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  • VA Form 10-10172, COMMUNITY CARE PROVIDER - Veterans Affairs
    (1) Complete RFS form 10-10172 (2) Attach appropriate medical records and care plan to support the request (3) Have the ordering provider sign and date the form
  • REQUEST FOR SERVICES (RFS) FORM - relievrx. com
    The Request for Services (RFS) Form 10-10172 must be submitted via an approved method (HSRM, Electronic Fax, Direct Messaging, Traditional Fax, or Mail) to your local VA community care office Completion of this form is REQUIRED and MUST BE SIGNED by the requesting provider for further care to be rendered to a Veteran patient NOTE: 1
  • Community Care Referrals and Authorizations
    The Request for Service (RFS), VA Form 10-10172, is the standard VHA document used by community providers to request authorization from the VA for clinical care on behalf of Veterans
  • Forms - VA Community Care
    The Fraud, Waste and Abuse Reporting Form is utilized to report suspected health care fraud perpetrated by a doctor, hospital or other health care professional To help us address the issue, please supply as much detail of the suspected illegal activity as you can
  • VA Form 10-10172 Request for Services (Rfs) Form - TemplateRoller
    Download Fillable Va Form 10-10172 In Pdf - The Latest Version Applicable For 2025 Fill Out The Request For Services (rfs) Form Online And Print It Out For Free Va Form 10-10172 Is Often Used In Request For Service, U s Department Of Veterans Affairs, United States Federal Legal Forms, Legal And United States Legal Forms
  • COMMUNITY CARE PROVIDER - REQUEST FOR SERVICE - KMC University
    REQUESTED SERVICE - ONE SERVICE PER FORM 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 a required field
  • REQUEST FOR SERVICES (RFS) FORM - ava. avaehr. com
    The Request for Services (RFS) Form 10-10172 must be submitted via an approved method (HSRM, Electronic Fax, Direct Messaging, Traditional Fax, or Mail) to your local VA community care office Completion of this form is REQUIRED and MUST BE SIGNED by the requesting provider for further care to be rendered to a Veteran patient
  • Request and Coordinate Care - Community Care - VA. gov | Veterans Affairs
    The Office of Integrated Veteran Care (IVC) has an updated, streamlined VA Form 10-10172, Community Care Provider-Request for Service (RFS) A blank RFS form will be sent with all referral packets and is also available for download by clicking the link below
  • VA Form 10-10172 - Complete Care
    Upon completion of the requested service(s), VA will provide all resulting medical documentation to the ordering provider If all criteria listed are not true and VA agrees the service(s) are clinically indicated, VA will provide a referral for services to be performed in the community
  • CCN Processes and Procedures - vaccn. triwest. com
    Request additional or extended care by submitting an RFS form directly to VA, preferably though HSRM or via an EDI 278 compliant interface The Veteran contacts his or her local VAMC to confirm CCN eligibility





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