VA Form 10-2649B "Provider Certification and Patient Consent for Transfer"

VA Form 10-2649B or the "Provider Certification And Patient Consent For Transfer" is a form issued by the U.S. Department of Veterans Affairs.

Download a PDF version of the VA Form 10-2649B down below or find it on the U.S. Department of Veterans Affairs Forms website.

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Download VA Form 10-2649B "Provider Certification and Patient Consent for Transfer"

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PROVIDER CERTIFICATION AND
PATIENT CONSENT FOR TRANSFER
PATIENT'S NAME:
PATIENT'S SSN:
FACILITY
In my medical opinion, this patient does not have an emergency medical condition or the condition has been stabilized.
Date
Provider's Signature
Time
If an emergency condition exists, the responsible physician must sign the following certification prior to transfer.
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.)
ADDITIONAL COMMENTS
Provider's Signature
Date
Time
CONSENT TO TRANSFER
I consent to be transferred to
Name of Facility
I have been informed of the benefits and risks of this transfer. The most significant risks are:
Patient's Signature
Date
Time
Witness's Signature
Date
Time
10-2649B
VA FORM
JAN 2017
PROVIDER CERTIFICATION AND
PATIENT CONSENT FOR TRANSFER
PATIENT'S NAME:
PATIENT'S SSN:
FACILITY
In my medical opinion, this patient does not have an emergency medical condition or the condition has been stabilized.
Date
Provider's Signature
Time
If an emergency condition exists, the responsible physician must sign the following certification prior to transfer.
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.)
ADDITIONAL COMMENTS
Provider's Signature
Date
Time
CONSENT TO TRANSFER
I consent to be transferred to
Name of Facility
I have been informed of the benefits and risks of this transfer. The most significant risks are:
Patient's Signature
Date
Time
Witness's Signature
Date
Time
10-2649B
VA FORM
JAN 2017
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