Items 1 to 3: submitter
Submitter name, submitter phone number and submitter email.
10-322
Clinical Determinations and Indications Question Submission Form (VA Form 10-322)
- Agency
- VA
- Revision
- February 2024
- Fillable fields
- 10
- Pages
- 1
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-322: Clinical Determinations and Indications Question Submission Form
VA Form 10-322 is the U.S. Department of Veterans Affairs Clinical Determinations and Indications Question Submission Form. VA's form page says to use it if you're a VA health care or community provider and you want to submit a question about VA Community Care Clinical Determinations and Indications (CDIs). This includes questions about whether a specific service or treatment meets clinical criteria.
The form is one page with ten numbered items: the submitter's contact details, the ordering provider's contact details and medical specialty, the CDI number, the subject and the question itself. It says at the top and bottom not to include PHI/PII information. It is a form for providers, not an application Veterans file. 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 10-322
Items 4 to 7: ordering provider
Ordering provider name, phone number, email and medical specialty.
Item 8: CDI number
The form says it is for published Clinical Determinations and Indications and asks for the CDI number relevant to the question.
Item 9: subject of question
The subject, with the form's examples of device, medical specialty or coverage.
Item 10: question with description
Open space for the question and its description.
PHI/PII notice
Printed at the top and bottom of the page: Please DO NOT include PHI/PII information on this form.
How to complete VA Form 10-322
- 1
Find the published CDI
Item 8 asks for the number of the published CDI that the question relates to.
- 2
Enter both sets of contact details
Fill in the submitter in Items 1 to 3 and the ordering provider in Items 4 to 7.
- 3
Write the subject and question
Name the subject in Item 9 and describe the question in Item 10.
- 4
Leave out patient details
The form says not to include PHI/PII information anywhere on it.
Why fill Form 10-322 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 the edition
Where to send it
Neither the PDF nor VA's form page prints a mailing address, email address, fax number or online submission option for this form.
Community care information
VA's form page links to information about the VA community care network, its covered services and answers to common questions about community care.
Edition
The footer reads VA FORM FEB 2024 10-322, matching the February 2024 revision date on VA's form page. The form is one page.
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Who uses VA Form 10-322?
VA's form page names providers as the people who use it.
Official sources and the blank
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Questions about Form 10-322
Who uses VA Form 10-322?
VA's form page says to use it if you're a VA health care or community provider and you want to submit a question about VA Community Care Clinical Determinations and Indications (CDIs).
What kinds of questions does it cover?
VA's page says this includes questions about whether a specific service or treatment meets clinical criteria. Item 9 gives device, medical specialty and coverage as examples of a subject.
Can patient information go on the form?
No. The form says Please DO NOT include PHI/PII information on this form, at both the top and the bottom of the page.
What does Item 8 ask for?
The form says it is for published CDIs and asks for the CDI number relevant to the question.
Where is VA Form 10-322 sent?
The PDF and VA's form page do not print an address, email, fax number or online option for sending it.