How to Fill Out and Submit VA Form 10-10172: DME and Prosthetics

VA Form 10-10172, the Community Care Provider Request for Service, is the form you send to the VA when a Veteran already referred to your practice needs care beyond what the original authorization covers, or needs a new authorization because the old one has expired. The form runs two pages: page 1 for medical services, page 2 for durable medical equipment (DME) and prosthetics. You submit only the page that fits your request, not both.¹

When to Use the Form

The Request for Service is not a first-contact referral tool. It applies after the VA has already referred the Veteran to your facility and issued an authorization number. Use it in two situations: the Veteran needs services outside the scope of that original authorization, or the authorization has expired and care is still needed. Your request goes to a VA clinical reviewer who decides whether to extend or expand coverage under the Veterans Community Care Program at 38 U.S.C. § 1703.²

Where to Get the Form

Download the current PDF from the VA’s forms website or through the HealthShare Referral Manager (HSRM) portal at ccracommunity.va.gov.³ The form was streamlined in June 2025 from three pages to two, and the revision removed fields providers were routinely leaving blank. Make sure you are working from the current version before you start filling anything in.

Completing Page 1: Medical Services

Page 1 has two sections and an attestation block at the bottom. Every field matters. Incomplete submissions are a leading cause of processing delays.

Section I: Veteran and Ordering Provider

Enter the Veteran’s full legal name and date of birth. The form does not ask for a Social Security Number or VA file number.⁴ Add the VA facility name and address tied to the Veteran’s care, then copy the VA authorization number from the original referral into field 4. Leaving that number blank makes it hard for the reviewer to connect your request to the Veteran’s record.

Then give your office name and address, phone, fax, and a secure email address. Indicate whether you are an Indian Health Service or Tribal Health Program provider. The only provider identifier the form asks for is the ordering provider’s NPI, which appears in the attestation block. No tax ID is required.

Section II: Type of Care

Section II captures the clinical request:

Field 10, the urgent care indicator: mark yes if the Veteran needs care within 48 hours.
Fields 11 and 12: indicate whether you are continuing existing care or referring to a different specialty.
Field 13: ICD-10 diagnosis codes with written descriptions.
Field 15: CPT or HCPCS procedure codes with descriptions for each service you are requesting.
Field 17: check the appropriate box if the request involves community nursing home care, home infusion, hospice, skilled home health, adult day health care, homemaker services, or respite care.
Field 18: a clear written explanation of why the Veteran needs these services.

The ordering provider then prints their name, enters the NPI, signs, and dates the form. An unsigned form will be denied.⁵

Completing Page 2: DME and Prosthetics

Page 2 repeats the Veteran and provider identification fields, then swaps the medical service sections for equipment-specific ones. It has four sections.

Home Oxygen

Section II covers oxygen requests: PaO2 at rest, O2 saturation at rest, flow rate, whether support is continuous or intermittent, equipment type (stationary or portable), and delivery system (cannula, mask, or other).⁴

Other DME and Prosthetics

Section III handles everything else. Enter HCPCS codes, brand and model, measurements, quantity, ICD-10 diagnosis codes, and the provisional diagnosis. Indicate whether the Veteran has received education, training, or fitting for the equipment. Choose a delivery preference; if you skip that field, the DME defaults to being mailed to your office, which the form warns can delay care.

Therapeutic Footwear

Section IV applies only to diabetic or amputation-related therapeutic footwear. Select the appropriate risk score (2 or 3) based on sensory loss, diminished circulation, foot deformity, or history of prior amputation or ulcer. Describe the foot deformity and explain why conventional footwear cannot accommodate it. Skip this section if the Veteran does not meet those clinical criteria.

What to Attach

Every Request for Service must include clinical records supporting medical necessity. The form’s instructions list office notes, current treatment plans, clinical history, laboratory results, radiology results, and relevant medications.⁴ The VA does not specify a set number of visit notes. Send enough for the reviewer to understand the Veteran’s current condition and why the requested services are necessary.

Requests without supporting documentation will be denied,⁵ and this is where most avoidable rejections happen. For a continuation of care or a specialized procedure, include records showing the Veteran’s response to previous treatment and a written rationale for why further services are needed. Lab and imaging results carry weight when they directly back the clinical picture you describe.

Urgent Situations

If the Veteran needs care within 48 hours, mark field 10 as “Yes” and call the VA facility directly rather than waiting for the standard review process. If there is a risk of suicide or homicide, call the VA facility first and submit the form afterward. The paperwork still has to be completed, but direct contact takes priority.

How to Submit

You have three submission options: HSRM, secure fax, or encrypted email.

HSRM

HSRM is the VA’s preferred channel. The portal at ccracommunity.va.gov lets you submit the form electronically and attach clinical documentation in the same session, which generates a digital record and makes tracking easier. Providers with “Community Care Provider” security access can also sign the form electronically inside HSRM, avoiding a print-sign-scan-upload loop.³

Access requires an active Community Care Network agreement with Optum or TriWest, or a Veterans Care Agreement with a VA medical center. Each user completes HSRM training, sets up an ID.me account, and gets added to the End User Tracker submitted to hsrmsupport@va.gov.⁶ Electronic signature is limited to credentialed providers: physicians, nurse practitioners, physician assistants, physical therapists, chiropractors, acupuncturists, massage therapists, and respiratory therapists. Support staff can prepare and submit a request but cannot sign it electronically.

Fax and Secure Email

Without HSRM, fax the completed page and attachments to the VA medical center handling the Veteran’s care. Fax numbers vary by facility. Check the VA’s facility care coordination contacts directory or call the referring VA medical center to confirm the right number.⁷ Encrypted email is also accepted; the encryption must meet federal standards for protected health information, and the VA supports Azure Rights Management Services for that purpose.

Whichever route you take, save the confirmation receipt or transmission log. That record proves when the VA received the request if timing is ever disputed.

After You Submit

A VA clinical reviewer evaluates medical necessity and confirms the Veteran’s eligibility under 38 U.S.C. § 1703. Approvals and denials are made at the VA facility’s discretion, and supporting documentation must accompany each request.¹ Straightforward requests are typically handled within a few business days; complex cases involving high-cost procedures or additional fiscal review take longer.

If the request is approved, you receive a new or updated authorization number. That number must appear on every claim for the authorized services. Without it, claims for non-emergent community care will not process correctly.⁸

If the Request Is Denied

A denial does not end the process. If it was caused by a missing document or missing signature, correct the deficiency and resubmit; that resolves most avoidable denials. For payment disputes after care has already been provided, the VA offers assistance requests, Veterans Care Agreement disputes (within 90 days of the explanation of payment), supplemental claims and higher-level reviews (both within one year of the decision), and appeals to the Board of Veterans’ Appeals (within one year).⁹ The right option depends on whether the care was authorized in advance and what agreement you hold with the VA, so check your contract’s dispute terms before choosing a path.

1
TriWest Healthcare Alliance. VA CCN June 2025 Provider Pulse
2
Office of the Law Revision Counsel. 38 USC 1703 – Veterans Community Care Program
3
VA Community Care. Community Care Referrals and Authorizations
4
Department of Veterans Affairs. VA Form 10-10172 – Community Care Provider – Medical Request for Service
5
U.S. Department of Veterans Affairs. VA Community Care – Care Coordination
6
Department of Veterans Affairs. Healthshare Referral Manager (HSRM) – Account Creation and Single Sign-On External Quick Reference Guide for Community Providers
7
U.S. Department of Veterans Affairs. Community Providers – How to Submit Medical Documentation to VA
8
U.S. Department of Veterans Affairs. File a Claim for Veteran Care – Information for Providers
9
U.S. Department of Veterans Affairs. Provider Disputes and Appeals for Veteran Care