VA Form 10-10172. Community Care Provider—Request for Service
The VA Form 10-10172 is a document used to request community care services from a healthcare provider outside of the Department of Veterans Affairs (VA) network. The form aims to ensure that veterans receive timely and appropriate medical care when they cannot obtain it from a VA facility.
The form consists of several sections, including patient information, provider information, service requested, and service authorization. It also includes fields for specific details such as the reason for the request, the type of service needed, and the estimated cost of the service.
The parties involved in the form are the veteran requesting care and the healthcare provider who will be providing the service. It is essential to ensure that all information provided on the form is accurate and complete to avoid delays or denials of service.
When filling out the form, veterans must provide their personal information, including name, address, phone number, and social security number. They must also include detailed information about the healthcare provider and the service needed, including the provider's name, address, phone number, and specialty.
Additionally, veterans must attach any relevant documentation, such as medical records or referral forms, to support their request for community care services. Examples of situations where this form may be required include appointments that are not available within a reasonable timeframe or distances that exceed the VA's geographic access standards.
Strengths of the VA Form 10-10172 include its ability to streamline the process of obtaining community care services and ensuring that veterans receive the care they need. However, weaknesses may include potential delays or denials due to incomplete or inaccurate information.
Alternative forms include VA Form 10-10EZ, which is used to apply for VA health benefits, and VA Form 10-7959c, which is used to request veteran community care services for caregivers.
Once submitted, the form is stored electronically in the VA system, and veterans can track the status of their request through the VA's electronic health record system. The form can be submitted online or in-person at a VA facility.
In conclusion, the VA Form 10-10172 is an essential document for veterans seeking community care services outside of the VA network. It facilitates the timely and appropriate delivery of medical care to veterans, but it is crucial to ensure that all information provided is accurate and complete to avoid any delays or denials of service.