COVID-19 Post-Acute Care Facility Transfer Form

COVID-19 Post-Acute Care Facility Transfer Form
Hospitals are required to test patients for COVID-19 within 48 hours prior to transfer them to a post-acute care facility.
Patient Name
First NameLast Name
Transferring Facility
Accepting Facility
COVID-19 Test Date
MonthDayYear
Date
Indication of Testing
COVID-19 Test Result
Please select the options that apply
Is another COVID-19 test planned/pending?
Patient is allowed to transfer to a post acute-care facility.
May not transfer unless facility is equipped to maintain transmission based precaution.
Await results.
Patient is allowed to transfer to a post acute-care facility. The required negative COVID-19 test result is submitted along with this transfer form.
Date
MonthDayYear
Date
Clinical Assessment Completed by
First NameLast Name
Signature
Clear
Reported to (name of facility staff)
First NameLast Name
Should be Empty: