How to Fill Out VA Form 10-10172: Request for Service and DME

VA Form 10-10172 is the Request for Service (RFS) that community care providers use to ask the VA to authorize additional visits, a new specialty referral, a procedure outside the original Standardized Episode of Care, or durable medical equipment for a Veteran already receiving community care. The form has two pages: page one is the medical RFS and page two is the DME and prosthetics RFS. Only one request goes on one form. Providers submit it through the HealthShare Referral Manager (HSRM), secure fax, or secure email, and the VA processes routine requests within three business days.¹² The current version is dated March 2025 and is available at va.gov/forms/10-10172/.³

When You Need To File a Request for Service

File an RFS in three situations:¹

The current authorization is about to expire or the Veteran needs more sessions than the original referral allowed.
The Veteran’s condition calls for a specialist not covered by the existing consult.
A procedure, diagnostic test, or other service not included in the original Standardized Episode of Care has become necessary.

Each requested service needs its own form. If a Veteran needs both additional physical therapy visits and an MRI, that’s two RFS submissions, not one form with two requests.¹

Filling Out Page 1: The Medical RFS

Section I: Veteran and Ordering Provider Information

Enter the Veteran’s legal full name and date of birth. The form does not ask for a Social Security number or VA file number.² Then enter the VA facility name and address tied to the Veteran’s care and the VA authorization number from the original referral. That authorization number is how VA staff link your request to the Veteran’s existing file, so check it carefully.

For the ordering provider, fill in your office name and address, phone, fax, and secure email. A separate field asks whether you are an Indian Health Services provider or Tribal Health Program. Mark yes or no.²

Section II: Type of Care Request

The first question asks whether care is needed within 48 hours based on the patient’s clinical need. If you mark yes, the form directs you to also contact the VA facility directly. Don’t rely on the form alone for time-sensitive care.²

Indicate whether the request is a continuation of care or a referral to another specialty. Then fill in the clinical coding: ICD-10 diagnosis codes with a written description, and CPT or HCPCS procedure codes with a written description of each requested service.

Field 17 covers geriatric and extended care categories: community nursing home, home infusion, hospice and palliative care, skilled home health care, community adult day health care, homemaker or home health aide services, and respite care. Check the box that applies if your request falls into one of these.²

Field 18, “Reason for Request,” is where most requests succeed or fail. Write a concise clinical narrative that explains why the existing authorization is insufficient and how the additional services will improve the Veteran’s condition or functional status. Connect the specific diagnosis to the specific service, and reference objective findings from your records. Generic language rarely holds up.

Signature

Print the ordering provider’s name, enter their NPI number, and have that provider sign and date the form. The signature is mandatory. Requests without a provider signature will be denied.¹

Filling Out Page 2: DME and Prosthetics

Page two is a separate RFS for durable medical equipment and prosthetics. Submit page one for medical services; submit page two for DME. Not both.¹

Page two repeats the Veteran and provider identification fields, then adds equipment-specific sections. The home oxygen section asks for PaO2 and O2 saturation at rest, flow rate, extent of support (continuous, intermittent, or activity-specific), equipment type, and delivery system. The general DME section asks for HCPCS codes, brand and model, measurements, quantity, ICD-10 codes, and provisional diagnosis. There’s a therapeutic footwear assessment for diabetic Veterans that asks for the risk score, any foot deformity, and whether the footwear is prefabricated or custom.²

For any DME request, confirm whether the Veteran has received education, training, and fitting as applicable, and pick a delivery preference: the provider’s office, the VA facility for pickup, a community vendor for delivery and setup, or the Veteran’s home.²

Documentation You Need To Attach

Every RFS submission must include supporting medical records and a care plan. The form itself lists what to attach:²

Recent office notes showing current condition and any lack of expected progress.
Current treatment plan and why it needs to change.
Relevant clinical history supporting medical necessity.
Lab and radiology results backing your clinical narrative.
Current medication list, especially if the request relates to medication management or side effects.

The form warns that requests without supporting documentation will be denied. A signed form with vague clinical justification and no attached records is the single most common reason for rejection.

Before you submit, check whether the VA has published a Clinical Determination and Indication (CDI) for the service you’re requesting. CDIs outline the clinical criteria and parameters for services Veterans may receive in the community. If your request matches the CDI, cite that in your narrative and review moves faster. If it doesn’t match, you’ll need stronger documentation to show why the service is still medically necessary.⁴ The CDI library is available through the VA’s community care provider portal after accepting an end-user agreement.

How To Submit the Form

Three channels are available:²

HSRM (HealthShare Referral Manager) is the VA’s preferred electronic platform and supports electronic signature. Access requires the Community Care Provider security group role, which your facility’s CCRA HSRM Administrator can set up by submitting an updated End User Tracker to HSRMSupport@va.gov. Only certain provider types qualify: MDs, DOs, NPs, PAs, DPTs, DCs, acupuncturists, massage therapists, and respiratory therapists.⁵
Secure fax to the local VA medical center handling the Veteran’s care.
Secure email to the same facility.

Each facility has its own fax number and secure email for incoming RFS forms, so confirm those with the specific VA medical center before sending.

What Happens After You Submit

The VA processes routine RFS submissions within three business days and notifies the community provider through their preferred communication method.⁶ From the Veteran’s side, the full referral and scheduling process can take up to 14 days.⁷

If approved, the VA issues an authorization covering the approved services. All non-urgent and non-emergent care requires that authorization in advance. Providing services without one puts you at risk of non-payment, because the VA treats it as unauthorized care and reimbursement is much harder to obtain.⁸ Keep a copy of every submission confirmation.

Urgent and Emergency Situations

If a Veteran needs care within 48 hours, don’t wait on the standard RFS process. Contact the VA facility directly and submit the RFS in parallel. For situations involving a risk of suicide or homicide, call the facility immediately and submit the form afterward.²

When a true emergency results in care before authorization, provide the emergency treatment and then notify the VA. The VA will decide whether the care can be authorized after the fact; if not, the claim may still be considered under the unauthorized emergent care provisions. Filing deadlines are tight. Claims for service-connected emergency care must be filed within two years. Nonservice-connected emergency claims under 38 U.S.C. § 1725 must be filed within 180 days of discharge or 90 days after exhausting third-party payment efforts, whichever is later.⁸

Prescriptions Are Not Handled on This Form

VA Form 10-10172 doesn’t cover prescription drug requests. Medications appear on the form only as supporting documentation for the clinical narrative, meaning what the Veteran is currently taking to justify the medical service being requested.²

If a Payment Claim Is Later Denied

When the VA denies a claim for payment, it issues VA Form 10-0998 explaining the provider’s options. There are three review paths:⁹

Supplemental Claim (VA Form 20-0995) if you have new evidence or want reconsideration based on a change in law. Mail or fax to the Claims Intake Center at P.O. Box 4444, Janesville, WI 53547-4444 (Attn: 104P Appeals), or fax 844-678-8979.
Higher-Level Review (VA Form 20-0996) for a senior reviewer to re-examine the original decision. No new evidence allowed. Same address and fax.
Board of Veterans’ Appeals (VA Form 10182). Mail to the Board of Veterans’ Appeals, P.O. Box 27063, Washington, DC 20038, or fax 844-678-8979.

All three must be filed within one year of the VA’s decision. You can also contact VA customer support to discuss a claims processing question before choosing a formal review path.⁹

1
Department of Veterans Affairs. Request and Coordinate Care – Community Care
2
Department of Veterans Affairs. VA Form 10-10172 Community Care Provider Request
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Veterans Affairs. VA Form 10-10172
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Department of Veterans Affairs. Clinical Determinations and Indications – Information for Providers
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Community Care Referral and Authorization (CCRA). Community Care Referrals and Authorizations
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Department of Веterans Affairs. Request and Coordinate Care – Community Care
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Veterans Affairs. How To Get Community Care Referrals and Schedule Appointments
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Department of Veterans Affairs. File a Claim for Veteran Care – Information for Providers
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Department of Veterans Affairs. Provider Disputes and Appeals for Veteran Care – Community Care