Patient Transfer Authorization Form printable pdf download

Patient Transfer Authorization Form

Patient Transfer Authorization

Patient Name

Date

Age

Sex

Guardian (if Patient is under 18)

Proxy (if Patient is incapacitated)

Proxy’s Relationship to Patient

Reason for Transfer:

Current Hospital/Clinic

Current Physician

Transfer Hospital/Clinic

Transfer Physician

Mode of Transportation

Special Equipment

Personnel

Further Instructions

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.

Patient/Guardian/Proxy

Date

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.

Physician Signature

Date

Witness Signature

Date

Patient Transfer Authorization Form