Patient Transfer Authorization
Guardian (if Patient is under 18)
Proxy (if Patient is incapacitated)
Proxy’s Relationship to Patient
Reason for Transfer:
Mode of Transportation
I, the Patient (or Guardian or Proxy), verify that my current physician has examined me and determined that my
condition requires transportation to the hospital or clinic listed above. My physician has explained my situation
and has adequately outlined the risks of transportation, as well as the risks of not transferring. I agree to be
transferred to the aforementioned physician and hospital, by means of the transportation listed above.
I, the patient’s current physician, verify that I have examined and diagnosed the patient. I judge him/her to be in
stable condition and capable of travel. I believe that the benefits of the transfer outweigh the risks, and that the
patient is in need of care that can only be provided at the hospital/clinic listed above. I have cleared the transfer
with the physician who will be receiving the patient.