How to Fill Out and Submit VA Form 10-2649A: Inter-Facility Transfer

VA Form 10-2649A is the inter-facility transfer form VA medical staff complete whenever a veteran moves between a VA facility and another hospital or care setting. To fill it out, work through the five sections in order (demographics, reason for transfer, transfer logistics, infection control, medications), obtain the physician certification and documented consent in Section II, assemble the accompanying records, and submit the packet by uploading it to the Electronic Health Record and sending a printed copy with the transport crew. The current fillable PDF is dated September 2025.¹

Where to Download the Form

The fillable PDF is on the VA’s public medical forms page.¹ VA staff can also pull it through the internal portal. Community hospitals sending a veteran back to a VA medical center use the same public download. The form is required for every transfer request to or from a VA medical facility, regardless of direction.

When the Form Is Required

Section II requires at least one checked reason for the transfer. The eight options on the form are:

Service not available at the referring facility
No bed available at the referring facility
Involuntary mental health hold
Transfer to a nursing facility or community living center
Transfer to the veteran’s home VAMC
Patient or family request
State of emergency declared by the facility director
Other, described in a free-text field

VHA Directive 1094 is the underlying policy governing inter-facility transfers within the Veterans Health Administration and sets the clinical and administrative requirements staff follow.²

How to Complete Each Section

Work the form top to bottom. Earlier sections feed later ones, and skipped fields create delays when the receiving facility reviews the record.

Section I: Demographic Information

Enter the veteran’s full name, Social Security number, age, home address, and home phone number. Record the current resuscitation status: Full Code, Do Not Attempt Resuscitation, or a limited directive allowing mechanical ventilation only if the patient has a pulse.¹ The transport crew and receiving team rely on this if the veteran deteriorates en route.

Section II: Reason for Transfer

Check the applicable reason. Below the checkboxes, write a clinical summary of the services the veteran needs when those details are not already in the discharge summary or provider note. Document any test results still pending so the receiving clinician knows what is outstanding. This section also holds the physician certification and consent documentation, covered separately below.

Section III: Transfer Information

Record the sending facility’s name, level of care, and the transferring clinician’s name and contact information. Do the same for the accepting facility and accepting clinician. Include the date of the veteran’s original admission or presentation and the date of the transfer itself.¹

Then indicate what support the veteran needs during transport. The checkboxes cover:

Cardiac monitor
Continuous oximetry
Oxygen, with the specific flow rate
Mechanical ventilation
Foley catheter
IV medications, fluids, or blood products
Restraints
Other nursing instructions, free text

Select the transportation mode: ambulette or wheelchair van, basic life support ambulance, advanced life support ambulance, or critical life support. The mode should match the support checked above. A veteran on mechanical ventilation should not be traveling in a wheelchair van.

Section IV: Infection Control Information

Indicate whether the veteran is currently in isolation for a communicable disease, and if so, the type of isolation. The form then asks about known infection, colonization, or history of positive culture for MRSA, VRE, ESBL-producing organisms, CRE, resistant Acinetobacter, and C. difficile. For each organism, mark whether the status is colonization or history versus an active infection currently on treatment.¹ Omissions here can trigger an outbreak investigation later.

Section V: Medication and Vaccine Information

List all known allergies and adverse drug reactions, then the veteran’s active medications and relevant immunizations. The receiving pharmacy team uses this to continue prescriptions without interruption and to avoid interactions or duplications on arrival.

Physician Certification and Consent

Section II holds two components that carry legal weight, and both must be complete before the veteran leaves the building.

The physician certification is a printed statement that the transferring physician signs, attesting that the expected medical benefits of treatment at the receiving facility outweigh any increased risk from the transfer itself.¹ The language mirrors the federal requirement under the Emergency Medical Treatment and Labor Act, which requires a signed physician certification with a summary of risks and benefits whenever a patient who has not been fully stabilized is transferred.³ If no physician is physically present at the time of transfer, a qualified medical person may sign after consulting with a physician, who then countersigns.

The consent checklist documents how the veteran’s agreement was obtained. The three options are:

The patient or surrogate gave verbal consent after a discussion of risks, benefits, and alternatives.
The patient lacks decision-making capacity and no authorized surrogate is available.
The transfer is occurring under a declared state of emergency or an involuntary mental health hold, where standard consent does not apply.

For the first option, the transferring clinician must actually have that conversation. Checking the box without the discussion creates a consent problem. When the patient lacks capacity and no surrogate is reachable, document that fact rather than skipping the consent section.

Documents That Must Travel with the Veteran

The form alone is not enough. Administrative staff print and send the following with the veteran at the time of transfer:¹

The completed VA Form 10-2649A
State Authorized Portable Orders such as MOST, MOLST, or POLST forms, if available
The ED provider note, if the veteran is transferring from an emergency department
A discharge summary, if available
A nurse-to-nurse handoff document, if available
A demographic face sheet

Federal transfer rules also require the sending hospital to include all medical records related to the emergency condition that are available at transfer time: history, diagnostic results, treatment provided, and the signed certification. Records not yet available, such as pending labs, must be forwarded as soon as they come in.⁴

How to Submit and Coordinate the Transfer

Once signed, upload the completed form into the VA’s Electronic Health Record so the receiving facility can review it before the veteran arrives. Send the physical packet with the transport crew. Keeping both a digital and paper copy avoids the situation where the receiving team has to call back for basic information.

Transfer coordinators at both facilities align their clinical teams around the form’s details: transport mode, in-transit support needs, and the accepting clinician. The nurse-to-nurse handoff, by phone or included document, covers current status, active drips, and any changes that happened after the form was completed. The receiving facility must have agreed to accept the transfer and confirmed it has available space, qualified personnel, and the ability to manage the veteran’s condition.⁴

Emergency Transfers

If completing the form would delay care in an emergent situation, staff may fill it out immediately after the transfer rather than before.¹ Paperwork should not hold up the ambulance when minutes matter. The physician certification and consent documentation still need to be completed, just after the fact. Note on the form that the transfer was emergent and document the reason for the delay in completion.

1
U.S. Department of Veterans Affairs. Inter-Facility Transfer Form
2
U.S. Department of Veterans Affairs. VHA Directive 1094 – Inter-Facility Transfer
3
Office of the Law Revision Counsel. 42 U.S. Code 1395dd – Examination and Treatment for Emergency Medical Conditions and Women in Labor
4
Centers for Medicare & Medicaid Services. Appendix V – Interpretive Guidelines for EMTALA