Outgoing Transfer Request
Sending/Requestor Facility
*
Chester
Conrad
Cut Bank
Kalispell
Shelby
Whitefish
Patient Account #
*
Sending Physician/Provider
*
Requestor Name
*
Requestor Phone Number
*
Requestor Department
*
Patient Last Name
*
Patient First Name + Middle Initial
*
Patient's Date of Birth
*
Calendar Icon
Calendar
Patient Gender:
*
Select or enter value
Caret Icon
Caret symbol
Patient Address, City, State, Zip, if tx'ing home
Patient Clinical Information
Patient COVID status
*
Positive
Negative
Not tested
Patient Height (Inches)
*
Patient Weight (KG)
*
Patient Blood Pressure
Patient Heart Rate
Patient O2 Needs (L/min)
Patient O2 Sat:
Patient Respiration Rate
Patient Temperature:
Patient FIO2
Patient Diagnosis
*
Patient Medications
*
Infusions/Titratable Meds: Anticipated-next 2 hrs
Patient Stability
*
Stable
Unstable
Patient Transport Information
Mode of transport requested
*
Air
EMS Ground
Air Ambulance Type
*
Fixed Wing
Rotor
Unknown
Clinical Needs for patient
*
Intubated
Bipap
Isolette
Cardiac Monitoring
Other (Add Comment)
None
Special Equip. Needs During Transport (if appl)
Transport Acuity Need
*
BLS
ALS
Critical Care-Air (ALERT)
Critical Care-Ground
Patient Authorization Requirements
Patient Transfer Priority
*
Emergent-must transfer within 6 hours (No auth required)
Urgent-patient needs to transfer outside business hours (Retro auth will occur)
Elective or Non-Urgent/Emergent-Often post-acute transfer (SNF, LTACH, Rehab Ctr, etc.) (Prior authorization or ABN required)
Requested Transfer Date
*
Calendar Icon
Calendar
Is transfer request to closest facility for needs?
*
Yes
No
Is patient requesting non-closest facility?
*
Yes
No
Is Advanced Beneficiary Notice (ABN) issued to pt?
Yes
No
Accepting Facility Information (if applicable)
Is there an accepting facility?
*
Yes
No
Not applicable, patient discharging to home
Does accepting facility need to be secured?
Yes
No
Accepting Facility Name
Accepting Facility NPI #
Accepting Facility Address
Accepting Facility Phone #
Accepting Provider Name
Accepting Provider NPI
Related Documents, as applicable
COBRA, PCS, Facesheets, etc.
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