Overview

When a Veteran needs care beyond what is already authorized in an active referral, the community provider must submit a Request for Service (RFS) to the local VA community care office. 

VA Form 10-10172, Community Care Provider–Request for Service (RFS), is included with all referral packets and is also available for download below.

When an RFS is needed

You need to complete and submit an RFS when requesting:

• Additional visits or time beyond what is authorized in an active referral (for example, when an authorization is expiring)
• A new specialty service referral
• An additional procedure or service not included in the original Standardized Episode of Care (SEOC)

RFS exceptions

Dental services and In vitro fertilization treatment/assisted reproductive technology (IVF/ART) services do not require VA Form 10-10172.

• For dental care, submit a complete ADA Dental Claim form.  Providers may also submit VA Form 10-10172 in addition to the ADA form if preferred.
• For In Vitro Fertilization (IVF) or Assisted Reproductive Technology (ART), contact the local VA community care office directly for coordination of care.

Durable Medical Equipment (DME), prosthetics, and orthotics guidance

• Routine DME: Submit an RFS within 24 hours or by the next business day after completion of the healthcare service that generated the prescription.
• Urgent/emergent DME: If needed immediately to stabilize the Veteran or prevent further injury, DME is covered under the existing authorization and may be provided without a separate RFS.
  • Implantable devices are also covered under authorization for the primary condition.
• DME rentals: DME rentals are only covered for the first 30 days. Rentals beyond the initial 30 days require an RFS submitted in advance to avoid disruption in service.  

Submission requirements

• Use a separate form for each service request.
• Supporting medical records, such as provider notes, care plans, lab results and/or radiology reports, must accompany the signed and dated VA Form 10-10172. The form must be signed (electronic signature or wet signature) by the provider requesting care.
• Use the Medical RFS page for medical services, or the DME/Prosthetics RFS page for those services.
• Requests that are missing supporting documentation or provider signature will be denied.

Where to send an RFS

Submit the completed form, with documentation, to your local VA community care office using one of the approved methods:

• HealthShare Referral Manager (HSRM)
• Secure email
• Direct messaging
• Fax (electronic or traditional)
• Mail (if permitted by your VA facility)

VA processes requests within 3 business days and notifies the provider using their preferred communication method.