VA Provider Request for Services (RFS) Form

Request for Services (RFS) Form

Please complete the required fields and sign electronically. Once you hit Submit, we'll reach out the VA and Veteran to get authorized for treatment. Please note: This form is REQUIRED and MUST BE SIGNED by the requesting provider for further care to be rendered to a Veteran patient.
Section 1: Veteran Information
Veteran's Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
VA Facility*
VA Location*
Section II: Ordering Provider Information
Requesting Provider's Name*

First NameLast Name
NPI #*
Specialty*
Secure Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Are you an Indian Health Services (IHS) Provider?

YesNo
Office Name*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ICD-10 Code*
Provisional Diagnosis (Panic Attacks, Panic Disorder, and/or PTSD)*
VA Authorization Number (This is the number assigned to the Veteran by the VA.)*
Requesting Provider Signature

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date
The VA requires the most recent medical/clinical notes to be submitted along with the RFS form. Please fax the most recent medical note to 844.824.8779.
Should be Empty:

Request for Services (RFS) Form