10-0454
Military Treatment Facility Referral to VA Liaison
VA Form 10-0454 is the U.S. Department of Veterans Affairs Military Treatment Facility Referral to VA Liaison. The PDF is headed VA Liaison for Healthcare Referral Form. The form says it is used to coordinate the transition into VA health care for transitioning Service members and new Veterans through a VA Liaison for Healthcare. It asks for the form to be completed in its entirety, as all information is needed to register for VA health care, and then returned to the site's VA Liaison for Healthcare. VA's form page lists it under VHA.
The form is two pages. It covers referral details, the patient's personal information, military service history and discharge information, then medical information and the VHA care requested, ending with the discharge plan from the military treatment facility. You can fill out the PDF free in your browser on this page and download the result without an account.
Date referred, assigned MTF, VA Liaison for Healthcare, MTF referral source, DoD lead coordinator, whether the referral packet is complete, the status of the 1010EZ and DD214, the requested VA facility and the type of VHA care requested.
Name, full SSN, date of birth, phone, post discharge and mailing addresses, email, sex, race or ethnicity, marital status, number of dependent children, place of birth, mother's maiden name, religion and an emergency contact.
DoD ID, branch of service from Army to Space Force, service component, service status, rank, service entry date and combat deployment history.
Discharge date and type, character of service, DoD rating and MEB referred conditions if known, VA rating, expected departure from the MTF, and a confirmation about using TRICARE, the nearest MTF and/or a Vet Center while on AD status.
Whether the SM is on the high interest list or designated seriously ill or injured, inpatient or outpatient, and whether a TRICARE authorization was requested, with the date, type and numbers.
Primary care, mental health including suicide prevention and Military Sexual Trauma, specialty care, biopsychosocial needs, medication and days requested for the transition period, durable medical equipment or prosthetics, and the discharge plan.
The form points to a VA Liaison for Healthcare locator at https://www.va.gov/POST911VETERANS/VA_Liaison_for_Healthcare_Locator.asp.
Complete Items 1 to 10, including the status of the 1010EZ and DD214, the requested VA facility and the type of VHA care requested.
Enter the demographic, military service history and discharge information in Items 11 to 39.
Answer the medical questions and describe the VHA care requested, medication needs and the discharge plan, including when and where the patient will be discharged, as Item 52 asks.
The form asks for every item to be completed and says to return the form to the site's VA Liaison for Healthcare.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form says to return it to your site's VA Liaison for Healthcare, found with the locator at https://www.va.gov/POST911VETERANS/VA_Liaison_for_Healthcare_Locator.asp.
The form prints no mailing address, fax number or email.
The PDF footer reads JUL 2026. VA's form page lists a form revision date of August 2026. The form has two pages.
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122 fields, 6 pages
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99 fields, 5 pages
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82 fields, 3 pages
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20 fields, 2 pages
10-5345
61 fields, 2 pages
The form does not name a single person who fills it in. It names these people and offices.
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The form says it is used to coordinate the transition into VA health care for transitioning Service members and new Veterans through a VA Liaison for Healthcare.
The site's VA Liaison for Healthcare. The form says to return it to the liaison once complete and links to a locator for finding one.
The form asks for it to be completed in its entirety and says all information is needed to register for VA health care.
Yes. Item 7 records the status of the 1010EZ and Item 8 the status of the DD214.
Item 49 asks about medication and Item 50 asks for the days of medication requested for the transition period.