Healthcare Transfer Application

HEALTHCARE TRANSFER APPLICATION

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History / Clinical Summary

Primary Care Physician:    Facility Medical Record #:

Transfer Details

Requested Transfer Date:

Acute inpatient care    Subacute care    Skilled nursing facility    Home health services    Outpatient services    Other:

Transfer of imaging/radiology required: Yes    Transfer of labs: Yes    Transfer of medication administration records: Yes

Authorization to Release Medical Information

I hereby authorize the release and transfer of the patient medical record and other information necessary to effect transfer of care from the transferring facility and providers to the receiving facility and providers identified above. This authorization includes, but is not limited to, history and physicals, progress notes, medication lists, laboratory and imaging reports, consult notes, operative reports, and discharge summaries.

Sensitive information that may be included in the record (such as behavioral health, HIV status, genetic information, and substance use disorder treatment) is authorized for release unless explicitly indicated below. I understand that the recipient may use this information for treatment, payment, and health care operations and that redisclosure may occur in accordance with applicable law.

Exclude behavioral/mental health records    Exclude substance use disorder treatment records    Exclude HIV-related records

Authorization to release (select one or more): Full medical record Clinical summary Imaging and radiology reports

This authorization is valid until:    If no date is provided, this authorization will expire ninety (90) days from the date of signature.

Acknowledgements and Certifications

By signing below, I certify that I am the patient or a person authorized to act on behalf of the patient. I acknowledge that I have the authority to request the transfer and to authorize disclosure of the medical information described above. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

I understand that authorizing the disclosure of this health information is voluntary. Treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on signing this authorization, except where allowed by law. I acknowledge that copies of this authorization shall be as valid as the original.

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