Get Va Form 10-10172 2021-2025

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.

1. Click ‘Get Form’ button to access the form and open it in your selected editing tool.
2. Fill in the VA facility name and location, including your VA authorization/referral number and today’s date in MM/DD/YYYY format.
3. In the veteran information section, provide the veteran's full name and date of birth in the specified format.
4. 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.
5. 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.
6. If applicable, fill out additional requests with the current provider, specifying additional time or visits needed.
7. Choose the service type from available options such as diagnostic tests or durable medical equipment, and include any relevant additional information.
8. Indicate the veteran's preferred location for the service, selecting from the given options.
9. Complete the attestation section, ensuring that the statement is signed and dated by the provider.
10. For durable medical equipment requests, provide all requested information regarding the item being prescribed, including HCPCS codes, brand, model, quantity, and delivery options.
11. 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.