Get Patient Transfer Form - College Of Physicians And Surgeons Of ... - Cpsbc

This guide provides clear instructions on completing the Patient Transfer Form required for the Maintenance Program in British Columbia. Follow each step carefully to ensure the form is filled out accurately and completely.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to obtain the Patient Transfer Form and open it in your document editor.
2. Fill out the patient information section. Begin with the surname and given name of the patient. Next, provide the date of birth (DOB) and personal health number (PHN) to accurately identify the patient.
3. Complete the physician information section by indicating the transferring physician's details including their name and CPSID (College of Physicians and Surgeons identification number). Also, specify the name and CPSID of the receiving physician.
4. Ensure that the receiving physician certifies that the patient meets the criteria for admission to the Maintenance Program by checking the 'AGREE' box.
5. The receiving physician must also confirm their commitment to managing the patient according to the program's guidelines by checking the second 'AGREE' box.
6. Complete the third certification by confirming that the prior treating physician has been contacted and mutual agreement has been reached for the transfer. Fill in the name and CPSID of this physician, and include their contact number and fax.
7. The receiving physician should sign and date the form, ensuring the date is written in the format of year, month, and day (YYYY-MM-DD).
8. In the patient consent section, the patient must provide their full name, sign and date the form, giving permission for the College to release their medication profile information.
9. Include the witness's signature and date in the designated area.
10. Once all fields are completed, check that all necessary signatures are provided. Save your changes, then download, print, or share the form as needed. It is advised to fax the completed form to the BC Program at 604-733-1267 for efficiency.

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