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 NO
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  O  EKG  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: 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                                         /