Section I: Demographic information
Patient name, Social Security number, age, address, home phone and resuscitation status: full code or do not attempt resuscitation, with a ventilation option.
10-2649A
Inter-Facility Transfer Form
- Agency
- VA
- Revision
- September 2025
- Fillable fields
- 82
- Pages
- 3
- Official source
- VA form page
- Checked
- October 20, 2026
VA Form 10-2649A: Inter-Facility Transfer Form
VA Form 10-2649A is the Veterans Health Administration (VHA) Inter-Facility Transfer Form. Its heading says it is to be completed for every transfer request to and from a VA medical facility, and that if completion of the form will delay emergent patient care, it may be completed immediately after transfer.
It is a clinical and administrative form, not an application a Veteran files. It holds a physician certification, the names and contact details of the transferring and accepting clinicians, and instructions for administrative staff on what to send with the Veteran. The PDF has three pages in five sections: demographics, reason for transfer, transfer information, infection control, and medication and vaccine information.
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 10-2649A
Section II: Reason for transfer
Reasons such as service not available, no bed, mental health hold, nursing facility transfer, transfer to home VAMC or patient or family request, then a clinical summary, pending test results, consent and the physician certification.
Section III: Transfer information
Current and accepting hospital, level of care (ED, ward, stepdown or ICU), clinicians, admission and transfer dates, support or treatment during transfer and the transportation mode.
Section IV: Infection control
Whether the patient is in isolation and its type (contact, droplet, airborne or other), and whether there is a known infection, colonization or history with MRSA, VRE, C diff, Acinetobacter, ESBL, CRE or another organism.
Section V: Medication and vaccine information
Allergies and adverse drug reactions, active medications and immunizations.
Instructions for administrative staff
A list of what to print and send with the Veteran at the time of transfer, with an Other line.
How VA Form 10-2649A is completed
- 1
Start with the transfer request
The form is completed for every transfer request. If completing it would delay emergent patient care, the heading says it may be completed immediately after transfer.
- 2
Fill in Sections I and II
Record the demographics, resuscitation status, reason for transfer, clinical summary, pending test results and the consent choice.
- 3
Complete the physician certification
The certification on page 1 is the physician's statement on the risks and benefits of the transfer.
- 4
Fill in Sections III to V
Add the transfer, infection control and medication details. Pages 2 and 3 repeat the patient's name and Social Security number at the top.
- 5
Send the packet with the Veteran
Administrative staff print the completed form and the listed documents and send them with the Veteran at the time of transfer.
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What goes with the Veteran
Documents to send
The completed Inter-Facility Transfer Form, State Authorized Portable Orders (e.g., MOST, MOLST, POLST) if available, the ED Provider Note (if transfer from ED), a discharge summary if available, a nurse to nurse handoff if available and the demographic face sheet.
No mailing address
The form prints no mailing address. Its instructions say it is sent with the Veteran at the time of transfer.
Edition
The page 1 footer reads VA FORM SEP 2025 10-2649A. VA's form page lists a form revision date of September 2025.
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Who uses VA Form 10-2649A?
The form names the staff and parties involved in a transfer.
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Questions about Form 10-2649A
Who completes VA Form 10-2649A?
VA medical facility staff. The form holds a physician certification, the transferring and accepting clinicians' details and instructions for administrative staff. It is not an application a Veteran files.
When is VA Form 10-2649A completed?
The heading says for every transfer request to and from a VA medical facility. If completion would delay emergent patient care, it may be completed immediately after transfer.
What is sent with the Veteran?
The form lists the completed transfer form, State Authorized Portable Orders if available, the ED Provider Note if the transfer is from the ED, a discharge summary and nurse to nurse handoff if available, and the demographic face sheet.
Which transportation modes does the form list?
Ambulette or wheelchair van, basic life support, advanced life support and critical life support, each with a short description of the patient's clinical state.
Does the form record consent?
Yes. Section II item 4 records whether the patient or a surrogate gives verbal consent, whether the attending physician authorizes the transfer for a patient who lacks capacity, or whether the transfer occurs without consent due to a declared state of emergency or involuntary mental health hold.