VA Form 10-10172: Community Care Request for Service (RFS) Explained
If you see a community care provider on VA's dime, you may hear the office say they "sent in a 10-10172" or are "waiting on the RFS." That form is how a community provider asks VA for services that are not on your current authorization. This guide explains what it is, who files it, and what you can do to follow up. We kept to what VA itself has published, and we left out anything we could not verify.
Quick answer: VA Form 10-10172 is the Community Care Provider—Request for Service. Your community provider fills it out, signs it and submits it to VA when you need services not on your original authorization, or a new authorization. You do not file it. If you need more care, you or your provider can request a new referral, so contact your VA health care team.
What is VA Form 10-10172?
VA's forms page lists VA Form 10-10172 as Community Care Provider—Request for Service, and also uses the title "Request For Services (RFS) Form." The PDF header reads "Community Care Provider - Medical Request for Service." It is a Veterans Health Administration (VHA) form. VA's page shows a revision date of May 18, 2025, and the PDF carries a March 2025 revision stamp.
The same PDF has two parts. The first page is the medical Request for Service. The second is a Durable Medical Equipment/Prosthetics Request for Service. Each page says a separate form is required for each service requested.
The form works inside community care, the program that lets eligible veterans get care from non-VA providers paid for by VA. For the program overview, see our guide to VA community care and the MISSION Act and the community care tool.
Who files VA Form 10-10172: you or the provider?
The community provider does. The form's own instructions list who does what: the provider completes the form, attaches supporting records, signs and dates it, and submits it. The fields ask for the "ordering provider's" office, phone, fax, secure email, NPI number and signature. There is no place for a veteran signature.
That means the practical steps for you are about communication. You can ask the office whether it has sent a Request for Service, and you can tell your VA health care team what the provider has recommended. VA's referral page adds that you or your community provider can request a new referral when you need more care, so asking your own VA team is always an option.
When is a Request for Service used?
The form's submission requirements say to use it "for services not on the original authorization or to request a new authorization for services." In plain terms, it is used when your community provider wants to do something VA has not yet approved. Examples the form itself points to include:
- Continuation of care. Field 11 asks "Is this a continuation of care?"
- A referral to another specialty. Field 12 asks whether the provider is referring you to another specialty and which one.
- Geriatric and extended care. Field 17 lists community nursing home, home infusion, hospice/palliative care, skilled home health care, community adult day health care, home homemaker/home health aide and respite.
- Durable medical equipment and prosthetics. The second page covers items such as home oxygen and therapeutic footwear.
The form does not say what happens after you reach a set number of visits, and we are not going to guess. Your authorization letter is where VA states how long you can continue to get care without another referral. See the "keep track" section below.
What information does the form ask for?
Knowing the fields helps you understand why a request can stall when something is missing. According to the form, the provider supplies:
- The veteran's legal name and date of birth, the VA facility, and the VA authorization number (from your authorization letter).
- The ordering provider's name, address, phone, fax, secure email and NPI.
- Whether the provider is an Indian Health Services (IHS) provider or Tribal Health Program (THP).
- Whether care is needed within 48 hours.
- ICD-10 diagnosis codes, a diagnosis description, and the requested CPT/HCPCS procedure codes.
- A "reason for request," with the form advising providers to include office notes, treatment plans, clinical history, lab and radiology results or medications "to support the medical necessity of services requested."
The form includes an attestation that VA may perform the requested service itself if certain criteria are met, such as the service being available at a VA facility by the clinically indicated date and being in your best interest. If those criteria are not all true and VA agrees the service is clinically indicated, VA will provide a referral for services in the community.
Tip: Keep your authorization number handy. It is one of the fields on the form, and it appears on the authorization letter VA sends after you schedule an appointment.
How is the form submitted?
The form says to submit the request "via HSRM, Fax, or Secure E-mail," with medical records and a care plan attached. A note on the form says "Requests are approved/denied at the VA facility's discretion and supporting documentation must accompany each request." Providers can find more information on VA's care coordination page for community providers.
The form also tells providers to call the VA facility directly if care is needed within 48 hours, and to call VA directly in cases of risk of suicide or homicide, in addition to submitting the form.
How can I follow up if my provider needs more visits or services?
Here is a practical order of steps, based on VA's published process:
- Read your authorization letter. VA says it lists your authorization number, your approved provider, a description of the care you can get, and how long you can continue to get care without another referral.
- Count your visits. VA tells veterans to keep track of how many appointments they have attended and how long they are approved. Services not included in the letter will not be covered.
- Ask your provider's office whether they need more services than the authorization covers, and whether they have submitted a Request for Service. Ask which VA facility they sent it to.
- Contact your VA health care team. Tell them what your provider recommends. VA says "you or your community provider can request a new referral."
- Call VA for the visit count. VA's referral page says to call if you have questions about how many appointments you have left. It lists hours of Monday through Friday, 8:00 a.m. to 9:00 p.m. ET. Use the number on the VA referral page.
- Document your contacts. Write down the date, who you spoke with and what they said. This is a good habit, not a VA requirement.
If you need urgent care, do not wait on paperwork. See our emergency resources page. If you are in crisis, use the Veterans Crisis Line link at the top of VA.gov.
What timelines has VA published?
We found no official processing time for a Request for Service, so we do not give one. These are the VA-stated timeframes that apply nearby:
| Step | What VA says |
|---|---|
| Preparing a new community care referral | "This part of the process can take up to 14 days." |
| If you schedule the appointment yourself | Tell your VA health care team within 14 days. |
| Requests for services on the RFS form | Approved or denied at the VA facility's discretion; no time limit stated on the form. |
| Care needed within 48 hours | Provider should contact the VA facility directly. |
The 14-day figure on VA's referral page describes the referral process for new community care. It is not a published deadline for an RFS decision, so do not read it as one. For wait-time standards that affect eligibility, see the next section.
How do I keep track of my authorization?
Treat your authorization letter as the controlling document. VA's referral page says "We won't cover services that your authorization letter doesn't include." A few habits help:
- Save every authorization letter and note the authorization number.
- Note the end date and the number of approved visits or services.
- Start the conversation about more care before the last approved visit, not after.
- Ask the provider's billing office whether upcoming visits fall under the current authorization.
Travel to appointments may also be a concern. See our guide to VA travel pay through BTSSS.
Does a Request for Service change whether I qualify for community care?
No. The RFS is a request for specific services under an existing or new authorization. Eligibility is decided under VA's community care rules. VA's community care eligibility page says you must be enrolled in or eligible for VA health care and have approval from your VA health care team before getting care from a community provider, except for certain cases like urgent or emergency care. At least one other condition must also be true. VA lists these conditions, including that VA cannot provide the care within its designated access standards:
- Primary care, mental health and extended outpatient care: 30-minute average drive time or 20-day wait time.
- Specialty care: 60-minute average drive time or 28-day wait time.
For more, see our guides on VA health care eligibility and priority groups, mental health wait times and community care and VA telehealth eligibility. You can also use our VA wait times tool, VA facilities finder and benefits finder.
For related coverage options, see CHAMPVA vs. TRICARE and Medicare for veterans.
Questions about VA benefits?
For help with health care appeals or disability claims, consider a VA-accredited attorney, claims agent or VSO. You can search VA's accreditation list at the link below.
Search VA accreditation →Frequently asked questions
No. The form is titled Community Care Provider—Request for Service, and the ordering provider has to sign and date it. The form lists the provider's office, NPI and signature. You do not file it, but you can ask your community provider's office whether they have sent one.
VA's forms page lists it as Community Care Provider—Request for Service. The PDF header reads Community Care Provider - Medical Request for Service, and the same PDF also includes a Durable Medical Equipment/Prosthetics Request for Service. VA also calls it the Request for Services (RFS) form.
The form's instructions say to complete it, attach medical records and a care plan, have the ordering provider sign and date it, and submit it through HSRM, fax or secure email. Only one request is allowed per form.
We could not find an official processing time for this form, so we do not state one. The form says requests are approved or denied at the VA facility's discretion. Call your VA health care team for the status of a specific request.
Your authorization letter says how long you can keep getting care without another referral. VA says that if you need more care, you or your community provider can request a new referral. Contact your VA health care team, and ask your provider's office whether it has sent a Request for Service.
VA says it will not cover services that your authorization letter does not include. Ask your VA health care team and your provider's billing office before you book visits that fall outside the current authorization.
The form asks the provider whether care is needed within 48 hours. Its note says that if so, the provider should contact the VA facility directly. If you are in crisis, use the Veterans Crisis Line link on VA.gov.
The VA community care eligibility page has a section on how to appeal if VA denied a request for community care. Start there, and ask your VA health care team to explain the reason for the decision.
Sources
- VA Form 10-10172 (VA.gov forms page)
- VA Form 10-10172 PDF (revised March 2025)
- How to get community care referrals and schedule appointments (VA.gov, last updated September 11, 2025)
- Eligibility for community care outside VA (VA.gov)
- Care coordination for community providers (VA.gov)
Form revision dates and VA processes can change. Check the VA pages above for the current version.