Inter-facility Patient Transfer Form - cdph ca 2026

1. Click ‘Get Form’ to open the Inter-facility Patient Transfer Form in the editor.
2. Begin by entering the Sending Facility Name and Address at the top of the form. This information is crucial for identifying where the patient is being transferred from.
3. Fill in the patient's Last Name, First Name, Date of Birth, and Medical Record Number. Accurate patient identification is essential for continuity of care.
4. Provide contact details for both the person completing the form and an alternate contact. Include names, telephone numbers, and fax numbers as needed.
5. Indicate if the patient has a positive culture of a multidrug-resistant organism (MDRO) by checking the appropriate boxes. Attach any relevant culture reports to ensure proper treatment upon transfer.
6. Document any current symptoms or infections that may affect patient care during transfer. This includes checking boxes for symptoms like productive cough or diarrhea.
7. Complete vaccination history by noting down dates administered and vaccine details if known. This information helps receiving facilities manage ongoing care effectively.
8. Finally, sign and date the form to validate it before sending it along with the patient to ensure all necessary information is communicated.

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