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
2 digit month, 2 digit day, 4 digit yearDate
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
2 digit month, 2 digit day, 4 digit yearDate
Clinical Assessment Completed by
First NameLast Name
Signature
Clear
Reported to (name of facility staff)
First NameLast Name
Should be Empty: