Ambulance Transfer Request Form

Patient Transfer Request Form

Utilize this form for any transport request at least 48 hours in Advance, if you need immediate assistance please Call 915-248-4863
Patient's Full Name*

First NameMiddle NameLast Name
DOB*

MonthDayYear
Date
Social Security Number*
Insurance*

MedicareMedicaidNo InsuranceSelf PayOther
Insurance Name*
Insurance ID number*
Insurance Group Number*
Transport Date*

MonthDayYear
Date
Pick Up Time*

Hour Minutes

AM/PM Option
Appointment Time

Hour Minutes

AM/PM Option
Patient Returning?*

YesNo
If Returning, shall crew stay with Patient?

YesNo
If this is a Team Transport:

Crew OnlyCrew and Patient
Flight/Tail Number
Pickup Facility / Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pick Up Room / Location*
Pick Up Phone Number*
Please enter a valid phone number.
If this is a Team Transport:

Crew OnlyCrew and Patient
Drop Off Facility / Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drop Off Room / Location*
Drop Off Phone Number*
Please enter a valid phone number.
Who is requesting transfer?*

First NameLast Name
Title of person requesting transfer*
Person requesting transfer phone number*
Please enter a valid phone number.
Reason for Transport?*

Verification Voucher

(if applicable)
Bill Patient (if NO, please upload PCS with form)*

YesNo
File Upload

Cancelof
Bill your Facility*

YesNo

Patient Care Information

(if applicable)
IV / Medications (a Physician's Order is required to administer any IV Medication / Blood Products during transport)*
Is Patient currently under these treatments or procedures (select all that apply)*

NONEOxygenEKGBiPAPCPAPChest TubePICC LineCentral LineArt LineInvasive Pressure MonitoringIVIV LockVentilatorTrachOther
Infectious Disease Precautions*

NONEC-DiffShinglesCovid-19MRSAOther
Weight of Patient*
Height of Patient*
Patient Diagnosis*
Ordering / Sending Physician*
Responsible Agency
Authorizing Signature*

Clear
Should be Empty: