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

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

• Personal Information
  • Full name (last, first, middle)
  • Application for: general practice or specialty
  • Present 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
• Active Military Duty
  • Date from
  • Date to
  • Serial or service number
  • Branch of service
  • Type of discharge
• Registration and Clinical Privileges
  • List of all states/territories where you are now or have ever been certified as a nurse
  • Registration number
  • Expiration date
  • Whether you are fully registered in every state in which you are now registered
  • Whether you have pending or have ever had any registration to practice revoked, suspended, denied, restricted, limited, or issued/placed on a probationary status or voluntarily relinquished
  • Whether you have ever held a registration that is no longer held or current
  • Whether you have or ever had clinical privileges at any health care institution, agency or organization
  • Name of current or most recent institution, agency or organization where held
  • Whether any of your staff appointments or clinical privileges were ever denied, revoked, suspended, reduced, limited, or voluntarily relinquished
• Nurse Anesthetist Certification
  • Whether you are certified as a nurse anesthetist by the Council on Certification of Nurse Anesthetists (CCNA)
  • Date of your most recent certification
  • American Association of Nurse Anesthetists (AANA) identification number
  • Whether your CCNA certification has ever been revoked
• Certification by Facility Director or Designee
  • Certification that director has verified registration with State boards and cited visa or evidence of citizenship.
• Professional Liability Insurance
  • 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
• Qualifications
  • Basic nursing education
    • Name of school
    • Address
    • Length of program
    • Date completed
    • Diploma or degree received
  • Additional education
    • Name of school
    • Address
    • Major
    • Date completed
    • Credits
    • Degree
  • Whether you have a professional biography compiled
• Nursing Experience
  • Employer
  • Address
  • Position
  • Whether position was full time
  • Part-time average hours per week
  • Dates of employment
  • Name and title of director of nursing or of other department to which you were assigned
• General Information
  • Any other names under which you were employed if different from given above
  • 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
  • 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 in the past 5 years
  • 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 ain one of these health occupations
  • Whether you are delinquent on any federal debt
• Signature
• Authorization for Release of Information
  • 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 

If you need additional space, you should attach a separate sheet and refer to the items being answered by number.