Healthcare Transfer Request

HEALTHCARE TRANSFER REQUEST

Patient Identification

Patient Name:    DOB:    Gender:

Insurance / Billing

Transfer Details

Transfer Date Requested:    Estimated Arrival / Time:

Continuity of care    Higher level of care    Patient request    Specialty consultation    Other:

Ground ambulance    Air ambulance    Private transport    Ambulatory    Medical escort    Medical records / documentation only

Immediate / Emergent    Urgent    Non-urgent / Routine

Clinical Summary (for receiving facility)

None known    Active infection (specify):

Attachments / Items Sent with Patient

Transfer summary    Discharge summary    Medication list    Imaging (CD/Reports)
Laboratory results    Advance directives / DNR    Signed consent forms    Other:

Authorization to Transfer and Release Records

I authorize the transferring facility and my health care providers to release and transfer to the receiving facility all medical records, images, laboratory results, and other protected health information necessary for continuity of care. This authorization specifically includes information related to behavioral health, substance use disorder treatment, HIV status, and genetic testing where applicable, unless indicated otherwise below.

I understand that: (a) this transfer is being requested for the reasons described above; (b) the receiving facility will use the information for treatment, care coordination, and billing; (c) I may revoke this authorization in writing at any time except to the extent action has already been taken in reliance on it; and (d) the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Electronic transfer of records: I consent to the secure electronic transmission of my records where feasible (including secure messaging, direct exchange, or encrypted email) and understand that some media (fax, CD) may be used as required.

Special handling / instructions:

Requestor / Facility Information (for administrative use)

By signing below, I certify that I am the patient or the patient's authorized representative and that I have the legal authority to request this transfer and authorize release of medical information as described. I understand the foregoing statements, and I authorize the transfer and disclosure as indicated.

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