KPC Global Transfer Request Form
For any questions, please call 844-937-2572
Transferring Facility Information
Case Mgr/SW/RN
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Requesting Facility
Date of Transfer
-
Month
-
Day
Year
Date
Referring MD
First Name
Last Name
Referring MD's Phone Number
Please enter a valid phone number.
Referring Specialist
First Name
Middle Name
Last Name
Referring Specialist's Phone Number
Please enter a valid phone number.
Admit Date
-
Month
-
Day
Year
Date
Unit
Unit Phone Number
Please enter a valid phone number.
Patient Information
Patient Name
First Name
Middle Name
Last Name
Suffix
Date of Birth
-
Month
-
Day
Year
Date
Sex
Isolation
Yes
No
Isolation Type
Height
Weight
Diagnosis
Level of Care Needed
Accepting Physician
First Name
Middle Name
Last Name
Suffix
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
Other
Code Status
Face Sheet
Sent
Yes
N/A
H&P
Sent
Yes
N/A
COVID Test Results (within last 3 days)
Sent
Yes
N/A
Transfer Order
Sent
Yes
N/A
Progress Notes (within last 2 days)
Sent
Yes
N/A
Consultation Notes
Sent
Yes
N/A
Most Recent Lab Results
Sent
Yes
N/A
Radiology Results
Sent
Yes
N/A
Medication List
Sent
Yes
N/A
All Treatments and Procedures in ED
Sent
Yes
N/A
Authorization from Insurance (if needed)
Sent
Yes
N/A
Submit
Should be Empty: