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. Community Providers are required to submit an RFS request to the local VA when a clinical evaluation has determined the need for 1) continuation of care (current authorization is expiring and/or the maximum number of visits authorized has been reached); 2) a new specialty service referral; and/or 3) when a procedure or service, not included in the original Standardized Episode of Care (SEOC), is needed. All RFS submissions must be signed by the Requesting Provider and include medical documentation supporting the request. Only one request per RFS form is permitted to allow for efficient tracking and processing of each request.
To submit the electronic Request for Services (RFS) 10-10172 form, begin by accessing it through the HealthShare Referral Manager (HSRM) portal. Complete all required fields with accurate information and attach any necessary supporting documents (required). An electronic signature is also required for submission; a wet signature is not needed. This electronic signature will verify authorization of the request and will display the name of the person who requested the RFS. After filling out the electronic RFS form, confirm the supporting documents are attached. Then click the Update button to submit the completed form via the HSRM system. For any issues or questions, please contact your support team for assistance. Thank you for your cooperation and dedication to serving our veterans.