Community care providers treating a veteran under a VA referral use this form when care goes beyond what the active referral authorizes: more visits, a new specialty, a procedure outside the original episode of care, home and extended care, or equipment. Page 1 is the medical request; page 2 covers durable medical equipment, prosthetics, home oxygen and therapeutic footwear. VA processes each request within 3 business days.
The ordering community care provider completes the medical or the DME and prosthetics page, attaches supporting records and signs and dates it with their printed name and NPI; the signature is required. Section I asks for the veteran's name, date of birth and VA authorization number along with the provider's office details.
Enter the veteran's legal full name, date of birth, VA facility and address and the VA authorization number, then the ordering provider's office name and address, whether the provider is an Indian Health Service or Tribal Health Program provider, and the provider's phone, fax and secure email. The same block opens both the medical page and the DME and prosthetics page. VA notifies providers by their preferred method, so these details should be current.
Answer whether care is needed within 48 hours, whether this is a continuation of care and whether it is a referral to another specialty, naming it. Enter ICD-10 diagnosis codes and descriptions and the requested CPT or HCPCS codes with descriptions. Check any geriatric and extended care service: community nursing home, home infusion, hospice or palliative care, skilled home health, respite, community adult day health care or homemaker and home health aide, with details in the justification.
Explain medical necessity and attach office notes, current treatment plans, clinical history, labs, radiology or medications. The attestation confirms the information is accurate and accepts that VA may perform the service itself if the veteran agrees, VA can provide it by the clinically indicated date and it is in the veteran's best interest; otherwise VA refers it to the community. The provider also accepts responsibility for reviewing results and continuing care, then prints their name and NPI, signs and dates.
On the DME and prosthetics page, oxygen requests record PaO2 at rest, O2 saturation at rest, oxygen flow rate, the extent of support (continuous, intermittent or for a specific activity), stationary or portable equipment and the delivery system, such as cannula or mask. The page repeats Section I first and warns that failing to complete the DME request thoroughly delays care and prevents VA from fulfilling the order.
List the HCPCS codes for each item, brand, make, model and part numbers, measurements, quantity, ICD-10 code and provisional diagnosis. Confirm whether education, training and fitting were provided to the veteran, and choose a delivery preference: the ordering provider's address, pickup at the VA facility, a community vendor for delivery and setup, or the veteran's home. If the preference is left blank, the DME is mailed to the requesting provider. Urgent DME follows VA's separate DME requirements page.
Mark left, right or bilateral and prefabricated or custom therapeutic footwear, then check the diabetic or amputation risk score; only patients meeting one can be prescribed this footwear. Risk score 2 documents sensory loss on the Semmes-Weinstein 5.07 monofilament, weak or absent pulses, foot deformity or minor infection, with diabetes. Risk score 3 adds combined findings, or on its own a prior ulcer, osteomyelitis or amputation, severe PVD, Charcot foot with deformity or end-stage renal disease. Describe any severe deformity conventional footwear cannot accommodate.
As on the medical page, explain why the equipment is medically necessary and attach office notes, treatment plans, clinical history, labs, radiology or medications. The ordering provider then signs the same attestation and adds their printed name, NPI, a required signature and the date. VA denies requests that arrive without supporting documentation or without the provider's signature.
Download the current version from the source each time; forms change without notice.
Community Care Provider - Request for Service (Medical Request for Service / Durable Medical Equipment / Prosthetics Request for Services)
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Whenever a veteran needs care beyond what an active community care referral authorizes: extra visits or time, a referral to another specialty, a procedure outside the original Standardized Episode of Care, geriatric and extended care, or DME, prosthetics and home oxygen. Each service needs its own form, and requests are approved or denied at the VA facility's discretion.
VA processes requests within 3 business days and notifies the provider by the provider's preferred method. If care is needed within 48 hours based on clinical need, the form tells providers to contact their VA facility directly. When there is a risk of suicide or homicide, providers call VA directly and also submit the form.
VA's requirements page says requests missing supporting documentation or the provider's signature will be denied. Attach provider notes, care plans, lab results or radiology reports that support medical necessity, and have the ordering provider sign and date the form, electronically or in ink. For equipment, an incomplete DME page delays care and keeps VA from filling the order.
Section II of the DME and prosthetics page asks for PaO2 at rest, oxygen saturation at rest, flow rate, the extent of support (continuous, intermittent or for a specific activity), stationary or portable equipment and the delivery system, such as cannula or mask. Supporting records go with the reason for request at the end of the page.