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Get Patient Transfer Authorization Form 2009-2024

7822 REQUESTED TRANSFER DATE: (Please note: Authorization #s are only valid for 24 hours) â–¡ Emergency Transfer â–¡ Non Emergency Transfer â–¡ Patient requires transportation and medical supervision by a paramedic â–¡ Patient requires transportation only, please indicate transportation provider SENDING HEALTHCARE FACILITY Patient Surname: First Name: Sending Healthcare Facility: Unit/Room: Healthcare Facility Unit Telephone (area code mandatory): ( ) - Healthcare Facility Unit Fax numb.

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