Va Form 10-0454 - Military Treatment Facility Referral Form To Va Liaison Page 2

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MTF HEALTH CARE TREATMENT AND PLAN

NBI

Disease/ Disorder

Date of injury:

INJURY/COMBAT RELATED INJURY/DIAGNOSIS DETAILS:

DISCHARGE PLAN from Military Treatment Facility [to include WHEN and WHERE patient will be d/c & discharge status, i.e. TDRL, convalescent leave

pending medical d/c, convalescent leave pending return to duty, Con Lv pending return to MTF, etc]:

1) What is the estimated departure date from MTF or arrival date home? (so VHA can arrange follow-up care):

2) Has MTF Case Manager requested a TriCare /MMSO authorization?

YES

If so when was clinical order entered?

3) Name of Attending Physician and Contact Number(s):

4) Name of Nurse/Nurses' Station Ward and Contact Number(s):

REQUEST FOR VA HEALTH CARE, Must be Completed by a MTF Health Care Clinician (i.e. Case Manager/SW/MD)

Requested VA Health Care Facility:

Is patient a VA Employee

YES

REQUESTED HEALTH CARE:

please check all that apply, and provide corresponding medical records.

INPATIENT CARE

Traumatic Brain Injury

Spinal Cord Injury

Mental Health (Psychiatry, PTSD, Substance Abuse)

Blind Rehabilitation

Long-term care/Nursing Home

Other:

OUTPATIENT CARE

Primary Care:

Mental Health (Psychiatry, Psychology, PTSD, Substance Abuse):

Therapy (PT, OT, Speech):

Pain Management:

Visually Impaired Services:

Durable Medical Equipment/Prosthetics:

Specialty Clinics (Neuro, Ortho, Cardiology, ENT, wound care, suture removal, Audiology):

TBI/Polytrama:

Other:

Please indicate the plan for the transfer of Medical Records:

NOTE: At the time of the patient transfer the discharge summary and current discharge medication list will need to be included.

(if referring to an inpatient setting (i.e. Polytrauma Center, TBI, SCI), or if clinically indicated (i.e. ortho, surgery) please request a CD of patient's films)

Patient's Last Name:

Patient's SSN:

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VA FORM

10-0454 MAR 2009