KPC Global Transfer Request Form
Fax Patient Form to (833) 642-0582
Transferring Facility Information
Case Manager/SW/RN
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Requesting Facility
Date of Transfer
-
Month
-
Day
Year
Date
Referring MD
Referring MD Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Specialist
Referring Specialist Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Admit Date
-
Month
-
Day
Year
Date
Unit
Unit Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Information
Patient Name
Date of Birth
-
Month
-
Day
Year
Date
Sex
Isolation
Yes
No
Type a question
Height
Weight
Diagnosis
Level of care needed
Attending Physician
Reason for Transfer
Lateral
HLOC
Reason for Transfer
Patient Insurance
Additional Information
Services Available
Yes
No
Sitter Required
Yes
No
Vent/Trach/Intubated/BiPAP/Drips
Yes
No
Dialysis
Yes
No
Patient/Family Consent to Transfer
Yes
No
COVID within 3 days
Yes
No
Rows
Sent
Yes
N/A
Face Sheet
H&P
COVID Test Results (within last 3 days)
Transfer Order
Progress Notes (within last 2 days)
Consultation notes
Most Recent Lab Results
Radiology Results
Medication List
All Treatment and Procedures in ED
Authorization from Insurance (if needed)
Submit
Should be Empty: