State of California--Health and Human Services Agency California Department of Public Health TRANSFER AGREEMENT BETWEEN __________________________________________ Name of Hospital __________________________________________ Street Address __________________________________________ City, State, and ZIP Code AND __________________________________________ Name of Facility __________________________________________ Street Address __________________________________________ City, State, and ZIP Code To facilitate continuity of care and the timely transfer of patients and records between the hospital and the facility, the parties named above agree as follows: 1. When a patient's need for transfer from one of the above institutions to the other has been determined and substantiated by the patient's physician, the institution to which transfer is to be made agrees to admit the patient as promptly as possible, provided admission requirements in accordance with federal and state laws and regulations are met. 2. The transferring institution will send with each patient at the time of transfer, or in the case of emergency, as promptly as possible, the completed transfer and referral forms mutually agreed upon to provide the medical and administrative information necessary to determine the appropriateness of the placement and to enable continuing care to the patient. The transfer and referral forms will include such information as current medical findings, diagnoses, a brief summary of the course of treatment followed in the transferring institution, nursing and dietary information, ambulation status, and pertinent administrative and social information, as appropriate. 3. The hospital shall make available it's diagnostic and therapeutic services, including emergency dental care, on an outpatient basis as ordered by the attending physician subject to federal and state laws and regulations. HS 602 (2/08) American LegalNet, Inc. www.FormsWorkflow.com State of California--Health and Human Services Agency California Department of Public Health 4. The institution responsible for the patient shall be accountable for the recognition of need for social services and for prompt reporting of such needs to the local welfare department or other appropriate sources. 5. The transferring institution will be responsible for the transfer or other appropriate disposition of personal effects, particularly money and valuables, and information related to these items. 6. The transferring institution will be responsible for effecting the transfer of the patient, including arranging for appropriate and safe transportation and care of the patient during the transfer in accordance with applicable federal and state laws and regulations. 7. Charges for services performed by either facility shall be collected by the institution rendering such services, directly from the patient, third-party payor, or other sources normally billed by the institution. Neither facility shall have any liability to the other for such charges. 8. The governing body of each facility shall have exclusive control of policies, management, assets, and affairs of its respective institutions. Neither institution shall assume any liability by virtue of the agreement for any debts or other obligations incurred by the other party to this agreement. 9. Nothing in this agreement shall be construed as limiting the rights of either institution to contract with any other facility on a limited or general basis. 10. This agreement shall be in effect from the date both parties sign. It may be terminated by either facility upon 30 days written notice, with copies sent to the district office of the Licensing and Certification Division, having jurisdiction for your facility. 11. This agreement shall be maintained in the facilities' files. _________________________________________________________ Date ________________________________________________________ Date _________________________________________________________ Administrator ________________________________________________________ Administrator _________________________________________________________ Facility ________________________________________________________ Hospital _________________________________________________________ Facility Provider Number ________________________________________________________ Hospital Provider Number HS 602 (2/08) ( American LegalNet, Inc. www.FormsWorkflow.com