Fillable Printable VA Form 10-2649B

VA Form 10-2649B

The patient does not request transfer, but it is my opinion, based on the information available to me at this

time, that the medical benefits reasonably expected from the provision of appropriate medical treatment at

another facility outweigh the risks of the transfer. (Any facility transferring patients with unstablilized medical

conditions must provide medical treatment, within its capacity, to minimize the risk to the individual; send all

pertinent medical records, including advanced directives; effect the transfer using qualified personnel and

equipment; and obtain consent of the receiving facility.)

In my medical opinion, this patient does not have an emergency medical condition or the condition has been stabilized.

CONSENT TO TRANSFER

I consent to be transferred to

I have been informed of the benefits and risks of this transfer. The most significant risks are:

If an emergency condition exists, the responsible physician must sign the following certification prior to transfer.

VA FORM

JAN 2017

10-2649B

PROVIDER CERTIFICATION AND

PATIENT CONSENT FOR TRANSFER

Provider's Signature

Date

Time

Provider's Signature Date

Time

PATIENT'S NAME: PATIENT'S SSN:

Name of Facility

FACILITY

Patient's Signature

Date

Time

Witness's Signature

Date

Time

ADDITIONAL COMMENTS