Submission requirements
Both pages start with four steps: complete RFS form 10-10172, attach medical records and care plan, have the ordering provider sign and date it, and submit via HSRM, fax or secure email. Only one request per form.
10-10172
Community Care Provider—Request for Service
- Agency
- VA
- Revision
- March 2025
- Fillable fields
- 56
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-10172: Community Care Provider Request for Service
VA Form 10-10172 is the Department of Veterans Affairs Community Care Provider Request for Service (RFS). The form says to complete the Medical or DME RFS form for services not on the original authorization or to request a new authorization for services. It is completed and signed by the Veteran's ordering provider, not by the Veteran, and the form says requests are approved or denied at the VA facility's discretion.
The PDF has two pages, and each is its own request. Page 1 is the Medical Request for Service, with Veteran and ordering provider details, the type of care requested and the reason for the request. Page 2 is the Durable Medical Equipment/Prosthetics Request for Service, with sections for home oxygen, DME and prosthetics, and therapeutic footwear. Both pages end with an attestation and the ordering provider's signature. The form says a separate form is required for each service requested.
You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-10172
Section I: Veteran and ordering provider
Veteran's legal full name, date of birth, VA facility and address, VA authorization number, ordering provider office name and address, IHS or THP status, phone, fax and secure email.
Page 1, Section II: type of care
Whether care is needed within 48 hours, continuation of care, referral to another specialty, ICD-10 diagnosis codes, requested CPT/HCPCS codes, geriatric and extended care options, and the reason for the request.
Page 2, Sections II and III: oxygen and DME
Home oxygen readings, flow rate, equipment and delivery system, then HCPCS codes, brand and model, measurements, quantity, diagnosis, education, training and fitting, and the delivery preference.
Page 2, Section IV: therapeutic footwear
Left, right or bilateral, prefabricated or custom footwear, a diabetic or amputation risk score of 2 or 3 as the form defines them, foot deformity details and the reason for the request.
Attestation and signature
The ordering provider attests the information is true, accurate and complete, then gives a printed name, NPI number, the required signature and today's date.
How to submit VA Form 10-10172
- 1
Pick the right page
Use page 1 for a medical service or page 2 for durable medical equipment or prosthetics. The form says a separate form is required for each service requested.
- 2
Complete Section I
Enter the Veteran's details, the VA facility and authorization number, and the ordering provider's office and contact details.
- 3
Describe the request
Fill in the request sections for the page used, including the reason for the request in the space provided.
- 4
Attach supporting records
The form asks for medical records and the care plan, and lists examples such as office notes, current treatment plans, clinical history, laboratory and radiology results and medications.
- 5
Sign and date
The ordering provider signs, which the form marks as required, and enters today's date.
- 6
Submit it
The form says to submit the request via HSRM, fax or secure email.
Why fill Form 10-10172 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the VA, not a copy someone retyped
- Works on a phone, tablet or computer
Sending it and urgent requests
How to submit
The form lists HSRM, fax or secure email. The PDF does not print a fax number or email address.
Care needed within 48 hours
Item 10 says: If care is needed within 48 hours, please contact your VA facility directly. For risk of suicide or homicide, it says to call VA directly and submit the RFS form.
Urgent DME
Page 2 points to va.gov/COMMUNITYCARE/providers/DME-Requirements.asp for urgent DME requests.
More information
Page 1 points to the Care Coordination and Care Coordination Facilities pages, and to the Clinical Determinations and Indications at va.gov/COMMUNITYCARE/providers/info-CDI.asp.
Edition
The PDF footer reads VA FORM MAR 2025 10-10172. VA's page lists a form revision date of May 2025.
Related forms
Who uses VA Form 10-10172?
The form describes who completes it and who decides on the request.
Official sources and the blank
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Questions about Form 10-10172
What is VA Form 10-10172 used for?
The form says to complete it for services not on the original authorization or to request a new authorization for services, as a Medical or DME Request for Service.
Who completes and signs it?
The ordering provider. The form asks for the ordering provider's printed name, NPI number and signature, which it marks as required.
Can one form cover several services?
No. The form says a separate form is required for each service requested, and only one request per form.
How is the request submitted?
The form says to submit it via HSRM, fax or secure email, with appropriate medical records and the care plan attached.
What if care is needed within 48 hours?
Item 10 says to contact your VA facility directly if care is needed within 48 hours.
Who decides on the request?
The form says requests are approved or denied at the VA facility's discretion. The attestation also says VA reserves the right to perform the requested services itself if the listed criteria are met.