Appendix C
PATIENT TRANSFER FORM

Patient Name_________________________________________________________________________________
Sex ______ Date of Birth _______________ Social Security No. _______________________________________
Marital Status _____ Religion ____________________________________________________________________
Referred To ___________________________________________________________________________________
Referred From _________________________________________________________________________________
Date of Transfer ________________________________________________________________________________
Referring Unit _________________________________________________________________________________
Referring Unit Phone No. ________________________________________________________________________
Authorization from Receiving Facility (non-physician)
Name/Title ____________________________________________________________________________________
Hospital Medical Record Number _________________________________________________________________
Dates in Acute Care ___________ to ______________________________________________________________
Dates in Skilled Nursing Facility Care ___________ to ________________________________________________
Address/Phone Where Patient To Be Seen (for Home Health Referral)
______________________________________________________________________________________________
Contact Person Name___________________________________________________________________________
Relation to Patient _____________________________________________________________________________
Contact Person ________________________________________________________________________________
Home Phone __________________________________________________________________________________
Work Phone ___________________________________________________________________________________

Family Notification
Nearest Relative (Name)_________________________________________________________________________
Relationship ____________________________________________ Notified Yes__________ No___________
Rehabilitation Potential: Good________ Fair________ Other ________________________________________

Plan of Care
Physician Responsible for Care ___________________________________________________________________
Office Phone __________________________________________________________________________________
Message Phone ________________________________________________________________________________
Other Physician(s) Involved in Care________________________________________________________________
Office Phone __________________________________________________________________________________
Message Phone ________________________________________________________________________________
Discharge Diagnosis ____________________________________________________________________________
______________________________________________________________________________________________
Surgery (Date, Type, Surgeon) ____________________________________________________________________
Other Health Problems __________________________________________________________________________
Physician Orders for Treatments __________________________________________________________________
Physician Orders for Medications _________________________________________________________________
______________________________________________________________________________________________
Allergies ______________________________________________________________________________________
______________________________________________________________________________________________
Diet __________________________________________________________________________________________
Code Status (check one) Resuscitation_____ Do Not Resuscitate______
Possessions Sent Ring______ Watch______ Glasses______ Dentures______ Hearing Aides______

Most Recent Patient Assessment
Height __________________________ Weight __________________________
Last Vital: Temperature __________ Pulse __________ Respirations __________
Blood Pressure __________ Lung Sounds __________ Pain Rating @ Transfer (1-10) _________________
Pain Acceptable Yes__________ No__________ Managed with ____________________________________

Follow-up Care
Follow-up Physician Appointments ________________________________________________________________
Follow-up Laboratory____________________________________________________________________________
Follow-up X-ray ________________________________________________________________________________

Medical Record Copies (if applicable)
Laboratory ________________________________________________________________________________
Occupational Therapy _______________________________________________________________________
Patient Teaching Sheet(s) ___________________________________________________________________
X-ray _____________________________________________________________________________________
Consultation Notes _________________________________________________________________________
Medication Administration ___________________________________________________________________
Physical Therapy ___________________________________________________________________________
Speech Therapy ___________________________________________________________________________
Record ___________________________________________________________________________________
Consultation Notes _________________________________________________________________________
Consultation Notes _________________________________________________________________________

Living Will Yes__________ No__________ and Copy Sent Yes__________ No__________
Durable Power of Attorney Yes/No__________ and Copy Sent Yes__________ No__________

Name/title of person completing transfer form
_____________________________________________________________________________________________
Title ______________________________________________________ Date _____________________________
Physician Signature_____________________________________________________________________________
Date _____________________________

Name/title of person in charge of admitting the patient
_____________________________________________________________________________________________
Title ______________________________________________________ Date _____________________________
Physician Signature_____________________________________________________________________________
Date_____________________________

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