Get Va Request For Additional Services Form

Filling out the VA Request for Additional Services Form online can be straightforward with the right guidance. This guide will provide you with step-by-step instructions to ensure all required information is accurately submitted.

Follow the steps to complete the VA Request for Additional Services Form.

1. Click ‘Get Form’ button to access the form and open it for completion.
2. Enter the requesting provider name in the designated field.
3. Fill in the NPI (National Provider Identifier) number associated with the requesting provider.
4. Input the requesting contact name for communication regarding the request.
5. Provide the requesting phone number where you can be reached.
6. Enter the veteran's name as it appears on official documents.
7. Input the last four digits of the veteran's Social Security Number.
8. Fill in the veteran's date of birth.
9. Enter the current authorization number associated with the veteran's services.
10. Specify the diagnosis for which additional services or visits are being requested.
11. Indicate whether you are requesting additional visits or new services by checking the appropriate box.
12. If requesting additional visits, specify the number of visits needed and the extension of service dates in the provided fields.
13. If requesting new services, provide the name, specialty, address, and phone number of the different provider if known.
14. Describe in detail the new services requested, including service type and any relevant medical necessity information.
15. If the request is surgical, identify the facility and NPI, and answer questions regarding the inpatient status, expected length of stay, and anesthesia details.
16. Enter the procedure codes and dates of service, along with the number of visits or days required.
17. Clearly explain the reason for the request, attaching additional pages or documents as necessary.
18. Review all entered information for accuracy before saving your changes, downloading, printing, or sharing the completed form.

Begin completing your VA Request for Additional Services Form online today!