Provider Reference Library - Community Care
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Community Care


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Provider Reference Library

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Stay up to date with VA Community Care by subscribing to our GovDelivery email distribution list. Click on the Email Updates image link to become a subscriber to the VHA Community Care Provider Updates newsletter.

Fact Sheets

The fact sheets listed below provide specific information that providers and office managers need to know in order to participate in Community Care programs.You can view fact sheets for all VHA Office of Community Care (VHA OCC) Veteran and family member programs on the Community Care Fact Sheets page.

Community Care Fact Sheets

VHA OCC fact sheets for providers
ProgramFact Sheet Title
Veteran Programs
General How to Become a VA Community Provider
General Medical Document Submission Requirements for Care Coordination
General Billing Fact Sheet for Community Providers
General VHA OCC Customer Service Contacts for Providers 
General Centralized Community Emergency Treatment Reporting and Care Coordination
General VHA OCC Ambulance Transportation
Foreign Medical Program Foreign Medical Program (FMP)–Information for Outpatient Providers and Office Managers (04-20) Fact Sheet 04-20 is also available in the languages listed below.
Foreign Medical Program  FMP Fact Sheet 04-20—GERMAN
Foreign Medical Program FMP Fact Sheet 04-20—GREEK
Foreign Medical Program FMP Fact Sheet 04-20—ITALIAN
Foreign Medical Program FMP Fact Sheet 04-20—JAPANESE
Foreign Medical Program FMP Fact Sheet 04-20—KOREAN
Foreign Medical Program FMP Fact Sheet 04-20—SPANISH
Foreign Medical Program FMP Fact Sheet 04-20—THAI
Family Member Programs
CHAMPVA CHAMPVA Payment Methodology
CHAMPVA CHAMPVA and the Use of Durable Medical Equipment
CHAMPVA CHAMPVA– Information for Providers and Office Managers
CWVV Children of Women Vietnam Veterans Payment Methodology
SBHCBP Spina Bifida Health Care Benefits Program Payment Methodology
SBHCBP Spina Bifida Health Care Benefits Program–Information for Providers and Office Managers


Below are forms frequently used by our providers. Forms for other Community Care programs can be found on tHe VHA OCC Forms page.

Forms for VHA OCC Programs

VHA OCC forms for providers
Form TitleForm description
CHAMPVA Mental Health Preauthorization Request – Fillable PDF This form is for mental health preauthorization for CHAMPVA, a Veterans Affairs family member program.
Community Care Provider-Request for Service (RFS), VA Form 10-10172 A standardized form for Community Providers to request additional or continued care or services for Veterans. The purpose of the Community Care Provider-Request for Service, VA Form 10-10172, is to manage requests from community providers and to allow for placement, tracking, managing, and reporting of those requests. The use of the RFS form is recommended for clinical requests from a community provider to facilitate review and authorization.
Health Insurance Claim Form (CMS-1500) – Print-Only form The CMS-1500 Claim Form is the basic paper claim form prescribed by many health care payers for claims submitted by physicians, other providers, and suppliers, and in some cases, for ambulance services.
Medical Billing Claim Form, UB-04 (CMS‑1450) Institutional Paper Claim Form* The CMS-1450 form can be used by an institutional provider to bill a Medicare fiscal intermediary when a provider qualifies for a waiver from the Administrative Simplification Compliance Act requirement for electronic submission of claims. It is also used for billing of institutional charges to most Medicaid State Agencies.
Refusal of Transfer to VA Health Care Facility, VA Form 10-8001 – Fillable PDF VA Form 10-8001 is used when a Veteran refuses to transfer to a VA Health Care Facility.
VA-FSC Vendor File Request Form,VA Form 10091 – Fillable PDF VA Form 10091 enables all vendors to apply for payment via Electronic Funds Transfer (EFT), or to submit changes/updates to their Financial Management System Vendor Record in order to receive VA payments that comply with the 1996 Debt Collection Improvement Act.

For questions regarding VA Form 10091, please contact the Nationwide Vendor File Division via email or phone listed below.


PLEASE NOTE: You can download a sample CMS-1450 from the website. However, copies of the form should not be downloaded for submission of claims, since they may not accurately replicate colors included in the form. These colors are needed to enable automated reading of information on the form.