In paragraph 1A, tell us how much you can pay each month. To set up a repayment plan, fill out an Agreement to Pay Indebtedness (VA Form 1100).
VA COPAY WAIVER FORM FULL
We usually require you to pay off the full debt within 3 years. We’ll review your proposed payment plan based on the amount of money you owe and your ability to pay within a reasonable time. If you can’t pay your copay bills all at once, you can set up a monthly repayment plan at any time. Option 2: Set up a repayment plan to pay your bills over time Submit your completed form and supporting letter to the business office or health administration office at your nearest VA medical center.įind the address of your nearest VA medical center If you want to request a hearing to help explain your financial issues, include this request in your letter. Write a letter describing the financial issues that make it hard for you to pay your copay debt. You can also request debt relief by mail or in person.įill out a Financial Status Report (VA Form 5655). Request help with copay bills By mail or in person You can request debt relief for copay bills online now. If we accept part or all of your request, you won’t have to pay the amount of the balance we agree to relieve. If we accept your offer, we’ll agree on a smaller, one-time payment to resolve your debt. If we accept your request, we’ll stop collection and forgive your debt. Request a waiver for all or part of your balance.You can request one of these types of debt relief:
If you don’t think you can pay your copay bills, you can request help. Learn more about VA late charges and debt collection Option 1: Request help to get debt relief To avoid late charges, including interest and other fees, you’ll need to take action within 30 days of receiving your bill. You can request either of the 2 financial hardship assistance options on this page, depending on your situation.
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