SINGLE PATIENT TRANSFER AGREEMENT - Huntsville Hospital System - huntsvillehospital 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and address in the designated fields at the top of the form.
3. Review each condition outlined in the agreement, ensuring that all necessary information is available for Huntsville Hospital regarding personnel, space, and facilities.
4. Fill in details about medical screening and stabilizing treatment provided by the transferring facility prior to transfer.
5. Provide information on patient coverage or eligibility under any applicable health plans, including Medicare or Medicaid.
6. Specify transportation arrangements, including type and any special requirements needed during transfer.
7. Ensure that copies of relevant medical records are prepared for submission to Huntsville Hospital.
8. Complete the signature section with authorized representatives' names, signatures, dates, and times.
9. Designate a contact person for transferring back the patient along with their phone number.

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