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  • Va Form 10-10172 2021

Get Va Form 10-10172 2021-2025

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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Rfs 10 10172 Related content

Download VA Form 10-10172 (PDF)
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Rfs va form Questions & Answers

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Use VA Form 20-0995 if you disagree with a VA decision and want to provide new evidence to support your claim.

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.

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.

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.

Resources and support. Call us. 800-698-2411. Visit a medical center or regional office. Find a VA location.

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.

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.

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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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232