VA Clinical Determinations and Indications (medical policies) describe standard VA health care benefits for services and procedures that community providers may recommend as necessary …

PREVIOUS AUTHORIZATION NUMBER: NOTE: The Request for Services (RFS) Form 10-10172 must be submitted via an approved method (HSRM, Electronic Fax, Direct Messaging, …

Prescription for prefabricated therapeutic footwear due to disease pathology resulting in neuropathy or peripheral artery disease. NOTE: Only patients who are experiencing medical …

Learn how to accurately fill VA Form 10-10172 with PDF Guru. Simplify the process and download your completed form today!

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. NOTE: Requests are approved/denied at VA Medical …

BRAND, MAKE, MODEL OR PRODUCT, PART NUMBERS, ETC. *Education, training, and/or fitting of DME must be completed before DME is issued or mailed to Veteran. If not completed, …

Jul 1, 2025 · The VA has released a new 1-page RFS form, which must be faxed to the veteran's assigned VA along with a treatment plan and the last two progress notes as supporting …

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 …