Fill Out VA Form 10-10172 in 2026

VA Form 10-10172 (Request for Service) is used by a community care provider to ask the Department of Veterans Affairs to approve care beyond a veteran’s current authorization. The request may cover more visits, a longer treatment period, or needed medical equipment. You may also see it called VA RFS Form 10-10172.

A provider should complete VA Form 10-10172 before the active referral expires or reaches its approved limit. The form gives VA the details needed to review the requested care. Sending a request does not mean VA has approved it. The provider must wait for authorization and follow VA instructions before giving added services, unless urgent care rules apply. Proper authorization can help prevent a break in treatment and reduce the risk of denied payment for care outside the referral’s limits.

You may receive VA Form 10-10172 (Request for Service) when a patient needs more visits or time under an active VA referral, including one that will soon expire. Providers also use it to ask VA to authorize new services, added treatment, or continued care within VA or in the community.

The request may cover specialty care, diagnostic tests, geriatrics or extended care, home oxygen, and durable medical equipment or prosthetics. Routine durable medical equipment requests should be sent within 24 hours, or by the next business day, after the service that led to the prescription. The details help VA decide if it will authorize the requested care, service period, or equipment.

The U.S. Department of Veterans Affairs (VA) issues VA Form 10-10172. PDFLeader has a blank VA Form 10-10172 fillable in our browser-based editor, so you do not need to download a template from another source. You can also get the blank form from the VA website.

You can fill out the blank form and download the completed VA Form 10-10172 PDF for future use. PDFLeader does not submit or file the form with the VA.

Send the completed VA Form 10-10172 Request for Service to the veteran’s local VA community care office. There is no single national mailing address. The correct office is part of the VA medical facility that manages the veteran’s community care.

Approved delivery methods include the HealthShare Referral Manager portal, Electronic Fax, Direct Messaging, traditional fax, or mail. Providers may submit online through the portal, Direct Messaging, or secure electronic fax when they have access to those systems. For mail or traditional fax, use the details supplied by the local VA community care office. In-person delivery is not listed as an approved method, so confirm with that office before attempting it.

The ordering or treating clinician at the community care provider completes VA Form 10-10172, not the veteran. The clinician must provide the required clinical details, attach medical records and a care plan, then sign and date the form. By signing, the provider confirms that the information is true, accurate, and complete.

After the provider sends the VA Form 10-10172 Request for Service through HSRM, fax, or secure email, VA community care staff review it. The local VA health care facility uses the form and supporting records to decide if continued community care services should be approved or denied.

The provider requesting care, not the veteran, must sign VA Form 10-10172. The signature may be electronic or handwritten, and no cryptographic digital certificate is required. You can add a simple electronic signature on PDFLeader, complete the blank form in your browser, and download it. PDFLeader does not submit the form, so send it through the required channel after downloading. Check the latest VA updates before you sign.

Before completing VA Form 10-10172, gather the VA Facility Information: facility name, today’s date in mm/dd/yyyy format, and fax number. For Veteran Information, have the last four Social Security number digits, date of birth, and name listed as last name, first name, and middle initial. Then collect the Ordering/Requesting Provider Information and Provider Identifiers & Contact Details, including practice and provider names, 24-hour emergency contact number, NPI, email, daytime phone, specialty type, facility address, and fax number.

For Requested Service, enter only one request per form. For Field 18 – Reason for Request, attach records that support medical necessity, such as office notes, current treatment plans, clinical history, laboratory or radiology results, and medication details. The ordering provider must accept the Attestation Statement, then sign and date the form. Attach the appropriate medical records and care plan before submission.

VA Form 10-10172 has no fixed deadline. Submit it when you need VA authorization for added services or continued care beyond the current authorization.

Send the request 3 to 4 weeks before the current authorization expires. VA review currently takes about 3 to 4 weeks. VA may accept an RFS packet after the authorization expires, so you should still submit it if services are needed. A late request will not receive faster processing.

VA Form 10-10172 is not required when the requested care is already covered by an active referral or authorized Standardized Episode of Care (SEOC). The request must not add visits, a new specialty, or a procedure outside the current authorization.

You also do not need this form for dental services or in vitro fertilization and assisted reproductive technology (IVF/ART) services. For dental care, submit a complete ADA Dental Claim Form instead.