VA Form 10-10171: VHA Veterans Care Agreement Guide

VA Form 10-10171: VHA Veterans Care Agreement Guide – VA Form 10-10171, officially titled the Veterans Health Administration (VHA) Veterans Care Agreement (VCA), is a 16-page legal agreement between the U.S. Department of Veterans Affairs and community healthcare providers. It enables eligible Veterans to receive medically necessary hospital care, medical services, or extended care services from approved community providers when those services are not feasibly available through a VA facility or VA’s primary Community Care Network (CCN).

This agreement operates under 38 U.S.C. § 1703A and 38 CFR §§ 17.4100–17.4135. It serves as a limited, supplemental option to VA’s main contracted networks (Optum and TriWest) and supports Veterans’ access to care under the VA MISSION Act framework.

Download the official form here:
Download VA Form 10-10171 – VHA Veterans Care Agreement (Fillable PDF)

The current revision date is May 2019. Always use the most recent version from va.gov.

What Is VA Form 10-10171?

VA Form 10-10171 is not a simple application or claim form that individual Veterans complete. It is a comprehensive provider agreement that establishes the legal terms, conditions, payment rates, quality standards, and compliance requirements for community providers delivering authorized care to Veterans.

The form covers 16 pages and includes detailed sections on:

  • Covered services and pre-authorization requirements
  • Provider qualifications and credentialing
  • Quality monitoring and medical records
  • Payment rates and claims processes
  • Disputes, discontinuation, and notices

Once signed and approved, the agreement remains active for three years from the effective date (Section P of the form).

Purpose of the VHA Veterans Care Agreement

VA uses Veterans Care Agreements in limited situations where:

  • Services are not available or sufficient through VA facilities
  • The primary Community Care Network (CCN) cannot meet the Veteran’s specific needs

VCA provides a direct agreement pathway between a local VA medical facility and a community provider. It is not the preferred or primary method for most community care. VA encourages providers to join the regional CCN networks first for broader referral opportunities.

Who Should Complete VA Form 10-10171?

This form is completed by:

  • Community healthcare providers and entities (physicians, hospitals, clinics, home health agencies, dental providers in certain cases, etc.)
  • Authorized representatives of VA medical facilities

Individual Veterans do not fill out or sign this form. Veterans receive care through a signed VCA only after VA issues a specific authorization or referral.

How to Establish a Veterans Care Agreement?

Either a community provider or a VA medical facility can initiate the process. Here are the typical steps:

  1. Assess the need — Confirm the required services cannot be met through VA or the regional CCN (Optum for Regions 1-3 or TriWest for Regions 4-5).
  2. Contact the local VA medical facility — Reach out to the Community Care office at your nearest VA medical center. Use the VA Facility Locator.
  3. Complete credentialing — All VCA providers undergo a full assessment through VA’s contractor, RLDatix/Verge Health. You will receive notifications to submit documentation, update references, and complete reappointment requirements.
  4. Review and sign VA Form 10-10171 — VA and the provider review and execute the agreement.
  5. Begin receiving referrals — Once approved, providers receive authorizations through HealthShare Referral Manager (HSRM), secure email, fax, or mail.

Note: An approved VCA is valid for three years. Providers must maintain ongoing compliance and credentialing standards throughout the term.

For most providers, joining the Community Care Network (CCN) through Optum or TriWest offers more consistent referral volume than a VCA.

Key Sections and Requirements in the Veterans Care Agreement

The form contains multiple detailed sections. Here are some of the most important:

  • Section C – Authorization of Covered Services: All services require advance written or electronic authorization from VA, including relevant medical history and medications. Services must match the specific authorization.
  • Section D – Provider Qualifications: Providers must maintain active licensure, malpractice insurance, NPI/Tax ID, and certification under 38 CFR § 17.4110. Immediate notification is required for any exclusion from federal programs (SAM/LEIE) or adverse actions.
  • Section H – Medical Records: Strict timelines apply for submitting documentation to VA (generally within 30 days for outpatient encounters).
  • Section I & K – Prices, Claims & Payment: Payment is generally the lesser of billed charges or Medicare-based rates (with specific rules for rural areas and dental). Clean claims must be submitted within 180 days. Electronic Funds Transfer (EFT) is required.
  • Section L – Payment Responsibility: VA payment is considered payment in full. Providers may not bill the Veteran or other health insurance for authorized VCA care.
  • Section M – Discontinuation: Either party may end the agreement with 45 days’ written notice (immediate in cases involving health/safety risks).
  • Section N – Disputes: Payment or authorization disputes must be filed in writing within 90 days to the designated VA official listed in Section O.
  • Section P – Term: The agreement lasts three years from the effective date.

Full details are in the official PDF linked above.

Important Compliance Obligations for Providers

Providers participating in a VCA must:

  • Remain in good standing with all federal exclusion databases (SAM, LEIE)
  • Meet VA quality standards for timely, safe, and Veteran-centered care
  • Submit required documentation and notifications within specified timeframes (often 5–10 business days)
  • Complete any required training (e.g., opioid safety, cultural competency for PTSD/MST/TBI)
  • Maintain current credentialing through RLDatix/Verge Health

Failure to comply can result in suspension of referrals, discontinuation of the agreement, or other actions.

What Veterans Need to Know About VCA Care?

If your VA provider refers you to a community provider under a Veterans Care Agreement:

  • You should not receive a bill from the provider for VA-authorized services.
  • VA must pre-authorize most non-emergency care.
  • The provider cannot seek payment from you or your other insurance for authorized care.
  • If you receive an improper bill, contact your VA facility’s Community Care office immediately.

For general information on community care eligibility, visit the official VA Community Care pages.

Frequently Asked Questions About VA Form 10-10171

Is VA Form 10-10171 a form Veterans fill out?
No. It is a legal agreement between community providers and VA. Veterans receive care through authorizations issued under an existing signed agreement.

How long does a Veterans Care Agreement last?
Three years from the effective date, subject to ongoing credentialing and compliance requirements.

Can a provider bill me for care authorized under a VCA?
No. For VA-authorized services, the provider receives payment from VA and is prohibited from collecting from the Veteran or other insurance.

How do I check if a provider has a VCA?
Contact your local VA medical facility’s Community Care office. They can confirm participating providers and issue authorizations.

What should I do if I have questions about my care under a VCA?
Contact the VA facility that authorized your care or use the VA contact resources.

This guide is based on official VA sources, including the current form, provider guidance pages, and regulations as of June 2026. VA policies and processes can change. For the most accurate and personalized information, always refer directly to va.gov or contact your local VA medical facility’s Community Care office.

Primary Sources

For questions about becoming a VA community provider or your specific care situation, start with your nearest VA facility. Thank you for your service.