VA Form 10-10172 Community Care RFS: Sections, Attachments, Submission

VA Form 10-10172 is the Community Care Provider Request for Service (RFS) that community providers use to ask the VA to authorize care that falls outside a Veteran’s existing referral. The form has two parts: a medical RFS on page one for clinical services and specialty referrals, and a Durable Medical Equipment and Prosthetics RFS on page two. You can submit it through the HealthShare Referral Manager (HSRM) portal, by fax, or by secure email to the VA medical center tied to the Veteran’s referral.¹ The current version was revised in May 2025 and is available as a downloadable PDF from the VA.²

When to File an RFS

File one before you deliver care that the current referral doesn’t already cover. The VA lists three triggers:³

The current authorization is running out of visits or time. A physical therapy plan that needs twelve sessions when six were approved is a typical example.
You’ve identified a condition that needs a different specialist. A surgeon who spots a nerve issue at a post-op visit files an RFS to refer the Veteran to neurology.
The service falls outside the Standardized Episode of Care (SEOC) attached to the referral. Anything not inside that bundle — an added imaging study, a therapeutic modality, a medication change — needs an RFS before you provide it.⁴

Timing matters. All non-urgent, non-emergent community care requires advance VA authorization, and services rendered without it can be denied or treated as unauthorized care.⁵

Completing Page One: The Medical RFS

Page one has two sections and an attestation block.¹

Section I: Veteran and Provider Information

Field 1 is the Veteran’s full legal name (first, middle initial, last). Field 2 is date of birth. The form does not ask for a Social Security number. Field 3 is the VA facility name and address tied to the Veteran’s referral — this is the VA medical center that issued the original authorization, not your office and not the geographically closest VA. Field 4 is the existing VA authorization number from that referral.

Fields 5 through 9 cover your practice: office name and address (5), a yes/no on whether you’re an Indian Health Services or Tribal Health Program provider (6), phone (7), fax (8), and a secure email address (9). The form doesn’t ask for a Tax Identification Number; the VA identifies your practice through the NPI you enter in the attestation.

Section II: The Care You’re Requesting

Field 10 asks whether the Veteran needs care within 48 hours based on clinical urgency. Field 11 marks the request as a continuation of ongoing care; Field 12 marks it as a referral to another specialty, with the specialty written in.

Fields 13 and 14 capture the diagnosis: ICD-10 codes in 13, a plain-language description in 14. Field 15 lists the CPT or HCPCS codes for the services you want, and Field 16 describes each service in words. Field 17 applies only to geriatric and extended care, with options for community nursing home, home infusion, hospice and palliative care, skilled home health, community adult day health care, home health aide, and respite care.

Field 18 is the clinical justification. Reviewers use this to decide medical necessity, so a line like “patient needs additional care” gives them nothing to work with. Describe the findings, what treatment has already been tried, and why the requested services are needed now.

Attestation

Print the ordering provider’s name in Field 19, enter the NPI in Field 20, sign in Field 21, and date in Field 22. The ordering provider must sign personally; administrative staff cannot sign for them, and an unsigned form will not be processed.

Completing Page Two: DME, Oxygen, and Therapeutic Footwear

Page two handles durable medical equipment, prosthetics, home oxygen, and therapeutic footwear. Section I repeats the identifying information from page one — Veteran name and date of birth, VA facility and authorization number, and your practice details.¹

Home Oxygen (Section II)

Fill in Section II only when prescribing home oxygen. Enter PaO2 at rest (Field 10), oxygen saturation at rest (Field 11), and the prescribed flow rate (Field 12). Field 13 indicates continuous, intermittent, or activity-specific support. Fields 14 and 15 specify stationary or portable equipment and the delivery system (cannula, mask, or other).

DME and Prosthetics (Section III)

Enter HCPCS codes for the prescribed items in Field 16 and the brand, make, model, and part numbers in Field 17. Field 18 is measurements; Field 19 is quantity. Fields 20 and 21 carry the ICD-10 code and provisional diagnosis.

Field 22 asks whether the Veteran has received education, training, and fitting — each sub-item must be marked yes, no, or not applicable. Field 23 sets delivery. If you leave it blank, the VA mails the equipment to your office. Other options are Veteran pickup at the VA facility, delivery through a community vendor for setup, or delivery to the Veteran’s home.

Therapeutic Footwear (Section IV)

This section applies only to diabetic or therapeutic footwear. Select the diabetic or amputation risk score (Risk Score 2 or 3), indicate left, right, or bilateral, and specify prefabricated or custom. Field 25 requires a description of the foot deformity; the VA limits therapeutic footwear to patients with severe deformity that conventional shoes cannot accommodate.

The form warns that failing to thoroughly complete the DME RFS will delay patient care and prevent the VA from fulfilling the equipment request.

What to Attach

The form itself tells providers to attach documentation supporting medical necessity. To keep the request moving, include relevant office notes, the current treatment plan, clinical history, laboratory results, radiology results, and a list of current medications.¹ Thin or generic notes are one of the fastest ways to have a request sent back.

A strong submission ties the diagnosis codes, the requested procedures, and the narrative in Field 18 together. Asking for more physical therapy? Attach progress notes that show functional improvement so far, alongside documentation of the deficits that justify continued treatment.

How to Submit

The form lists three accepted submission methods: HSRM, fax, or secure email.¹

HSRM Portal

HealthShare Referral Manager, at ccracommunity.va.gov, is the electronic portal that lets community providers submit RFS forms directly into the VA system.⁶ HSRM supports electronic signatures, so there’s no need to print, sign, scan, and upload. Submissions route automatically to the right VA reviewers. Access requires an active Community Care Network agreement with Optum or TriWest, or an active Veterans Care Agreement with a VA medical center, plus per-user onboarding through the VA help desk.⁷

Fax and Secure Email

Providers without HSRM access can fax the completed form to their local VA medical center’s Office of Community Care. The correct fax number varies by facility, so contact the VA medical center associated with the Veteran’s referral to confirm it, and keep the fax confirmation page as proof of delivery. Secure email is also accepted; the form does not specify a universal address, so confirm the destination with the local VA facility.

After You Submit

VA clinical staff review the RFS against the Veteran’s health benefits and medical necessity criteria. If approved, the VA issues a new authorization number or amends the existing one, giving you the ability to deliver and bill for the specified services within a defined timeframe. Your office receives the decision through HSRM or by mail, and the Veteran is notified separately.

A denial is not necessarily final. The notification lists the clinical or administrative reasons, and you can adjust the treatment plan, gather additional evidence, and submit a revised RFS addressing what the VA flagged.

Routine requests are generally handled within a few business days, though complex cases and high-volume periods at a given facility can stretch the timeline. If you marked Field 10 for care within 48 hours, flag the urgency when submitting so reviewers can prioritize it.

Emergency Care Uses a Different Process

Form 10-10172 is not for emergencies. When a Veteran receives emergency care at a non-VA facility, the provider or the Veteran must notify the VA within 72 hours of when the emergency care begins, through the VA emergency care reporting portal or by calling the VA directly.⁸ Missing that 72-hour window doesn’t automatically deny the claim, but it falls under the stricter criteria for unauthorized emergency care.⁵

Mistakes That Slow the Request Down

A few avoidable errors account for most delays:

Missing provider signature and date. The ordering provider has to sign and date the attestation block personally; an unsigned form won’t be processed.
No supporting documentation. Without office notes, lab results, or a current treatment plan, the VA has to request records separately, adding days or weeks.
Vague clinical justification. Field 18 needs specific findings, the treatment already provided, and why the additional services are medically necessary.
Incomplete DME fields. Every applicable field — HCPCS codes, measurements, education and training status, delivery preference — must be filled in, or the VA cannot fulfill the request.¹
Wrong VA facility in Field 3. It has to be the VA medical center that issued the referral, not the closest one to your office. Sending it to the wrong facility creates routing delays.

1
Department of Veterans Affairs. VA Form 10-10172 Community Care Provider Request for Service
2
Veterans Affairs. VA Form 10-10172 – Community Care Provider Request for Service
3
U.S. Department of Veterans Affairs. Request and Coordinate Care – Community Care
4
U.S. Department of Veterans Affairs. Clinical Determinations and Indications – Information for Providers
5
U.S. Department of Veterans Affairs. File a Claim for Veteran Care – Information for Providers
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Community Care Referrals and Authorizations. Community Care Referrals and Authorizations
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U.S. Department of Veterans Affairs. HSRM Community Provider Account Creation Information
8
Veterans Affairs. Getting Emergency Care at Non-VA Facilities