Ptac Transfer Authorization Form – Fill Out and Use This PDF

Please Fax this Document to 1-866-301-5262

Enquiries call 1-866-869-7822

REQUESTED TRANSFER DATE:

(Please note: Authorization #s are only valid for 24 hours)

□ Emergency Transfer

□

Non Emergency Transfer

SENDING HEALTHCARE FACILITY

Patient Surname:

First Name:

Sending Healthcare Facility:

Unit/Room:

Healthcare Facility Unit Telephone (area code mandatory): (

)

-

ext:

Healthcare Facility Unit Fax number (area code mandatory): (

)

-

Patient sex: M □

F □ Age or DOB is Mandatory: Age ________ or DOB ________ / _____ / _____ (YYYY/MM/DD)

Nurse/Clerk – filling out this form must provide: Name (print)

______________________

Signature

__________________ Sending Physician Name: ______________________________

1)

Is the patient admitted or being transferred for admission?

Yes □

No □

2)

Does the patient work for a health care agency/organization?

Yes □

No □

3)

Is the patient a resident of a long-term care facility?

Yes □

No □

4)

Does the patient have new/worse cough or SOB?

Yes □

No □

5)

Is the patient feeling feverish or had shakes or chills within the last 24 hours? Yes □ No □ Temp

° C

6)

Has the patient lived/visited: MEXICO, Vietnam, Hong Kong, Taiwan, Thailand, China, Indonesia, Cambodia

and/or Malaysia within the last 30 days?

Yes □

No □

7)

Has the patient had contact with poultry or other fowl while living or traveling in these areas? Yes □

No □

8)

Has the patient come in contact with a sick person in the last 30 days who has traveled to these same areas?

Yes □

No □

Receiving Health Care Facility:

Unit/Room:

Healthcare Facility Unit Telephone (area code mandatory): (

)

-

, ext:

Receiving Physician: