[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283913-105":53,"doc-detail-283913-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","va-form-10-10172-community-care-provider-request-for-service","VA Form 10-10172 - Community Care Provider Request for Service","","VA Form 10-10172 is used by community providers to request services under the Department of Veterans Affairs Community Care program. The form requires completing a separate request for each service, attaching supporting medical records and a care plan, and obtaining the ordering provider’s signature and date. It collects veteran and ordering provider details, indicates care timing and whether it continues or refers to another specialty, and specifies diagnosis codes, CPT/HCPCS codes, requested service types, and the reason for the request. Requests are approved or denied at the VA facility’s discretion and must include documentation.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/va-form-10-10172-community-care-provider-request-for-service/283913/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/va-form-10-10172-community-care-provider-request-for-service/283913.png","ImageObject",442,249,{"name":88,"@type":89},"Miles","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-04","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is VA Form 10-10172 used for?","Question",{"text":108,"@type":109},"It is used to request services under the VA Community Care program from community providers.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What must be submitted with the request?",{"text":113,"@type":109},"Complete the RFS form, attach appropriate medical records and a care plan, have the ordering provider sign and date it, and submit via HSRM, fax, or secure email.",{"name":115,"@type":106,"acceptedAnswer":116},"How are requests decided?",{"text":117,"@type":109},"Requests are approved or denied at the discretion of the VA facility, and supporting documentation must accompany each request.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283913,1790012788,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},13056703019404,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","| Department of Veterans Affairs   |  |  | COMMUNITY CARE PROVIDER -MEDICAL  \u003Cbr>REQUEST FOR SERVICE  \u003Cbr>Separate Form Required for Each Service Requested)   |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Request for Service(RES)Submision Requirements:Complete the Medicl or DME RFS form for services not on the originalauthoriztion or to request a new  \u003Cbr>authoriztion for services.Only one request er orm(1)Complete RFS form 10-10172.(2)Attach appropriate medical records and care plan to support the request.  \u003Cbr>(3)Have the ordering provider sign and date the form.(4)Submit request via HSRM,Fax,or Secure E-mail.   |  |  |  |  |  |  |  |\n| NOTE:Requests are approved/denied at the VA facility's discretion and supporting documentation must accompany each request.   |  |  |  |  |  |  |  |\n| SECTION I:VETERAN &ORDERING PROVIDER INFORMATION   |  |  |  |  |  |  |  |\n| 1.VETERAN'S LEGAL FULL NAME (First,MI,Last):   |  |  |  |  |  | 2.DATE OF BIRTH (MM/DD/YYYY):   |  |\n| 3.VA FACILITY&ADDRESS:   |  |  |  |  |  | 4.VA AUTHORIZATION NUMBER:   |  |\n| 5.ORDERING PROVIDER OFFICE NAME&ADDRESS:   |  |  |  |  |  | 6.INDIAN HEALTH SERVICES (IHS)PROVIDER/  \u003Cbr>TRIBALHEALTH PROGRAM (THP)?  \u003Cbr>□NO □YES   |  |\n| 7.ORDERING PROVIDER PHONE NUMBER  \u003Cbr>((999)999-9999):   |  | 8.ORDERING PROVIDER FAX NUMBER  \u003Cbr>((999)999-9999):   |  |  | 9.ORDERING PROVIDER SECURE EMAIL ADDRESS:   |  |  |\n|  |  |  |  |  |  |  |  |\n| SECTION II:TYPE OF CARE REQUEST   |  |  |  |  |  |  |  |\n| 10.IS CARE NEEDED WITHIN 48 HOURS?(Based on the clinical need of the patient)  \u003Cbr>□NO □YES(Note:If care is needed within 48 hours,please contact your VAfacility directly  \u003Cbr>(Risk of Suicide/Homicide,call VA directly and submit RFSform)   |  |  |  |  |  | 11.IS THIS A CONTINUATION OF CARE?  \u003Cbr>□NO  \u003Cbr>YES   |  |\n| 12.IS THISAREFERRAL TO ANOTHER SPECIALTY?  \u003Cbr>□NO  \u003Cbr>□YES,SPECIALTY:   |  |  |  |  |  |  |  |\n| 13.DIAGNOSIS CODES (ICD-10):   | 14.DIAGNOSIS DESCRIPTION:   |  |  | 15.REQUESTED CPT/HCPCS CODE:   |  |  | 16.DESCRIPTION CPT/HCPCS CODE   |\n| 17.GERIATRIC ANDEXTENDED CARE (Note:Add needed details to thejustification section):  \u003Cbr>HOSPICE/PALLIATIVE CARE  \u003Cbr>HOME INFUSION  \u003Cbr>□COMMUNITY NURSING HOME  \u003Cbr>SKILLED HOME HEALTH CARE  \u003Cbr>□RESPITE  \u003Cbr>□COMMUNITY ADULTDAY HEAL  \u003Cbr>□HOME HOMEMAKER/HOME HEALTH AIDE   |  |  |  |  |  |  |  |\n| 18.REASON FORREQUEST (To avoid delaysin care,inchude appropriate documentation such as ofice notes,curent reatment plans,cinical history,laboratory  \u003Cbr>resultsradiology results &/or medications to support the medical necessity of services requested):   |  |  |  |  |  |  |  |\n| ATTESTATION:I do hereby attest that the forgoing information is true,accurate,&complete to the best of my knowledge &Iunderstand that any falsification,  \u003Cbr>omission,or concealment of material fact may subject me to administrative,civil,or criminal liability.Ido hereby acknowledge that VA reserves the right to perform  \u003Cbr>the requested service(s)if the following criteria are met:(1)The patient agrees to receive services from VA(2)Service(s)are available at VA facility &are able to be  \u003Cbr>provided by the clinically indicated date(3)It is determined to be within the patient's best interest.Upon completion of the requested service(s),VA will provide all  \u003Cbr>resulting medical documentation to the ordering provider.If all criteria listed are not true &VA agrees the service(s)are clinicallyindicated,VA will provide a referral  \u003Cbr>for services to be performed in the community.I do hereby attest that upon receipt of order/consult results,I will assume responsibility for reviewing said results,  \u003Cbr>addressing significant findings,&providing continued care.   |  |  |  |  |  |  |  |\n| 19.ORDERING PROVIDER NAME(PRINTED):   |  |  |  |  |  | 20.ORDERING PROVIDER NPI\\#:   |  |\n| 21.ORDERING PROVIDER SIGNATURE(Required):   |  |  |  |  |  | 22.TODAY'S DATE (MM/DD/YYYY):   |  |\n\nFor more information please visit:https://www.va.gov/COMMUNITYCARE/provide","cbCaitWgqcFdJGX4","https://ap.wps.com/l/cbCaitWgqcFdJGX4","pdf",942273,"English","# Request for Service (RES) Submission Requirements\n# Section I: Veteran & Ordering Provider Information\n# Section II: Type of Care Request\n# Attestation and Ordering Provider Signatures","[{\"question\":\"What is VA Form 10-10172 used for?\",\"answer\":\"It is used to request services under the VA Community Care program from community providers.\"},{\"question\":\"What must be submitted with the request?\",\"answer\":\"Complete the RFS form, attach appropriate medical records and a care plan, have the ordering provider sign and date it, and submit via HSRM, fax, or secure email.\"},{\"question\":\"How are requests decided?\",\"answer\":\"Requests are approved or denied at the discretion of the VA facility, and supporting documentation must accompany each request.\"}]","VA Form 10-10172 - Community Care Provider Request for Service | PDF",1789622389]