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
Should be Empty:

Behavior Health Service Transport Request Form

Transferring Facility

Destination Facility

Transfer Request Form

Pre-transport Risk Assessment

Sign & Date