Scribd
Upload
4K views1 page

Transfer To Hospital of Choice Form: Physician Section Hospital Section

1) This document is a transfer form for transferring a patient from one hospital to another hospital of choice. 2) It contains information about the patient, reason for transfer, accepting physician, patient's medical condition, risks of transfer, and consent from the patient. 3) Upon transfer, the receiving hospital must accept the patient, vital signs and medical information are reported, and copies of records are provided.

Uploaded by

Aina Haravata
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
4K views1 page

Transfer To Hospital of Choice Form: Physician Section Hospital Section

1) This document is a transfer form for transferring a patient from one hospital to another hospital of choice. 2) It contains information about the patient, reason for transfer, accepting physician, patient's medical condition, risks of transfer, and consent from the patient. 3) Upon transfer, the receiving hospital must accept the patient, vital signs and medical information are reported, and copies of records are provided.

Uploaded by

Aina Haravata
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

Form No.

:
Case No.:
Hospital No.:
TRANSFER TO HOSPITAL OF CHOICE FORM
PATIENT’S NAME: AGE: SEX: ROOM No:.
ATTENDING PHYSICIAN:

PHYSICIAN SECTION HOSPITAL SECTION


8. TRANSFER DATE/ TIME: / /
1. Reason for Transfer
☐ Need for higher level of care not available at BMC
☐ Need for diagnostic equipment not available at BMC A. HOSPITAL ACCEPTANCE OF TRANSFER
☐ Patient/responsible person's request. B. Address: _____________________________________________
☐ Appropriate service/resource not at BMC
C. Accepted by:
Name of person at Destination Hospital Time
List:

2. Alternatives to transfer discussed D. Acceptance obtained by:_


with patient: BMC Staff Person
List if any_
10.PATIENT CONSENT TO TRANSFER
3. ACCEPTING PHYSICIAN: I understand the risks and benefits of my transfer. Be it known also that I
fully understand the explanation in the language I can comprehend.
__________________________ ___________ ☐ I hereby CONSENT to transfer with the recommended mode of
NAME TIME transport.
☐ I hereby consent to transfer but refuse the recommended mode of
4.MEDICAL CONDITION (list diagnosis)
transport.
______________________________________________________ ☐ Patient involuntary transfer (72 hour hold)
☐ I hereby REFUSE transfer
5. PATIENT CONDITION
☐ A. There is no reasonable likelihood of deterioration from ______________________________________
or during transport.
Patient signature or patient's legally responsible representative
☐ B. The patient may be at risk for deterioration from or during
transport, but benefits outweigh the risks.
_____________________________________
☐ C. Patient is pregnant – contractions ( )
Reason patient unable to sign
6. LEVEL OF TRANSFER (Must check a level)
(If patient / family refuses level of transfer assigned, see # 10) ___________________________________
Qualified personnel will transfer the patient. Witness
☐ BLS Ambulance ☐ Critical Care Ground
11. TRANSPORTATION
☐ ALS Ambulance ☐ Critical Care Flight Service contacted:____________By:____________________ Time:________
7.RISKS OF TRANSFER BMC Staff Person
☐ Cardiac 12. VITAL SIGNS REPORTED AT HAND OFF
decompensation
☐ Pulmonary decompensation bleeding
☐ Deterioration of medical condition: PAINSCALE RATING TEMP
PULSE RESP BP
☐ Vehicular
Based upon myaccident/transport hazards
examination of the patient and the information O2 SAT
available to me at the time of transfer, I certify that the risks of
transfer are outweighed by the benefits reasonably anticipated Report given to :_ By:_
from proper care at the receiving facility. I have explained this to Receiving Hospital RN BMC RN
the patient / patient's legally responsible representative
COPIES OF MEDICAL INFORMATION
☐ Medical Record ☐ EKG ☐ Other :_
__________
Physician’s Signature Date ☐ X-ray / Lab ☐ Medication/IV

This Hospital is required by law to provide any presenting patient with a medical screening examination to determine whether an emergency medical condition exist and
to provide necessary stabilizing care within its capabilities for emergency medical conditions without regard to means or ability to pay.

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy