Fill Out VA Form 10-10172 in 2026
Ask for added visits, extended treatment, or durable medical equipment beyond what your current referral covers, then sign where allowed and download your copy.
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How to fill out a VA Form 10-10172
Follow the steps below and finish without guesswork.
Open the blank form
Access the pre-loaded form in our editor, already set up so no upload is needed.
Fill in the required fields
Complete every required field, including the Veteran's name, DOB, and diagnosis codes.
Download as PDF
Save your completed form as a PDF, ready to print, sign, or send to the VA facility.
What is a VA Form 10-10172?
VA Form 10-10172, Community Care Provider–Request for Service (RFS), is the standard document community providers use to ask VA for authorization to give a Veteran clinical care. Providers submit it when a patient needs more visits or time than the current referral allows. Since the VA facility reviews each request along with supporting medical records, complete and accurate details help avoid delays or denial of needed care.
Key Takeaways
- VA Form 10-10172 requests extra care visits
- Community providers file it for VA authorization
- Requires supporting medical records for approval
What is a VA Form 10-10172 used for?
Community providers use this form to ask VA for approval before giving care that goes beyond what's already authorized. Common uses include:
- Requesting more visits or services once an active referral's authorized care runs out or expires
- Requesting extended or continued treatment that needs new VA authorization
- Requesting durable medical equipment (DME), including rentals lasting beyond 30 days
It does not cover dental or IVF/ART services, which use their own forms.
What information does VA Form 10-10172 need?
Veteran's Legal Full Name (First, MI, Last)
Enter the veteran's full legal name exactly as it appears on official records.
DOB (MM/DD/YYYY)
Enter the veteran's date of birth in month, day, year format.
VA Facility / VA Location
Name the VA facility and location responsible for coordinating the referral.
NPI # / Requesting Provider's Name
Provide the requesting provider's National Provider Identifier and full name.
Specialty / Office Name & Address / Secure Email / Fax Number / Phone Number
List the provider's specialty along with complete office contact and address details.
Indian Health Services (IHS) Provider?
Indicate whether the requesting provider is affiliated with an Indian Health Services or Tribal Health Program.
Diagnosis (ICD-10 Code/Description)
Enter the ICD-10 code and description for the diagnosis supporting the request.
Clinical Urgency Indication / CPT-HCPCS Code & Description of Requested Services
Mark the urgency level and list the CPT-HCPCS code and description of services requested.
When is a VA Form 10-10172 due?
VA Form 10-10172 has no fixed due date. Submit it whenever a community provider needs authorization for a new service or continued care. Since VA review typically takes 3–4 weeks, send the VA Form 10-10172 (RFS) that far ahead of the current authorization's expiration. For urgent cases, call the VA directly the same day instead of waiting on paperwork.
Get VA Form 10-10172 ready
Open VA Form 10-10172 here, fill in each field, and download your completed Request for Service form.
When is a VA Form 10-10172 not required?
You skip VA Form 10-10172 request for services when a patient needs dental care or IVF/ART treatment, since these services fall outside its scope. For dental visits, submit a complete ADA Dental Claim form instead. Providers may still attach the RFS alongside the ADA form if they prefer extra documentation.
What does a VA Form 10-10172 form look like
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