VA · Official form

VA Form 10-10172: Community Care Provider - Request for Service

VA Form 10-10172 is the request-for-service form community providers use when a veteran they are treating under VA community care needs additional services beyond the original referral. VA reviews the request before the extra care is authorized.

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What is VA Form 10-10172?

VA Form 10-10172, Community Care Provider - Request for Service, is used within the VA community care program, where veterans receive VA-authorized care from non-VA providers. When the community provider determines the veteran needs services outside the scope of the existing referral or authorization, such as additional visits, imaging, specialty consults, or a procedure, the provider documents the clinical request on this form and sends it to VA for review.

VA facility or Office of Community Care staff review the request and either approve it, ask for more information, or handle the need another way, such as scheduling the service inside VA. The form captures the veteran's identifying information, the referring authorization, the requested services with supporting clinical rationale, and provider details. Care delivered without an approved authorization risks not being covered, which is why the form matters to both providers and veterans. The current revision is dated May 2025.

Who files VA Form 10-10172?

Community medical providers treating veterans under a VA community care referral who need to request additional services
Provider office staff submitting requests for continued care beyond the initial authorization
Third-party network staff helping route a request for service to the authorizing VA facility
VA community care staff processing and tracking requests for additional services

How to fill out VA Form 10-10172

Confirm the veteran's existing VA community care referral or authorization and gather the referral number.
Complete the veteran and provider identification sections.
Describe the requested services and the clinical justification, attaching supporting documentation such as progress notes or test results.
Sign the request as the treating provider or authorized office staff.
Submit the form to the authorizing VA facility's community care office through the channel identified in the referral paperwork, and wait for VA approval before providing the additional services.

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Page 1 22 fields

SECTION 1: VETERAN AND ORDERING PROVIDER INFORMATION. 1. VETERAN'S LEGAL FULL NAME (First, Middle Initial, Last).

2. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

3. V. A. FACILITY AND ADDRESS.

4. V. A. AUTHORIZATION NUMBER.

5. ORDERING PROVIDER OFFICE NAME AND ADDRESS.

6. INDIAN HEALTH SERVICES (I H S) PROVIDER / TRIBAL HEALTH PROGRAM (T H P)? NO.

7. ORDERING PROVIDER PHONE NUMBER. Please use digits formatted as (999) 999-9999.

8. ORDERING PROVIDER FAX NUMBER. Please use digits formatted as (999) 999-9999.

9. ORDERING PROVIDER SECURE EMAIL ADDRESS.

SECTION 2: TYPE OF CARE REQUEST. 10. IS CARE NEEDED WITHIN 48 HOURS? (Based on the clinical need of the patient). NO.

11. IS THIS A CONTINUATION OF CARE? NO.

12. IS THIS A REFERRAL TO ANOTHER SPECIALTY? NO.

12. Specify SPECIALTY.

13. DIAGNOSIS CODES (I C D - 10).

14. DIAGNOSIS DESCRIPTION.

15. REQUESTED C P T / H C P C S CODE.

16. DESCRIPTION C P T / H C P C S CODE.

17. GERIATRIC AND EXTENDED CARE (Note: Add needed details to the justification section). COMMUNITY NURSING HOME.

18. REASON FOR REQUEST (To avoid delays in care, include appropriate documentation such as office notes, current treatment plans, clinical

Read Attestation above. 19. ORDERING PROVIDER NAME (PRINTED).

20. ORDERING PROVIDER N P I NUMBER.

22. TODAY'S DATE. Enter 2 digit month, 2 digit day and 4 digit year.

Page 2 32 fields

Read Requirements and Note above. SECTION 1: VETERAN AND ORDERING PROVIDER INFORMATION. 1. VETERAN'S LEGAL FULL NAME (First, Middle

2. DATE OF BIRTH. Enter 2 digit month, 2 digit day and 4 digit year.

3. V. A. FACILITY AND ADDRESS.

4. V. A. AUTHORIZATION NUMBER.

5. ORDERING PROVIDER OFFICE NAME AND ADDRESS.

6. INDIAN HEALTH SERVICES (I H S) PROVIDER / TRIBAL HEALTH PROGRAM (T H P)? NO.

7. PHONE NUMBER. Please use digits formatted as (999) 999-9999.

8. FAX NUMBER. Please use digits formatted as (999) 999-9999.

9. SECURE EMAIL ADDRESS.

SECTION 2: HOME OXYGEN REQUEST. 10. P. A. 0 2 AT REST.

11. O 2 SAT AT REST.

12. OXYGEN FLOW RATE.

13. EXTENT OF SUPPORT (Continuous, Intermittent, Specific Activity).

14. OXYGEN EQUIPMENT (Stationary / Portable).

15. DELIVERY SYSTEM (Cannula, Mask, Other).

SECTION 3: D M E AND PROSTHETICS REQUEST. Please see https://www.va.gov/COMMUNITYCARE/providers/DME-Requirements.asp for URGENT D M E

17. BRAND, MAKE, MODEL, PART NUMBERS.

18. MEASUREMENTS.

19. QUANTITY. Enter number.

20. I C D - 10.

21. PROVISIONAL DIAGNOSIS.

22. EDUCATION, TRAINING, AND / OR FITTING OF DME MUST BE PROVIDED TO THE VETERAN. HAS THE FOLLOWING BEEN COMPLETED. A. EDUCATION. NO.

22. B. TRAINING. NO.

22. C. FITTING. NO.

23. DELIVERY PREFERENCE (If incomplete, D M E will be mailed to requesting provider). DELIVER TO ORDERING PROVIDER'S ADDRESS.

SECTION 4: THERAPEUTIC FOOTWEAR ASSESSMENT INFORMATION. LEFT FOOT.

24. CHECK APPROPRIATE DIABETIC / AMPUTATION RISK SCORE (Only patients with medical conditions below can be prescribed therapeutic /

25. DESCRIBE FOOT DEFORMITY AND DETAILS (Requires severe or gross foot deformity which cannot be accommodated with conventional footwear).

26. REASON FOR REQUEST (To avoid delays in care, include appropriate documentation such as office notes, current treatment plans, clinical

Read Attestation above. 27. ORDERING PROVIDER NAME (PRINTED).

28. ORDERING PROVIDER N P I NUMBER.

30. TODAY'S DATE. Enter 2 digit month, 2 digit day and 4 digit year.

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Frequently asked questions

I am a veteran; do I fill out this form?

Generally no. VA Form 10-10172 is completed by the community provider treating you and sent to VA. If you think you need more care than your referral covers, tell your provider and your VA care team; the provider submits the request and VA decides on the authorization.

What happens if care is provided before VA approves the request?

Services delivered outside an approved authorization risk not being paid by VA, which can leave the provider unpaid or create billing disputes. Providers should wait for VA's decision on the request for service, except in the emergency situations covered by separate rules.

How does the provider know where to send the request?

The referral or authorization paperwork identifies the authorizing VA facility and how it accepts requests, which may be through a portal, secure fax, or the community care office. When in doubt, the provider can contact the VA facility community care office listed on the referral.

VA Form 10-10172: Community Care Provider - Request for Service

What is VA Form 10-10172?

Who files VA Form 10-10172?

How to fill out VA Form 10-10172

Quick fill VA Form 10-10172 on this page

Frequently asked questions

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