0

CHANGE OF PRIMARY CARE PROVIDER REQUEST

Veterans

Attached is a SAMPLE and the FORM itself to be completed for the TRANSFER from one CLINIC to another( EXAMPLE: Beaumont to Lake Charles).

Remember, that includes the VA PRIMARY CARE Physician authorizing the transfer, thus the clarity on the part of the form.

This a FILL IN THE BLANK form or you can print it and fill it out manually. Please fill in your specific request for transferring so the PCP will understands your reason. (Example: I now have a CBOC closer to where I live)

Anyone wanting to pursue a transfer, complete the form, and have it reviewed at your origin clinic . Copy it with the current date and have someone ACKNOWLEDGE (get the name of the person) that you give the copy to.

You will be notified by the VA of the Acceptance of transfer as indicated on the transfer form.

 

 

 

 

 

 

Image may contain: text

 

Comments are closed.