VA Community Care Provider Request for Service Form

Submit the completed VA Community Care Provider Request for Service Form along with supporting documentation via fax to the specified number or send it by mail to the VA facility address provided in the form. Ensure all required fields are accurately filled out and that the form is signed and dated. For urgent requests, contact your VAMC directly using the contact number provided. Advice: Double-check all entered information and supporting documentation before submission to avoid processing delays.

Important submission dates for this form in 2024 and 2025 vary by specific needs and urgency. Ensure you check the VA’s guidelines for the latest deadlines and timelines for submission.

The VA Community Care Provider Request for Service Form facilitates the process of requesting medical services through authorized community care providers. It ensures that veterans receive the necessary medical attention from external providers when services are not readily available through VA facilities. This form helps streamline communication between veterans, healthcare providers, and the VA Medical Center, ensuring that all necessary information is included and that services are provided in a timely manner. By filling out this form, healthcare providers can request various medical services, including specialty care, diagnostics, and support services for veterans. The comprehensive nature of the form ensures that all relevant details are captured, which helps the VA Medical Center make informed decisions regarding the authorization of requested services. The form also mandates the inclusion of supporting documentation, which aids in the evaluation process and ensures that the requested services meet the required criteria. In summary, this form is a crucial tool for facilitating the coordination of community care services for veterans. It helps manage the administrative process, ensuring that services are authorized efficiently and in the best interests of the veteran. Healthcare providers and VA facilities rely on this form to maintain accuracy and compliance in the provision of medical services to veterans.

• 1. VA FACILITY INFORMATION: Contains the facility name, today's date, fax number, and phone number. Provides contact information for the VA Medical Center.
• 2. VETERAN INFORMATION: Requires the veteran's name, SSN (last four digits), date of birth, individual or group practice name. Captures essential identification information.
• 3. REQUESTING PROVIDER INFORMATION: Includes the provider's name, contact number, NPI, specialty type, email address, facility address, and fax number. Details identifying the request origin.
• 4. REQUESTED SERVICE: Indicates the type of service requested, type of request, and specialty. Defines the specific medical need and urgency level.
• 5. SUPPORTING SERVICES: Specifies additional services required, such as anticoagulation, audiology, telehealth, and more. Captures comprehensive support needs.
• 6. SERVICE TYPE: Defines the type of service required, such as evaluation, diagnostics, or treatment. Helps categorize the nature of the request.
• 7. REASON FOR REQUESTED SERVICE: Provides space for scheduling instructions, provisional diagnosis, anticipated dates of care. Essential for evaluating the service necessity.
• 8. ATTESTATION: Includes a section for the provider's signature and date. Confirms the validity and accuracy of the information provided.

Failure to submit this form may result in delays or denial of requested services. Ensure accurate and timely submission to prevent issues.

• Service Denial: Requested services may be denied if the form is not submitted within the required timeframe.
• Delays in Care: Delays in processing the request can lead to delays in the veteran receiving necessary medical care.
• Inaccurate Information: Incomplete or inaccurate information on the form may result in processing issues or additional verification steps.

• 1. Specialty Care Requests: For requesting specialist services not available at VA facilities.
• 2. Diagnostic Services: To obtain diagnostics and tests from community providers.
• 3. Support Services: For services such as telehealth, audiology, and cancer coordination.
• 4. Treatment Evaluations: When evaluating a veteran's need for specific treatments or procedures.
• 5. Home Health Services: To request home health aid and related in-home medical services.