Healthcare PTE Document

HEALTHCARE PTE DOCUMENT

Patient Information

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Clinical Status

Vitals summary (most recent):

Mental status / Orientation:

Mobility: Ambulatory Requires assistance Bed-bound   Other:

Transfer Details and Clinical Justification

Requested mode of transport: Ground ambulance Air ambulance Private vehicle

Isolation / Precaution status: Standard Contact Droplet Airborne

Risks, Benefits, and Patient Rights

The patient or legal representative is advised that transfer may involve risks including, but not limited to, delay in treatment due to transport, potential exacerbation of medical conditions during transfer, and limitations in services available in transit. Potential benefits include access to higher level of care or specialized services at the receiving facility.

The undersigned acknowledges that the alternative to transfer (continuing care at the current facility) has been explained and that questions regarding the purpose, risks, and anticipated benefits of transfer have been addressed to their satisfaction. The undersigned further acknowledges the right to refuse transfer, except in circumstances where transfer is required by law or where clinically necessary to prevent immediate harm.

I acknowledge that I have been informed of the risks and benefits of transfer and that I have had an opportunity to ask questions. I acknowledge

Authorization to Release Health Information (HIPAA Authorization)

I authorize the release and exchange of my medical records, including relevant medical history, current medications, laboratory results, radiology reports, and other clinical information necessary to effectuate the transfer and continuity of care between the transferring and receiving entities identified in this document. This authorization includes disclosure of information related to communicable diseases, mental health, and substance use disorders to the extent required for treatment.

This authorization is valid for purposes of the transfer and for continuity of care unless an earlier expiration date is specified below. Disclosure is limited to the minimum necessary information required for the stated purpose.

I understand that I may revoke this authorization at any time by delivering a written revocation to the releasing facility, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures made before the revocation was received.

Clinical Certification (To be completed by Clinician)

Clinical Notes / Assessment Summary:

Clinician Contact Number:

I certify that the information provided in this Patient Transfer Evaluation is true and accurate to the best of my knowledge and that the clinical justification for transfer has been documented. Clinician certifies

Consent and Signature

By signing below, the undersigned authorizes the transfer, acknowledges receipt of the information contained herein, consents to the release of protected health information necessary for the transfer, and verifies that they are the patient or the patient's legal representative with authority to sign.

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