Healthcare Transfer Forms

HEALTHCARE TRANSFER FORM

Transfer Details

Transfer Date:   Time:

Transfer initiated by: Patient Family Physician Other   If Other, specify:

Patient Information

Date of Birth:   Gender: Male Female Other

Insurance Information

Clinical Summary

Most recent vital signs: BP   HR   RR   Temp

Clinical Orders & Precautions

Code Status: Full Code Do Not Resuscitate (DNR) Do Not Intubate (DNI) Comfort Measures Only

Contact Droplet Airborne None Other  If Other, specify:

Oxygen:   Ventilator settings (if applicable):

Accompanying Documentation

Documents included: Transfer Summary Medication List Imaging Reports Laboratory Results Consent Forms Advance Directive

Patient Authorization and Acknowledgment

I, , authorize the transfer of my care from to .

By signing below I acknowledge that transfer involves potential risks, including but not limited to changes in condition during transport and delays in care. I acknowledge that the information provided herein is true and accurate to the best of my knowledge and that I have been afforded the opportunity to ask questions about the transfer and the destination facility.

I authorize the sending facility to release relevant medical records, diagnostic tests, and treatment information to the receiving facility and to authorized personnel involved in my care for the purpose of continuity of treatment.

Certification by sending clinician: I certify that the clinical information above is accurate and complete to my knowledge and that the patient is medically appropriate for transfer under the conditions stated.

Patient / Representative Signature

If signing as legal guardian or representative, provide relationship and authority to consent:

By signing below I attest that I am the patient or authorized representative and that I have read and understand this transfer authorization and release.

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