Department of Veterans Affairs
REQUEST FOR SERVICES (RFS) FORM
PREVIOUS AUTHORIZATION NUMBER
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TODAYS DATE MMDDYYYY
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Month
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Day
Year
Date
SECTION I: VETERAN INFORMATION
1 VETERANS LEGAL FULL NAME First MI Last
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2 DOB MMDDYYYY
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3 VA FACILITY
4 VA LOCATION
SECTION II: ORDERING PROVIDER INFORMATION
5 REQUESTING PROVIDERS NAME
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6 NPI
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7 SPECIALTY
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8 OFFICE NAME ADDRESS
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9 SECURE EMAIL ADDRESS
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example@example.com
SECTION III: TYPE OF CARE REQUEST
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Format: (000) 000-0000.
11 FAX NUMBER
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SECTION III: TYPE OF CARE REQUEST
13. PLEASE INDICATE CLINICAL URGENCY
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ROUTINE
URGENT
14 DIAGNOSIS ICD10 CodeDescription
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15 DATE OF SERVICE MMDDYYYY OR ANTICIPATED LENGTH OF CARE
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Month
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Day
Year
Date
17 HOW MANY VISITS HAVE OCCURRED SO FAR (If known)
18. IS THIS A REFERRAL TO ANOTHER SPECIALTY?
NO
SECTION IV: TYPE OF SERVICE REQUESTED
OUTPATIENT CARE
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PT
OT
SPEECH THERAPY
FREQUENCY DURATION
CHOOSE ONE
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ADDITIONAL OFFICE VISITS
Amount of visits being requested
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36 JUSTIFICATION FOR REQUEST (To avoid delays in care include appropriate documentation such as office notes current treatment plans clinical history laboratory results radiology results or medications 10 support the medical necessity of services requested)
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56 REQUESTING PROVIDER SIGNATURE Required
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57 TODAYS DATE MMDDYYYY
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Month
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Day
Year
Date
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