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The Request for Services (RFS) Form, VA Form 10-10172, is the standard Veterans Health Administration (VHA) document used by community providers to request authorization from the Department of Veterans Affairs (VA) for clinical care on behalf of Veterans. Community providers are required to submit an RFS to the local VA when a clinical evaluation has determined the need for:

• Continuation of care (i.e., current authorization is expiring and/or the maximum number of visits authorized has been reached)
• A new specialty service referral
• A procedure or service that is not included in the original Standardized Episode of Care (SEOC).

Online RFS Form

• Community providers are now able to submit online RFS forms through HealthShare Referral Manager (HSRM). This form will allow electronic signature of the RFS and can be accessed by two security groups:
  • Community Staff, which allows provider staff to access and create an RFS
  • Community Care Provider, which allows credentialed providers to access, create, and also sign an RFS
• To submit an online RFS, the provider facility must have at least one user with Community Care Provider security group access to electronically sign the form.
• To obtain access to the Community Care Provider security group, please ask the CCRA HSRM Administrator for your facility to submit an updated End User Tracker (EUT) to HSRMSupport@va.gov
• To receive this security role, you must be an MD, DO, NP, PA, DPT, DC, Acupuncturist, Massage Therapist, or Respiratory Therapist.

For additional information on how to submit an online RFS in HSRM, please review the HSRM Community Provider User Guide or the HSRM Community Provider Quick Reference Guide.