Behavior Health Service Transport Request Form

Behavior Health Service Transport Request Form
Patient Last Name:*
Patient First Name:*
Patient Middle Name:
Street Address:*
City:*
State:*
Zip:*
Age:*
DOB:*
Social Security #:
Insurance:
Policy #:
Emergency Contact:*
Emergency Contact Phone:*
Transferring Facility
Transferring Facility:*
Street Address:*
City:*
State:*
Zip:*
Room:*
Phone:*
Requesting/Contact Person:*
Contact Person Phone:*
Physician (Printed Name):
Destination Facility
Destination Facility:*
Street Address:*
City:*
State:*
Zip:*
Room:*
Phone:*
Requesting/Contact Person:*
Contact Person Phone:*
Physician (Printed Name):
Has the Destination Facility agreed to admit the patient?*
Transfer Request Form
All forms have been completed, signed and submitted with this transfer request.*
Note- transporting units will be dispatched only after receipt of completed Transport Request Form
Pre-transport Risk Assessment
Do physical limitations prohibit transport by car; ambulatory, weight, or other?*
Is the patient a juvenile?*
Does the patient require restraints for transfer (has the patient recently been restrained)?*
Are there identified complicating medical conditions with potential for difficulty enroute?*
Was there assaultive behavior in connection with this admission?*
Was there use of PRN medications for agitation with this admission?*
Does the patient exhibit imminent suicidal ideations?*
Does the patient have a recent history of attempted elopement (fleeing the hospital)?*
Is the patient sufficiently stabilized for transport?*
Is patient a court committal/ judicial hold?*
Sign & Date
Printed Name*
Date*
Signature

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Behavior Health Service Transport Request Form

Transferring Facility

Destination Facility

Transfer Request Form

Pre-transport Risk Assessment

Sign & Date