Patient Transfer and Return Agreement

Patient Transfer and Return Agreement
Patient Information
Name*
Date of Birth

MonthDayYear
Date of Birth

MonthDayYear
Date
Any other name patient may be known by
Diagnosis
Reason for Transfer*
Date of Transfer
Date of Transfer*

MonthDayYear
Date
Anticipated Return Date
Anticipated Return Date*

MonthDayYear
Date
Payor
ID Number
Transferring Facility Information
Facility*
Physician
Patient Account Number
Contact Name*
Contact Title*
Contact Phone Number
Numbers only, please
By the signature of the authorized representative below,

Clear
By the signature of the authorized representative below,
hereinafter referred to as the Transferring facility, hereby affirms and/or agrees that the following conditions are met:
1. The transfer is not based on financial criteria.
2. The transfer is deemed to be medically necessary and believed to increase the patient’s level of care.
3. The patient, his or her designated representative or legal representative has given written informed consent for the transfer.
4. The patient is, to the best of the transferring facility’s ability, medically stable for transport.
5. The transferring facility shall provide all pertinent medical information, including, but not limited to:
  - History of injury or illness
  - Patient condition, including vital signs and any other medical information as requested by the receiving facility or physician at DCH
  - Name, address and telephone number of the physician at the Transferring facility
The Transferring Facility shall be responsible for arranging for the Patient’s appropriate, safe transportation both to and, if applicable, from DCH. The Transferring Facility must arrange for and be the payor of last resort for the transport to DCH with no obligation on the part of DCH. The Transferring Facility shall accept, without limitation or condition and without regard to any infectious disease status, the Patient in return within twenty-four (24) hours of being notified that the determination has been made by the Patient’s physicians at DCH that the condition of the transferred Patient has stabilized and that the particular expertise initially prompting the transfer is no longer required.
Transferring Facility Name
Authorized hospital representative signature*

Clear
Please type name
Title*
Date*
Date

MonthDayYear
Date
Should be Empty: