	Please fill out the appropriate sections of this form and fax or email the completed form. Once received, a MEDIC EMS Dispatcher will contact you to finalize the transfer. If this is an EMERGENT or time critical patient transport, please contact our dispatch center immediately at 563-323-1000.	1204 East High Street Davenport, IA 52803 Phone: (563) 323-1000 Fax: (563) 326-4988
Secure Patient Transfer Form

First Name:

Last Name:

MI:

DOB:

Pickup Facility/Address:

Pickup Room/Location:

Pickup
Phone#:

Drop Off
Facility/Address:

Pickup
Room/Location:

Contact Person:

Contact Phone#:

Contact Fax#:

Transport Date:

Pickup Time:

Appoint. Time:

Patient Returning:Patient Returning:Patient Returning:Patient Returning?:	YES NO	Insurance:	Medicare Medicaid Other
If Returning, shall crew stay with Patient?:	YES NO	Reason for Transport?:

Date/Time of Admission to Your Facility:

Verification Voucher (if applicable)

Bill Patient:

YES

NO (If YES, please fax PCS with form)

Bill your Facility:

YES

Responsible Agency:

Authorizing Signature:

Patient Care Information (if applicable)

IV/Medications*:

*A Physician's Order is required to administer any IV Medications/Blood Products during transport.

Check:	None O₂EKG BiPAP CPAP Chest Tube PICC Line Central Line Art Line Invasive Pressure Monitoring
	IV IV Lock Ventilator Trach Other

Infectious Disease
Precautions:

MRSA C-DIFF Shingles Other:
COVID-19

PPE:

Gown Mask

Weight of Patient:

Kg Lbs

Height of Patient:

Cot Size:

Regular Winged Bariatric

Patient Diagnosis:

Ordering/Sending Physician:

Ventilator/BiPAP Settings (if applicable)

Assist Control Volume

Assist Control Pressue

SIMV Volume

SIMV Pressue

BiPAP /