COMMUNITY CARE PROVIDER REQUEST FOR SERVICE (Separate Form Required for Each Service Requested)If care is needed within 48 hours or if Veteran is at risk for Suicide/Homicide, please call the VA directly.*Indicates.
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How to fill out the VA Form 10-10172 online
This guide provides a step-by-step approach to completing the VA Form 10-10172 online. Whether you are a veteran or a healthcare provider, understanding how to properly fill out this form will facilitate the request for community care services.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to access the form and open it in your selected editing tool.
- Fill in the VA facility name and location, including your VA authorization/referral number and today’s date in MM/DD/YYYY format.
- In the veteran information section, provide the veteran's full name and date of birth in the specified format.
- Complete the ordering provider information by entering the provider's name, NPI, 24-hour emergency contact number, office phone, fax number, and secure email address.
- Select the requested service, ensuring each service request is made on a separate form. Indicate whether it is a primary care request or a specialty care procedure, and provide the ICD-10 code.
- If applicable, fill out additional requests with the current provider, specifying additional time or visits needed.
- Choose the service type from available options such as diagnostic tests or durable medical equipment, and include any relevant additional information.
- Indicate the veteran's preferred location for the service, selecting from the given options.
- Complete the attestation section, ensuring that the statement is signed and dated by the provider.
- For durable medical equipment requests, provide all requested information regarding the item being prescribed, including HCPCS codes, brand, model, quantity, and delivery options.
- Review all entered information for accuracy before finalizing. Once completed, you can save your changes, download, print, or share the form as needed.
Complete your VA Form 10-10172 online to ensure timely processing of your community care requests.
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Get answers to your most pressing questions about US Legal Forms API.
What form do I use for Veteran affairs provider appeal?
Use VA Form 20-0995 if you disagree with a VA decision and want to provide new evidence to support your claim.
What is the VA form for medical reimbursement?
Medical Care Reimbursement Request A signed written request for reimbursement and receipt of payment, must be submitted to your local VA medical facility Community Care office in a timely manner. You may use VA Form 10-583, Claim for Payment of Cost of Unauthorized Medical Services to fulfill this requirement.
What is VA Form 10 10172 used for?
Community Care Provider-Request for Service (RFS), VA Form 10-10172, is used to request additional services or continued care from VA. The requested care may be performed within VA or in the community based on a Veterans eligibility.
How much does the VA pay for travel expenses?
The VA requires a small deductible before reimbursing you for travel-related expenses. The current (2022) deductible is $3 one-way or $6 round-trip, up to $18 per month. If you surpass the $18 deductible, the VA will pay the full cost of your travel for the remainder of the month.
How do I submit a prior authorization to the VA?
Resources and support. Call us. 800-698-2411. Visit a medical center or regional office. Find a VA location.
What is the VA Form 10 10HS used for?
Fill out a Request for Hardship Determination (VA Form 10-10HS). Write a letter explaining why you're requesting a hardship determination. The letter should describe the financial issues that make it hard for you to pay your copays.
Does VA insurance require prior authorization?
All non-urgent and non-emergent care requires authorization from VA in advance. Eligibility and claims submission information for emergent care will be provided after notification is made to the VA.
Who qualifies for VA mileage reimbursement?
You have a VA disability rating of 30% or higher, or. You're traveling for treatment of a service-connected condition, even if your VA disability rating is less than 30%, or. You receive a VA pension, or. You have an income that's below the maximum annual VA pension rate, or.
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