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VA Form 10-10172. Community Care Provider - Request for Service 2025

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The document is a request form for community care services for veterans, detailing the necessary information required for service authorization. It includes sections for veteran and provider information, requested services, and medical justification. The form emphasizes that requests are subject to approval by the VA Medical Center and outlines the process for urgent care needs.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the VA Facility Information, including the facility name, today's date, and contact numbers. Ensure all required fields marked with an asterisk are filled out.
Fill in the Veteran Information section with the last four digits of the SSN, date of birth, and full name of the veteran.
In the Requesting Provider Information section, provide details such as practice name, provider's name, emergency contact number, NPI number, email address, and specialty type.
Specify the Requested Service by selecting one service per form from options like Acute Rehab or Surgical Procedure. Remember to attach any supporting documentation.
Complete the Medical Justification section by detailing reasons for service requests and anticipated care dates. Ensure you sign and date at the end to attest to the accuracy of your information.

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See more VA Form 10-10172. Community Care Provider - Request for Service versions

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (46 Votes)
2019	4.3 Satisfied (261 Votes)

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What qualifies for VA community care?

You must meet both of these basic requirements: Youre enrolled in or eligible for VA health care, and. You have approval from your VA health care team before you get care from a community provider (except for certain cases like urgent or emergency care)

What is community-based care in VA?

Community Care Overview VA provides care to Veterans through community providers when VA cannot provide the care needed. Community care is based on specific eligibility requirements, availability of VA care, and the needs and circumstances of individual Veterans.

What is a standard episode of care VA?

In contrast, a Standardized Episode of Care (SEOC) allows VA to clearly request and deliver bundled health care services as part of a treatment plan within a specific period of time. VA issues SEOCs to community providers to clarify allowable services and procedures within a particular referral.

Who pays for VA community care?

This care is provided and paid for by VA. Community care must be first authorized by VA before a Veteran can receive care from a community provider.

Where do I send my VA claim form?

Department of Veterans Affairs. Evidence Intake Center. PO Box 4444. Janesville, WI 53547-4444.

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What is community-based care in Virginia?

Community-based continuing care or CBCC means a program providing or committing to provide a range of services, including long-term care services, to an individual, other than an individual related by blood or marriage, (i) pursuant to an agreement, including mutually terminable contracts, effective for the life of

Does the VA have a provider portal?

If you filed a claim with VA directly for Veteran care, you can check the status of your VA claim through the eCAMS Provider Portal (ePP). ePP is a reporting tool that allows registered users on demand access to claim status and line level adjudication information.

Who is eligible for CLC VA?

You must first be enrolled in the VA health system and be medically and psychiatrically stable. A copay may be charged for CLC care based on your VA service- connected disability status and financial information.