Items 1 to 10: station and Veteran
Name and address of the VA station, date, the Veteran's name, date of birth, Social Security number, claim number, ward number, home address and religion.
10-2406
Recommendation for Release of Patient in Home Other Than Patient's Own
- Agency
- VA
- Revision
- May 2003
- Fillable fields
- 73
- Pages
- 2
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-2406: Recommendation for Release of Patient in Home Other Than Patient's Own
VA Form 10-2406 is the U.S. Department of Veterans Affairs Recommendation for Release of Patient in Home Other Than Patient's Own, listed under VHA on VA's form page. Its subtitle calls it a Summary of Psychiatric, Medical and Social Data. It records information about a Veteran patient who is being recommended for release to a home other than the patient's own.
The two pages open with the VA station and the Veteran's identification, then three parts: Part I is to be completed by the ward physician, Part II by the Medical Administration and Part III by the Social Worker. The physician and the social worker sign in ink. It is a VA staff form, not something Veterans file, and neither the PDF nor VA's form page gives filing instructions.
You can fill out the PDF free in your browser on this page and download the result without an account.
What's on VA Form 10-2406
Part I: ward physician
Reason for referral, diagnosis, description of the patient, whether the patient is medically considered able to handle own funds, legal status, supervision, medication and diet needed, and the physician's signature and date.
Part II: Medical Administration
Guardian and nearest relative with addresses and relationship, the patient's source of income from VA compensation, pension, military retirement, insurance or other, whether aid and attendance has been awarded, and amounts of the institutional award, estate held at the hospital and amounts held elsewhere.
Military service
Branch of service, length of service, highest rank or grade, date of last discharge and a yes or no box for combat action.
Part III: hospital and employment history
Length of hospitalization before, during and since military service, type of hospitalization other than VA, and a brief employment history before and after discharge.
Part III: readiness for placement
Attitudes toward the placement, activities, household tasks, associations, personal friends, special needs, the type of home and community desired, supervision required, desirable qualities and preferred age range of the person assuming responsibility, rural or urban area, and the social worker's signature and date.
How VA Form 10-2406 is completed
- 1
Fill in the station and Veteran details
Items 1 to 10 identify the VA station, the date and the Veteran.
- 2
Ward physician completes Part I
Items 11 to 18 cover referral, diagnosis, description, funds, legal status, supervision, medication and diet. The physician signs Item 19 in ink and dates Item 20.
- 3
Medical Administration completes Part II
Items 21 to 34 record the guardian, nearest relative, sources of income and amounts held.
- 4
Record military service
Items 35 to 39 at the top of page 2 record branch, length of service, rank or grade, last discharge date and combat action.
- 5
Social Worker completes Part III
The social worker records history and readiness for placement, recommends a rural or urban area, and signs Item 58 in ink and dates Item 59.
Why fill Form 10-2406 on indox
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Where it goes and edition
Where it goes
The form prints no mailing address, fax number or submission instructions, and VA's form page gives none.
Signatures
The physician signs Item 19 and the social worker signs Item 58. The form says to sign each in ink.
Edition
The footer reads VA FORM MAY 2003 10-2406, matching the May 2003 revision date on VA's form page. The PDF prints no OMB control number.
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Who uses VA Form 10-2406?
The form assigns each part to a member of VA staff.
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Questions about Form 10-2406
What is VA Form 10-2406?
It is the Recommendation for Release of Patient in Home Other Than Patient's Own, a two page VHA form that its subtitle calls a Summary of Psychiatric, Medical and Social Data.
Who fills out VA Form 10-2406?
VA staff. The form says Part I is completed by the ward physician, Part II by the Medical Administration and Part III by the Social Worker.
Does the Veteran sign it?
The form has signature lines only for the physician, Item 19, and the social worker, Item 58. It has no signature line for the Veteran.
What does the physician's part ask?
The reason for referral, diagnosis, a description of the patient, whether the patient is medically considered able to handle own funds, legal status, and the supervision, medication and diet needed.
What does the social worker's part cover?
Hospital and employment history and the patient's readiness for placement, including the type of home and community desired and whether placement in a rural or urban area is recommended.
Where is VA Form 10-2406 sent?
The form prints no address or submission instructions, and VA's form page gives none.