Va Form 10-0454 - Military Treatment Facility Referral Form To Va Liaison
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3MILITARY TREATMENT FACILITY REFERRAL FORM TO VA LIAISON
MTF Case Manager/Social Worker: Please complete this form in its entirety, as all information is needed to register a patient with the Veterans Health Administration. Once complete,
please return it to the VA Liaison for Health Care at your MTF. If there is not a VA Liaison assigned to your facility, please forward this form directly to the OEF/OIF Program Manager
at the requested VA Health Care Facility.
Military Treatment Facility
Date of Referral
MTF Referral Source
Phone Number
Cell/Pager Number
Military Social Worker/Case Manager (If different than referral source) Phone Number
Cell/Pager Number
VA Liaison for Health Care
Phone Number
Cell/Pager Number
PATIENT PERSONAL INFORMATION
Last Name
First Name
Middle Name
Suffix
Full SSN
Home Phone Number
Cell Phone Number
Complete Home Address (City & State & Zip)
County
Email Address
DOB
Mother's Maiden Name
Age
Religion
Marital Status
Place of Birth (City&State&Zip)
Gender
Male
Female
Is the patient Spanish, Hispanic, or Latino?
Yes
No
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
What is Patient's Race? (You may check more than one.)
(Information is required for statistical purposes only.)
Asian
White
Black or African American
Father's Name
Mother's Name
EMERGENCY CONTACT
Next-of-Kin
Family
Durable Power of Attorney for Health Care
Name
Relationship
Complete Address & City & State & Zip
Does the Patient have an Advance Directive?
Home Phone Number
Cell Phone Number
Yes
No
PATIENT MILITARY INFORMATION:
(complete details in these responses aid in the planning of long term veterans benefits)
Branch of Military
Army
Air Force
Navy
Marine Corps
Coast Guard
Rank
Component
National Guard
Reserve
Active
OIF
OEF
N/A (non-OIF/OEF)
Service Status:
Active Duty (currently)
Retired - Date of retirement
TDRL
PDRL
Service Entry Date
ETS
Release from Active Duty
Combat Dates & Theater (locations)
Parent Command & POC & Phone Number
In process of discharge:
ETS
MEB
Limited Duty
Admin Sep
Other:
Anticipated date of separation (if known):
Status of MEB/PEB:
Patient's Last Name:
Patient's SSN:
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VA FORM
10-0454 MAR 2009
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