / Adverse Reactions: Prior Surgeries / Procedures: Chronic Conditions / Diagnoses:

By signing below the patient certifies that the information provided on this Care Plan is accurate to the best of their knowledge, authorizes the actions described above, and understands the responsibilities, limitations, and privacy provisions set forth in this document.

Patient Printed Name:

Signature:

Date:

If signed by guardian/representative, Relationship:

What the Healthcare Non-VA Care Plan Is

The Healthcare Non-VA Care Plan documents authorized clinical services provided to a Veteran outside the Department of Veterans Affairs (VA) system. It records patient identity, justification for community care, authorized services, ordering provider details, and administrative routing for claims and scheduling. The form supports continuity of care by summarizing medical necessity, referral instructions, scheduling windows, and billing instructions so both VA and community providers can coordinate treatment and follow-up.

Why a Clear Non-VA Care Plan Matters

A complete Healthcare Non-VA Care Plan reduces care delays, clarifies clinical responsibilities, and supports accurate claims processing while preserving patient privacy under HIPAA and maintaining electronic validity under ESIGN and UETA.

Who typically completes and uses this form

Multiple roles interact with the Healthcare Non-VA Care Plan during referral, approval, scheduling, and billing.

VA clinicians and case managers responsible for clinical justification and referral details.
Community providers who receive authorized orders, schedule care, and submit claims.
Administrative and billing staff who manage authorizations, verify coverage, and file claims.

Each participant needs accurate contact, identity, and signature information to avoid processing errors and ensure timely care.

Essential components every plan should include

A professional Healthcare Non-VA Care Plan combines clinical, administrative, and legal elements so community providers can deliver covered care with clear billing instructions.

Patient Identity

Full legal name, VA claim ID or social identifier, date of birth, and contact details to match records and avoid duplicate charting or billing errors.

Authorization

Authorized service(s), scope, number of visits, and limits that define what the community provider may deliver and bill under the VA authorization.

Clinical Summary

Concise reason for referral, relevant diagnosis codes, prior treatments, and clinical goals so the receiving clinician can provide continuity of care.

Provider Instructions

Preferred scheduling window, location, pre-visit requirements, and contact information for the referring VA clinician or care coordinator.

Billing Details

Payer information, authorization codes, billing address and invoice instructions to reduce claim denials and speed reimbursement.

Follow-up Plan

Planned return-to-care reporting, required documentation for closure, and timelines for post-service communication to ensure case closure.

Privacy and security data points to confirm

Encryption: TLS 1.2/1.3; AES-256

HIPAA: BAA required

Audit Trail: Timestamps and IP logs

Access Control: Role-based permissions

Retention: Policy-backed retention

Secure Formats: PDF/A or signed PDF

Step-by-step: completing a typical Non-VA Care Plan

Follow these steps in order to prepare a complete, actionable care plan for community-based treatment.

01

Collect patient data: Verify full name, VA ID, DOB, and contact details.
02

Add clinical justification: Summarize diagnosis, previous treatment, and reason for non-VA referral.
03

Authorize services: List services, visit counts, and any pre-authorization codes.
04

Sign and route: Clinician signs, then send to community provider and billing office.

Configuring a digital workflow for this form

Design a routing and authentication flow so each signer receives a tailored view of fields to complete.

Field	Configuration
Signers	Referring clinician, community provider, billing representative
Authentication	Email link or SMS code; two-factor for sensitive approvals
Routing	Sequential: clinician → provider → billing
Notifications	Automated reminders at 3 and 10 days

Platform and integration considerations

Choose a platform that supports secure e-signing, audit trails, and your existing integrations.

Integrations: Salesforce, Microsoft 365, NetSuite
File formats: PDF, DOCX, fillable forms
Authentication: SMS codes, SSO, KBA options

Ensure the vendor supports a HIPAA BAA if PHI is present, retains audit logs, and allows export to your EHR and billing systems.

Typical e-submission flow for a Non-VA Care Plan

Electronic submission follows a predictable sequence from creation to archival; ensure each step captures required evidence.

Upload document: Import PDF or create from template with required fields.
Place fields: Add signature, date, and clinical text fields.
Send to signer: Deliver via email link or secure portal to assigned signer.
Archive: Store signed file with audit trail in EHR or document repository.

Typical timelines and processing expectations

Processing times vary; these are common operational timeframes to plan around for scheduling and claims.

Authorization validity:

Often valid for 60–90 days from issue depending on payer rules.

Provider acceptance:

Community provider typically confirms appointment within 7–14 days.

Scheduling window:

Many systems request scheduling within 30 days of authorization.

Claim submission:

Submit claims within 30–90 days of service per payer rules.

Appeals timeframe:

Appeal or reconsideration windows commonly run 30–60 days.

Key milestones in the authorization lifecycle

Track these numbered milestones from request to closure to reduce administrative delays.

01

Request Submitted

VA or clinician submits referral with clinical justification for community care.

02

VA Review

Review team confirms eligibility, medical necessity, and scope of authorized services.

03

Provider Approval

Community provider accepts order and schedules treatment within the authorization window.

04

Care Completed

Service performed, documentation sent back to VA, and claims forwarded for payment.

Common preparation errors to avoid

Incomplete patient identifiers that cause record mismatches and delayed care coordination.
Vague clinical justification lacking diagnosis codes or specific treatment scope for the community provider.
Missing or unsigned authorization blocks that lead to claim denials and rejected appointments.
Incorrect billing instructions or payer information that result in reimbursement delays or denials.

Risks and potential consequences

Delayed Care: Claim denials

Financial Loss: Unpaid invoices

HIPAA Exposure: Regulatory fines

Audit Risk: Documentation shortfalls

Provider Disruption: Scheduling gaps

Legal Liability: Malpractice exposure

eSignature vendor comparison for Healthcare Non-VA Care Plan workflows

Cost and capability vary; the table compares starting price, trial availability, bulk send, audit trail, HIPAA support, and envelope caps across major providers.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes (plan-dependent)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/yr	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and practical answers

Common questions about use, e-signing, privacy, corrections, and retention when preparing a Healthcare Non-VA Care Plan.

Need help? Contact support

Can this form be e-signed?
Yes. Electronic signatures are legally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; ensure the signer demonstrates intent and consent and that records are retained.
Is a HIPAA BAA required?
If the platform or vendor will access, store, or transmit protected health information (PHI), execute a Business Associate Agreement (BAA) to comply with HIPAA privacy and security requirements.
Who is authorized to sign?
Typically the referring VA clinician or delegated official; signatures must match documented authority and credentials in the clinician's record.
How do I correct an error?
If unsigned, correct and reissue the form. If already signed, create an amended plan and include a clear audit trail showing the correction and reason.
Are notarization or witnesses required?
Most clinical authorizations do not require notarization, but state rules differ; consult local statute and the plan's legal counsel if notarization is requested.
How long must I keep the record?
Follow HIPAA's six-year baseline (45 CFR §164.530(j)), IRS retention where applicable, and any state-specific longer retention periods; retain until statute of limitations and audit windows close.

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