Official VA Form

VA Form 10-10172

Community Care Provider—Request for Service

VA Form 10-10172 — Community Care Provider—Request for Service is an official U.S. Department of Veterans Affairs form. The current version was last revised 2021-05-18. It is 3 pages long. Download the up-to-date PDF below — BaseNeed syncs form data directly from VA.gov so you always get the current edition.

Download the official PDF (VA.gov) →

Last revised: 2021-05-18
First issued: 2024-06-17
Pages: 3
Administered by: VHA

Frequently asked questions

What is VA Form 10-10172 used for?

Community Care Provider—Request for Service. It is an official VA form, administered by VHA.

Where can I download the current VA Form 10-10172?

Download the official PDF from VA.gov here: https://www.va.gov/vaforms/medical/pdf/VA%20Form%2010-10172.pdf (last revised 2021-05-18).

How long is VA Form 10-10172?

VA Form 10-10172 is 3 pages long, last revised 2021-05-18.

Always the current version — synced from VA.gov. BaseNeed is not affiliated with the U.S. Department of Veterans Affairs.

You are not the first person to deal with this

BaseNeed is a members-only community for service members, veterans, spouses and their families. Nothing posted inside is public — not on Google, not on Facebook. That is the point: people talk about moves, money and paperwork there, and that only works behind a door.

Nearby form numbers

VA Form 10-10164 — Opt-Out of Sharing Protected Health Information Through Health Information Exchanges

VA Form 10-10169 — Volunteer Consent Form

VA Form 10-10171 — Veterans Health Administration (VHA) Veterans Care Agreement

VA Form 10-10173 — Veterans Grant Program Grant Agreement

VA Form 10-10176 — Environmental Hazard Registry (EHR) Worksheet

VA Form 10-1023 — Information Regarding Possible Claim Against Third Party