Medical Data Transfer Log Form
Record each medical data transfer event, including what was transferred, between which parties, how it was sent, and the transfer status.
Transfer Record Details
Date of Transfer
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Transfer
*
Hour Minutes
AM
PM
AM/PM Option
Transfer Direction
*
Outgoing
Incoming
Internal Transfer
Data Category Being Transferred
*
Lab Results
Imaging
Visit Notes
Prescriptions
Discharge Summary
Other Medical Records
Transfer Method
*
Please Select
Secure Email
EHR System
Fax
Encrypted File Transfer
Physical Media
Other
Sender and Recipient Information
Sending Department or Organization Name
*
Receiving Department or Organization Name
*
Sender Contact Name and Role/Title
*
Recipient Contact Name and Role/Title
*
Recipient Destination / Contact Details
*
Authorization and Tracking
Authorization Basis for Transfer
*
Treatment
Patient Request
Internal Care Coordination
External Provider Request
Other
Transfer Status
*
Completed
Pending
Completion Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Notes / Exceptions
Submit
Should be Empty: