VA Form 10-10172. Community Care Provider - Request for Service 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Fill in the Veteran Information section with the last four digits of the SSN, date of birth, and full name of the veteran.
4. 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.
5. Specify the Requested Service by selecting one service per form from options like Acute Rehab or Surgical Procedure. Remember to attach any supporting documentation.
6. 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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