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

To fill out VA Form 10-10172, community providers pick the correct page for the service type, complete the veteran and provider identifiers, enter diagnosis and procedure codes with a clinical narrative explaining medical necessity, sign the attestation, and submit the form with supporting records to the referring VA medical facility. The VA processes requests within three business days and will not reimburse services performed without a valid authorization, so accuracy on the first submission protects both the veteran’s continuity of care and the provider’s payment.¹

The form is two documents on one PDF. Page one is the Medical Request for Services. Page two is the Durable Medical Equipment and Prosthetics Request for Services. You submit only the page that matches what you are requesting.²

When This Form Is the Right One

Use Form 10-10172 in three situations: the current authorization is about to expire and the veteran needs more visits or more time; the veteran’s condition calls for a specialty not covered in the original referral; or a procedure outside the original Standardized Episode of Care becomes clinically necessary.¹

It is not the initial referral. That step happens inside the VA before the veteran ever reaches your office. The RFS picks up from the existing authorization and asks the VA to approve the next phase.

What to Gather Before You Open the Form

Missing documentation is the most common reason an RFS gets denied or bounced back. Pull everything together first.¹

Veteran’s full legal name, date of birth, and the VA authorization number from the original referral.
Name and address of the VA medical center that issued the referral.
Your practice name, address, phone, fax, secure email, and National Provider Identifier.
ICD-10 diagnosis codes with written descriptions.
CPT or HCPCS procedure codes with written descriptions.
Clinical documentation: office notes, current treatment plan, clinical history, lab and radiology results, and medication list.

The clinical documentation is where requests are won or lost. VA reviewers apply a medical-necessity standard, and the supporting records are the evidence. A bare form with codes but no narrative context invites either a denial or a slow round of follow-up questions.²

Filling Out Page 1: Medical RFS

Page one covers medical service requests and runs in two sections plus an attestation.

Section I: Veteran and Ordering Provider Information

Fields 1 and 2 capture the veteran’s full legal name and date of birth. Field 3 is the referring VA facility’s name and address. Field 4 is the existing VA authorization number, which links this new request back to the veteran’s care record. Fields 5 through 9 hold your practice information: office name and address, whether you are an Indian Health Services or Tribal Health Program provider, phone, fax, and secure email.²

Section II: Type of Care Request

Field 10 asks whether care is needed within 48 hours based on the patient’s clinical condition. If you check yes, the form directs you to call the VA facility directly rather than waiting for the standard review. For any risk of suicide or homicide, contact the VA immediately and file the form as follow-up.

Fields 11 and 12 ask whether the request continues existing care and whether it is a referral to a different specialty. Fields 13 and 14 hold the ICD-10 codes and their written descriptions. Fields 15 and 16 hold the requested CPT or HCPCS codes and descriptions.

Field 17 applies only to geriatric and extended care categories: community nursing homes, home infusion, hospice and palliative care, skilled home health, community adult day health care, homemaker and home health aide services, and respite care. Skip it for anything else.

Field 18 is the reason-for-request narrative. This is where you connect the codes to the clinical picture and explain why the additional services are medically necessary. Do not treat it as a formality. Reviewers rely on this box to decide the case.²

Attestation

Fields 19 through 22 require the ordering provider’s printed name, NPI, signature, and the date. An unsigned form is denied without further review.¹

Filling Out Page 2: DME and Prosthetics RFS

Page two is a separate form for durable medical equipment and prosthetics. Section I repeats the veteran and provider identifiers. Section II covers home oxygen, with fields for arterial oxygen levels, flow rate, extent of support, equipment type, and delivery system. Section III handles other DME and prosthetics and asks for HCPCS codes, brand and model, measurements, quantity, ICD-10 codes, and whether the veteran has received education, training, and fitting. Section IV addresses therapeutic footwear with a diabetic or amputation risk assessment.²

One page or the other, never both. If you are requesting a medical service, submit page one only. If you are requesting equipment, submit page two only. Sending both when only one applies slows processing.

How to Submit the Completed Form

Three channels are available: the HealthShare Referral Manager portal, fax, or secure email.² HSRM is the VA’s preferred channel because it supports electronic signature and real-time status tracking.³

Providers without HSRM access should fax or securely email the signed form along with all supporting clinical documentation to the referring VA medical center. The form does not list a universal fax number; each VA facility has its own intake line. Contact the facility that issued the original referral for the correct number.

What Happens After You Submit

The VA processes requests within three business days and notifies you through your chosen channel, whether that is HSRM, fax, or email.¹ An approval comes with an authorization number confirming the VA will reimburse the listed services. Keep that number in your billing records. It is the key to getting paid.

If reviewers need more information, you will get a request for additional clinical notes or code clarification. Respond quickly. Delays push the veteran’s care past the clinically appropriate window and can force a resubmission. Keep a copy of your original submission confirmation in case there is ever a dispute about what was sent and when.

If the Request Is Denied

Two of the most frequent denial reasons, missing clinical documentation and a missing signature, are easy to fix. Attach the missing records, sign the form, and resubmit. The corrected request goes back into the three-business-day queue.¹

If the VA denies on clinical grounds, concluding the services are not medically necessary, the veteran has formal review options. A Clinical Appeal asks the VA care team to reconsider the treatment decision. Beyond that, the VA’s decision review system offers a Supplemental Claim with new and relevant evidence, a Higher-Level Review by a senior reviewer without new evidence, or an appeal to the Board of Veterans’ Appeals. An accredited attorney, claims agent, or Veterans Service Organization representative can help with any of these paths.⁴

1
Department of Veterans Affairs. Community Care – Care Coordination
2
U.S. Department of Veterans Affairs. VA Form 10-10172 Request for Services
3
U.S. Department of Veterans Affairs. Community Care Referrals and Authorizations
4
Veterans Affairs. VA Decision Reviews and Appeals