VA Form 10-10172: Community Care Request for Service – If you’re a U.S. veteran or a community care provider working with VA patients, understanding VA Form 10-10172 is essential for accessing timely medical services outside the VA system. This comprehensive guide covers everything you need to know about the Community Care Provider—Request for Service form, including how to complete it, submission requirements, and tips for approval.
Updated for 2025: The current version of VA Form 10-10172 (revised March 2025) streamlines requests for additional or continued care in the VA Community Care Network (CCN).
What Is VA Form 10-10172?
VA Form 10-10172, officially titled Community Care Provider—Request for Service (RFS), is the standard form used by community providers to request authorization from the Department of Veterans Affairs for additional clinical care, extensions of existing authorizations, or new services for eligible veterans.
It applies to both medical services and Durable Medical Equipment (DME)/prosthetics requests. The form ensures that veterans receive necessary care—either at a VA facility or through community providers—based on clinical need and VA guidelines.
Who Needs to Use VA Form 10-10172?
This form is primarily for:
- Community care providers treating VA-enrolled veterans who need additional visits, procedures, or services beyond the original authorization.
- Requests for continuation of care when an existing authorization is expiring.
- New service requests not covered in the initial referral.
- DME, prosthetics, orthotics, home health, hospice, and other specialized care.
Veterans themselves do not typically fill out this form; it must be completed and signed by the ordering community provider.
When to Submit VA Form 10-10172
Submit the form in these common scenarios:
- Additional services or visits beyond the original authorization.
- Extension of care authorization.
- Referral to another specialty.
- DME/prosthetics prescriptions requiring VA approval (routine requests).
- Home health, nursing home, or palliative care coordination.
Urgent cases (within 48 hours): Contact your local VA facility directly. For suicide/homicide risk, call the VA immediately.
How to Download VA Form 10-10172?
Download the latest VA Form 10-10172 PDF here (official VA source).
The form is fillable and includes separate sections for medical services and DME/prosthetics.
Step-by-Step Guide: How to Fill Out VA Form 10-10172?
Section I: Veteran & Ordering Provider Information
Provide the veteran’s full legal name, date of birth, VA facility details, and authorization number. Include your (the provider’s) office information, phone, fax, and secure email. Indicate if you are an Indian Health Services or Tribal Health Program provider.
Section II: Type of Care Requested
Specify urgency, whether it’s a continuation of care, referral to another specialty, diagnosis codes (ICD-10), and requested CPT/HCPCS codes. For geriatric/extended care, check applicable options like home health or hospice.
Reason for Request & Justification
Clearly explain the medical necessity. Attach supporting documentation such as office notes, treatment plans, lab results, and radiology reports to avoid delays.
Attestation and Signature
The ordering provider must print their name, provide NPI number, sign, and date the form. The attestation confirms accuracy and understanding of VA review processes.
Tip: Only submit one request per form. Use the medical page for clinical services and the DME page for equipment needs.
Submission Requirements and Methods
Follow these steps for successful submission:
- Complete VA Form 10-10172 fully.
- Attach all supporting medical records and care plans.
- Obtain the ordering provider’s signature.
- Submit via HealthShare Referral Manager (HSRM), fax, secure email, or mail to your local VA community care office.
VA facilities review requests based on clinical necessity, availability of services at VA, and the veteran’s best interest.
VA Form 10-10172 for DME and Prosthetics
Page 2 of the form is dedicated to Durable Medical Equipment requests. Include HCPCS codes, brand/model details, measurements, oxygen saturation data (if applicable), and diabetic foot risk assessments. Thorough completion prevents delays in DME fulfillment.
Common Reasons for Delays or Denials
– Incomplete forms or missing signatures
– Lack of supporting documentation
– Services available at VA facilities
– Insufficient medical necessity justification
Always reference VA Clinical Determinations and Indications (CDIs) for guidance.
Tips for Faster Approval
- Use the online HSRM portal when available for credentialed providers.
- Include two patient identifiers on all documents.
- Submit promptly—ideally within 24 hours for routine DME.
- Check your local VA Community Care contact information.
Additional Resources for Veterans and Providers
– VA Care Coordination Overview
– DME Requirements
– Find Your Local VA Facility
– Clinical Determinations and Indications
Frequently Asked Questions (FAQs)
Is VA Form 10-10172 required for all community care?
No, only for additional services or extensions beyond the original authorization.
Can veterans submit this form themselves?
The form requires a signed attestation from the ordering community provider.
How long does approval take?
Processing times vary by facility and urgency. Urgent requests receive priority.
For the most current information, always refer to official VA.gov resources. This article is for informational purposes and does not replace official VA guidance.