Sections A to C: scope and authorization
The parties, the Covered Services, the VA National Formulary for prescriptions, and the rule that all Covered Services are authorized in advance by VA through a written or electronic authorization.
10-10171
Veterans Health Administration (VHA) Veterans Care Agreement
- Agency
- VA
- Revision
- May 2019
- Fillable fields
- 13
- Pages
- 16
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10171: Veterans Health Administration (VHA) Veterans Care Agreement
VA Form 10-10171 is the Veterans Health Administration (VHA) Veterans Care Agreement. Section A says it is entered into by and between the undersigned entity or provider (Provider) and the U.S. Department of Veterans Affairs, in accordance with section 1703A of title 38, United States Code, and 38 CFR 17.4100-4135. Under it, the Provider furnishes medically necessary hospital care, medical services and extended care services that VA authorizes, which the agreement calls Covered Services. It is an agreement between VA and a health care provider, not a form Veterans file.
The agreement is 16 pages of terms in Sections A to Z and AA: authorization of care, provider qualifications and credentialing, quality and inspection, medical records, prices and rates, claims, payment, discontinuation, disputes, notice, term and general provisions. It ends with signature blocks for the Provider's authorized representative and the VA Medical Facility Director or Designee. Section P sets a term of three (3) years, beginning on the Effective Date.
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What's in VA Form 10-10171
Sections D to G: qualifications and quality
Certification, NPI and licenses, malpractice insurance, exclusion lists, opioid safety and competency training, VA credentialing, quality standards and VA inspection of services.
Section H: medical records
Time frames for returning medical documentation, the data elements it includes, and secure electronic submission to the authorizing VA facility through HIE, HealthShare Referral Manager (HSRM), encrypted email or community viewer.
Sections I to L: rates, claims and payment
The payment methodology, clean claim requirements, the EDI payer IDs, payment by electronic funds transfer, prompt payment, overpayments and the rule that VA payment is payment in full.
Sections M to O: discontinuation, disputes and notice
How either party may discontinue the agreement, how disputes are raised under 38 CFR 17.4135, and blanks for the VA and Provider points of contact, mailing addresses and emails.
Sections P to AA: term and signatures
The three-year term, applicable federal law, the Privacy Act statement, assignment, force majeure, waiver, amendment, severability, the entire agreement and the signature blocks.
How VA Form 10-10171 is completed
- 1
Read all 16 pages
Section AA says the parties acknowledge that they have read and understand the agreement in its entirety.
- 2
Fill in the notice contacts
Section O has VA's Office of Community Care add the VA points of contact and the parties fill in all applicable Provider points of contact, mailing addresses and emails.
- 3
Provider signs
Enter the name of Provider, the title and printed name of its authorized representative, then the signature and date signed.
- 4
VA signs
The VA Medical Facility Director or Designee enters a title and printed name, signs and dates it. The agreement is effective upon the date of last signature.
- 5
Set up payment before the first claim
Section K asks for EFT information to the Designated Office no later than 10 business days before the first claim, and a completed FMS Vendor File Request form (VA Form 10091) and W-9 at the authorizing VA facility.
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Notices, claims and edition
Notices
Section O says notices are in writing and sent by mail or email to the individuals designated at the addresses listed in that section.
Claims
Section J says claims go to the VA facility that issued the authorization within 180 days of the date of service. Electronic claims use payer IDs 12115 for medical claims and 12116 for dental claims.
Medical documentation
Section H says documentation goes directly to the VA facility that issued the authorization, by secure electronic submission where available, otherwise to the mailing address or fax number on the authorization.
Term
Section P says the term of the agreement is three (3) years, beginning on the Effective Date.
Edition
The PDF footer reads VA FORM 10-10171, MAY 2019, matching the May 2019 revision date on VA's page.
Related forms
Who signs VA Form 10-10171?
The agreement names its parties and the others it covers.
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Questions about Form 10-10171
What is VA Form 10-10171?
It is the Veterans Care Agreement between VA and a community entity or provider under section 1703A of title 38, United States Code, and 38 CFR 17.4100-4135, for hospital care, medical services and extended care services VA authorizes.
Who signs the Veterans Care Agreement?
An authorized representative of the Provider and the VA Medical Facility Director or Designee. The agreement is effective upon the date of last signature.
Does the agreement authorize care by itself?
No. Section C says all Covered Services are authorized in advance by VA through a written or electronic authorization, and authorizations are only valid for the specific services and dates they identify.
How long does the agreement last?
Section P says the term is three (3) years, beginning on the Effective Date.
When does VA pay a claim?
Section K says payment will be made within 30 calendar days of receipt of a clean electronic claim and within 45 calendar days of receipt of a clean paper claim, by electronic funds transfer.
Can the provider bill the Veteran?
Section L says Provider shall not collect any cost share or copayment from any VA beneficiary for Covered Services, or seek payment from any party other than VA, including missed appointment fees or charges.
How can the agreement be discontinued?
Section M says Provider gives written notice that VA receives at least 45 calendar days before the discontinuation date, and lists the reasons for which VA may discontinue it.