Fillable Printable VA Form 10-2649A
Fillable Printable VA Form 10-2649A
VA Form 10-2649A
MAY 2005
VA FORM
10-2649A
Page 1 of 2
INTER-FACILITY TRANSFER FORM
GUIDELINES FOR TRANSFERRING PATIENTS FROM EMERGENCY DEPARTMENT
1. Notify receiving facility by telephone; then document the time, name of person contacted at receiving facility and name
of person at VAMC (VA Medical Center) who made the call.
2. Confirm that physician to be responsible for the patient's care at the receiving facility has been contacted. Document
time and name of person who made the call (this should be a physician.)
3. Document the reason patient is being transferred (patient request, no beds, etc.)
4. Make photocopies of all Emergency Department records and send with the patient to receiving facility.
5. Sign transfer form after all above are completed; attach copy of records going with patient to receiving facility.
Retain original with hospital records.
TO BE COMPLETED FOR EVERY TRANSFER REQUEST TO AND FROM A VA MEDICAL FACILITY
SECTION I - DEMOGRAPHIC AND ELIGIBILITY INFORMATION
1. VETERAN'S LAST NAME- FIRST NAME- MIDDLE INTIAL
2. SOCIAL SECURITY NO.
4. ADDRESS
6.ELIGIBILITY FOR VA CARE
5. DATE AND TIME
7.ELIGIBILITY FOR TRAVEL/SPECIAL MODE
8. PATIENT HAS ADVANCED DIRECTIVE
YES NO
(If Yes send copy with patient)
9A. NAME OF CONTACT 9B. TITLE OF CONTACT 9C. TELEPHONE NUMBER
NOTE: PHYSICIAN IS TO COMPLETE THE REMAINDER OF THIS FORM
SECTION II - REASON FOR TRANSFER
1. NATURE OF SERVICES NEEDED BY PATIENT REQUIRING TRANSFER (Identify)
DIAGNOSIS
TREATMENT
LONG TERM CARE
RETURN TO PRIMARY HEALTH FACILITY
CONSULTATION/EVALUATION
OTHER (Specify)
SERVICE NOT AVAILABLE AT REFERRING FACILITY
NO BED AT REFERRING FACILITY
2. DESCRIBE SERIVICES NEEDED
SECTION III - TYPE AND LEVEL OF SERVICES REQUIRED
1. DIAGNOSIS
2. DESCRIPTION OF TREATMENT PRIOR TO TRANSFER
3. DESCRIPTION OF FURTHER TREATMENT CONTEMPLATED
4. LEVEL OF CARE PRIOR TO TRANSFER (ER, Outpatient, Ward, ICU etc.)
3. DATE OF BIRTH
MAY 2005
VA FORM
10-2649A
Page 2 of 2
SECTION IV - CONDITION OF PATIENT ON TRANSFER
1. IS PATIENT MEDICALLY
STABLE FOR TRANSFER
YES
1. IS PATIENT BEHAVIORALLY
STABLE FOR TRANSFER
DESCRIBE (e.g. vital signs, significant history, physical findings, mental status, airway status, lab tests etc.)
DESCRIBE
NO
SECTION V - MODE OF TRANSPORTATION
1. DESCRIBE SPECIAL MODE AND STAFF REQUIREMENTS
2. IV MEDICATIONS OR OTHER TREATMENTS ON ROUTE
SECTION VI - INFORMATION TO BE SENT WITH PATIENT
COMPLETE MEDICAL RECORD DISCHARGE SUMMARY TRANSFER NOTE ER NOTE CLINIC NOTE
OTHER (Imaging studies, laboratory reports, EKGs, etc.)
2. SOCIAL SECURITY NO.
1. VETERAN'S NAME
SECTION VII - PATIENT/FAMILY CONSENT RECEIVED (Must be completed for every transfer of an unstable patient.)
PATIENT CONSENTS TO TRANSFER
REFERING PHYSICIAN CERTIFIES THAT BENEFITS OF TRANSFER
OUTWEIGH RISKS
SIGNATURE:
SECTION VIII - RESPONSIBLE INDIVIDUALS
1. NAME OF TRANSFERRING/RECEIVING PHYSICIAN AT THIS FACILITY 2A. TRANSFERRING /ACCEPTING FACILITY FACILITY
2B. NAME OF PHYSICIAN 2C. TELEPHONE NUMBER
SECTION IX - DECISION (To be completed for all transfer requests into a VA facility.)
1. NOT ACCEPTED (Specify reason) 2. ACCEPTED (Complete items 2A t hrough 2H below)
2A. NAME AND WARD OF VA ACCEPTING PHYSICIAN
2C. TRANSPORTATION AUTHORIZED. 2D. NON-VA MEDICAL SERVICES AUTHORIZED.
2B. DATE AND TIME OF TRANSFER
2E. NAME AND SIGNATURE OF PHYSICIAN COMPLETING THIS FORM
2F. TELEPHONE NUMBER
2G. DATE AND TIME
YES
NO
NO
YES
NOYES
