Problem Transfer Report Form - Los Angeles County Department Of Health Services
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1
2LOS ANGELES COUNTY
DEPARTMENT OF HEALTH SERVICES
Page 1 of 2
PROBLEM TRANSFER REPORT FORM
TODAY’S DATE: ____________________________
TO:
John Quiroz, Program Manager
Problem Transfer Reports that involve Intra-
Emergency Medical Services Agency
County or inpatient transfer issues are to be
10100 Pioneer Blvd.
submitted directly to John Quiroz,
Santa Fe Springs, CA 90670
Emergency Medical Services Agency
Tel: (562) 347-1510
Fax: (562) 946-5716
E-mail: jquiroz@dhs.lacounty.gov
Or
Eric Stone, Program Manager
Problem Transfer Reports that involve
Health Facilities Inspection Division
potential EMTALA violations are to be
Los Angeles County Department of Public Health
submitted directly to Eric Stone, Health
3400 Aerojet Avenue, Suite #323
Facilities Division
El Monte, California 91731
Tel: (626) 312-1142
Fax: (626) 927-9293
E-mail: Eric.Stone@cdph.ca.gov
FROM:
NAME OF HOSPITAL:
______________________________________________________________
DEPARTMENT:
______________________________________________________________
CONTACT PERSON:
_____________________________ TELEPHONE#:____________________
ALTERNATE:
_____________________________ TELEPHONE#:____________________
BEST TIME TO CONTACT:
______________________________________________________________
AM
PM
Date/Time of Occurrence:
_____/_____/_____
:
Patient’s Name:
__________________________________
HOSP #: ________________________________________
ED to ED Transfer
Inpatient Transfer
Sending Facility ______________________________________
Contact #
_____________________________________
Sending Physician
__________________________________
Contact #
_____________________________________
Receiving Facility
__________________________________
Contact #
_____________________________________
Receiving Physician __________________________________
Contact #
_____________________________________
Instructions
This form may be used by Department of Health Services (DHS) Acute Care Facilities to report a non-County facility to
Health Facilities Investigation Division for incidents that involved the inappropriate transfer or discharge arrangement of a
patient to a DHS facility which may have violated an element of the Emergency Medical Treatment and Active Labor Act
(EMTALA) and may have resulted in an adverse outcome. Please complete this form and include as much pertinent
clinical information or attachments to demonstrate the patient’s medical condition, specific treatment concerns and
other details relevant to the patient transfer arrangement. The Problem Transfer report and attachments are to be
submitted to the Health Facilities Investigation Division.
1/15/2015
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