A Form Hfel-7 is a document that is used to request an abatement of real property taxes. This document must be filed with the assessor's office by May 1st in order to receive any relief for the upcoming tax year. The form can be used to request relief for a variety of reasons, including changes in ownership, or if the property has been damaged or abandoned. The amount of relief that will be granted depends on the situation, so it is important to carefully fill out the form and provide all relevant information.
| Question | Answer |
|---|---|
| Form Name | Form Hfel 7 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Defib, nj universal transfer form, new jersey universal transfer form, C-Diff |
NEW JERSEY UNIVERSAL TRANSFER FORM
(Items 1 – 28 must be completed)
1. |
TRANSFER FROM: |
|
|
|
|
|
|
|
|
|
|
|
|
|
2. |
DATE OF TRANSFER: |
|
|
|
|
|||||
|
TRANSFER TO: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
TIME OF TRANSFER: |
|
|
|
AM/ PM |
||||
3. |
PATIENT NAME: |
|
|
|
|
|
|
|
|
|
|
|
|
|
4. |
LANGUAGE: |
English |
Other: ____________ |
|||||||
|
|
|
|
|
|
|
Last |
|
First Name and Nickname |
|
|
MI |
|
|
|
|
|
|
|
|
|||||
|
PATIENT DOB (mm/dd/yyyy): |
|
|
|
|
GENDER |
|
M |
F |
6. |
CODE STATUS: |
DNR |
DNH |
|
DNI |
||||||||||
5. |
PHYSICIAN NAME |
|
|
|
|
|
|
|
|
|
PHONE |
|
|
|
|
|
|
Out of Hospital DNR Attached |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
7. |
CONTACT PERSON |
|
|
RELATIONSHIP |
|
|
|
Check if Contact Person: |
|
|
|
||||||||||||||
|
PHONE (Day) |
|
|
|
|
|
(Night) |
|
|
|
|
(Cell) |
|
|
|
|
Health Care Representative/Proxy |
Legal Guardian |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
NAME OF |
HEALTH CARE REPRESENTATIVE/PROXY |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
OR |
LEGAL GUARDIAN, IF NOT CONTACT PERSON: |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||
|
PHONE (Day) |
|
|
|
|
|
(Night) |
|
|
|
|
(Cell) |
|
|
|
|
|
|
|
|
|
|
|
||
8.REASONS FOR TRANSFER: (Must include brief medical history and recent changes in physical function or cognition.)
V/S: BP |
|
P |
|
R |
|
T |
|
PAIN: |
None
Yes, Rating |
|
Site |
|
Treatment |
9. |
PRIMARY DIAGNOSIS |
|
|
|
|
|
|
|
|
|
|
|
|
Pacemaker |
|||
|
Secondary Diagnosis |
|
|
|
|
|
|
|
|
|
|
|
|
Internal Defib. |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
Mental Health Diagnosis (if applicable) |
|
|
|
|
|
|
|
|
|
|
|
|||||
10. |
RESTRAINTS: |
No |
Yes (describe) |
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|||||||
11. |
RESPIRATORY NEEDS: |
None |
|
Flow Rate |
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
CPAP |
BPAP |
Trach |
Vent |
Related details attached |
Other |
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
||||||
12. |
ISOLATION/PRECAUTION: |
None |
MRSA |
VRE |
ESBL |
Other |
|||||||||||
|
Site |
|
|
|
Comments |
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
Colonized |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
20. |
AT RISK ALERTS: |
|
None |
|
Falls |
Pressure Ulcer |
|
|
Wanders |
Elopement |
|
|
Harm to: |
N/A |
Self |
|
Weight Bearing Status: |
|
|
|
Left Leg: |
Limited |
|
|
Right Leg: |
Limited |
|
21. |
MENTAL STATUS: |
|
|
Aspiration
Seizure
Others
None
Full
Full
13. |
ALLERGIES: |
None |
Yes, List |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
14. |
SENSORY: |
Vision |
|
Good |
Poor |
Blind |
Glasses |
|
|
|
|
Hearing |
|
Good |
Poor |
Deaf |
Hearing Aid |
Left |
Right |
|
|
Speech |
|
Clear |
Difficult |
Aphasia |
|
|
|
15. |
SKIN CONDITION: |
No Wounds |
|
|
|
|
|
||
Alert |
|
Forgetful |
Oriented |
|
Unresponsive |
|
Disoriented |
Depressed |
|
Other |
|
|
|
|
|
|
|
|
|
22. FUNCTION: |
Self |
With Help |
Not Able |
|
Walk
Transfer
Type:
Site
Type:
Site
16. DIET:
YES, Pressure, Surgical, Vascular, Diabetic, Other
P |
S |
V |
D |
O |
|
|
|
|
|
Size |
|
|
Stage (PRESSURE) |
|
Comment |
|
|
|
|
|
|
|
|
P |
S |
V |
D |
O |
|
|
|
|
|
Size |
|
|
Stage (PRESSURE) |
|
Comment |
|
|
|
|
|
|
||
Regular |
Special (describe): |
|
|
||||
SEE ATTACHED TAR
Toilet
Feed
23. IMMUNIZATIONS/SCREENING:
Flu Date: |
Tetanus Date: |
|||||
|
|
|
|
|
|
|
Pneumo Date: |
PPD +/- Date: |
|||||
|
|
|
|
|
|
|
Other: |
Date: |
|||||
|
|
|
|
|
|
|
|
Tube feed |
Mechanically altered diet |
Thicken liquids |
|
|
|
|||||
17. |
IV ACCESS: |
None |
PICC |
Saline lock |
IVAD |
AV Shunt |
Other: |
||||
|
|
|
|
|
|
|
|
||||
18. |
PERSONAL ITEMS SENT WITH PATIENT: |
None |
Glasses |
Walker |
Cane |
||||||
|
Hearing Aid: |
Left |
Right |
Dentures: |
Upper/Partial |
Lower/Partial |
Other: |
||||
|
|
|
|
|
|
|
|
|
|
|
|
24.BOWEL: Continent Incontinent Date last BM Comments:
25. BLADDER: |
Continent |
Incontinent |
Foley Catheter |
Comments:
19.ATTACHED DOCUMENTS: MUST ATTACH CURRENT MEDICATION INFORMATION
Labs |
Operative Report |
Respiratory Care |
Advance Directive |
Other:
Face Sheet Code Status
MAR |
Medication Reconciliation |
|
Discharge Summary |
PT Note |
|
TAR POS
OT Note
Diagnostic Studies
ST Note |
HX/PE |
26. |
SENDING FACILITY CONTACT: |
|
Title |
|
Unit |
|
Phone |
|||
|
REC’G FACILITY CONTACT (if known): |
Title |
|
Unit |
|
Phone |
||||
|
|
|
|
|
|
|
|
|
|
|
27. |
FORM PREFILLED BY (if applicable): |
Title |
|
Unit |
|
Phone |
||||
|
|
|
|
|
|
|
|
|
||
28. |
FORM COMPLETED BY: |
|
Title |
|
|
|
Phone |
|||