Follow the steps to successfully complete the VA Form 10-10172.

1. Press the ‘Get Form’ button to access the VA Form 10-10172 and open it in your preferred editor.
2. Begin by filling out the VA facility information. This includes the facility name, the today's date in mm/dd/yyyy format, and the fax number.
3. Next, in the veteran information section, enter the last four digits of the Social Security Number, date of birth in mm/dd/yyyy format, and the veteran's name in the order of last name, first name, and middle initial.
4. In the requesting provider information section, input the name of the individual or group practice, the requesting provider's name, and their 24-hour emergency contact number for critical findings. Also, provide the provider’s National Provider Identifier (NPI), email address, daytime contact number, specialty type, facility address, and fax number.
5. Specify the requested service in the designated section. Keep in mind that only one service per form is permitted. Options include acute rehab, surgical procedure, and others as listed.
6. Indicate the type of request, whether it is for additional time, visits, or another type. If the service needed is not listed, reach out to the local VA Medical Center directly.
7. Select the appropriate specialty for the requested service from the options provided, such as medical, surgical, mental health, etc.
8. Complete the service type section, and indicate preference for the location of service by choosing between VA facility/provider, community facility/provider, or no preference.
9. If the request is for Durable Medical Equipment (DME) or prosthetics, include required details like HCPC codes, ICD-10 codes, descriptions, and the quantity needed.
10. Fill in the medical justification for the DME, reason for requested service, provisional diagnosis, anticipated dates for care, and number of visits needed.
11. Lastly, attesting to the accuracy of the information provided is essential. Fill in your signature and the date in mm/dd/yyyy format to finalize the submission.
12. After reviewing your entries, you can save any changes made, download the completed form, print it, or share it as necessary.

Complete your VA Form 10-10172 online to ensure a timely and efficient processing of your service request.