Va Form 10-8001 - Refusal Of Transfer To Va Health Care Facility
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1DEPARTMENT OF VETERANS AFFAIRS
[Non-VA Medical Care Office]
[Non-VA Medical Care Office Telephone Number/Fax Number]
[VA Facility Name]
[VA Facility Address Line 1], [VA Facility Apt/Suite #]
[VA Facility City, State, Zip code]
Letter Generation Date:
Apr 7, 2015
Refusal of Transfer to VA Health Care Facility
[Veteran Name]
Admission Date:
[Admission Date]
Last 4 digits of SSN:
Non-VA Facility:
[Last 4 digits of the Veterans SSN]
[Non-VA Facility]
I have been offered transfer to a VA health care facility, and I have elected not to transfer.
Initialing each statement below indicates that I have read and acknowledged each statement:
I acknowledge that efforts have been made for my transfer to a VA health care facility, and
I have been advised of the risks and benefits of transfer.
I understand I may be responsible for any charges incurred from the date of my refusal to
transfer to a VA health care facility (or other federal facility that VA has an agreement
with to furnish health care services for Veterans) for continuation of treatment until
discharge.
I elect to continue my health care treatment at this “Non VA Facility” at My OWN
EXPENSE and to not use VA benefits (38 U.S.C. 1703, 1725, or 1728).
Reason for refusal to transfer:
Date:
Time:
Print Veteran's Full Name:
Veteran's Signature:
Veteran is unable to sign
Signature of spouse, significant other, or POA/legal surrogate if the Veteran is unable to sign.
Date:
Time:
Print Name:
Relationship
Veteran has been advised of this information above and has refused to sign
Form instructions: Please provide this form to the Veteran/legal surrogate to complete. Please witness patient signature
and/or refusal to sign and fax completed form to the number listed above.
Date:
Witness Signature
Time:
Witness Title:
Please contact Non VA Medical Care office if you or the Veteran have any questions.
Print Name/Signature
Telephone
VA FORM 10-8001
March 2015
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