VA Form 10-2478 "Veteran Request for Refill of Medications and/or Medical Supplies"

VA Form 10-2478 is a U.S. Department of Veterans Affairs form also known as the "Veteran Request For Refill Of Medications And/or Medical Supplies". The latest edition of the form was released in July 1, 2006 and is available for digital filing.

Download an up-to-date VA Form 10-2478 in PDF-format down below or look it up on the U.S. Department of Veterans Affairs Forms website.

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Download VA Form 10-2478 "Veteran Request for Refill of Medications and/or Medical Supplies"

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VETERAN REQUEST FOR REFILL OF MEDICATIONS
AND/OR MEDICAL SUPPLIES
Instructions: This form is for your use in requesting additional medications or supplies. Mail in at least 14 days
before your supply is exhausted. Before mailing this form, please check it over to be sure all patient identification
blanks have been completed. Prescriptions more than six months old cannot be refilled.
NAME(S) OF MEDICATION AND/OR MEDICAL SUPPLY
PRESCRIPTION NUMBER
(Be sure to list only current prescriptions)
Caution - Always carefully check all medications after receiving them. If any medication appears to be different from what you
have been taking, please immediately phone the Pharmacy(
) for clarification.
Please be sure that name and address are entered in the space to insure prompt delivery of medication.
PATIENT'S IDENTIFICATION (Print or Type)
NAME (Last, First, Middle Initial)
SOCIAL SECURITY NO.
DATE
NUMBER AND STREET
TELEPHONE (Include area code)
CITY, STATE AND ZIP CODE
PATIENT'S SIGNATURE
The information requested on this form is solicited under authority of Title 38, U. S. Code, Veterans' Benefits, and will be used to process your
prescription in the shortest time. Disclosure is voluntary. However, if information is not furnished the processing of of your prescription may
be delayed. Failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled.
VA FORM
10-2478
EXISTING STOCK OF VA FORM 10-2478, MAY 1991, WILL BE USED.
JUL 2006 (R)
VETERAN REQUEST FOR REFILL OF MEDICATIONS
AND/OR MEDICAL SUPPLIES
Instructions: This form is for your use in requesting additional medications or supplies. Mail in at least 14 days
before your supply is exhausted. Before mailing this form, please check it over to be sure all patient identification
blanks have been completed. Prescriptions more than six months old cannot be refilled.
NAME(S) OF MEDICATION AND/OR MEDICAL SUPPLY
PRESCRIPTION NUMBER
(Be sure to list only current prescriptions)
Caution - Always carefully check all medications after receiving them. If any medication appears to be different from what you
have been taking, please immediately phone the Pharmacy(
) for clarification.
Please be sure that name and address are entered in the space to insure prompt delivery of medication.
PATIENT'S IDENTIFICATION (Print or Type)
NAME (Last, First, Middle Initial)
SOCIAL SECURITY NO.
DATE
NUMBER AND STREET
TELEPHONE (Include area code)
CITY, STATE AND ZIP CODE
PATIENT'S SIGNATURE
The information requested on this form is solicited under authority of Title 38, U. S. Code, Veterans' Benefits, and will be used to process your
prescription in the shortest time. Disclosure is voluntary. However, if information is not furnished the processing of of your prescription may
be delayed. Failure to furnish this information will have no adverse effect on any other benefit to which you may be entitled.
VA FORM
10-2478
EXISTING STOCK OF VA FORM 10-2478, MAY 1991, WILL BE USED.
JUL 2006 (R)
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