Patient Transfer Request Form

The Patient Transfer Request Form streamlines the process of transferring a patient's care and medical records from one healthcare provider to another. Whether a patient is relocating, seeking a specialist, switching insurance networks, or simply choosing a new primary care physician, this medical records transfer request form ensures that all the necessary information is collected in a single digital submission so the administrative staff at both the sending and receiving practices can coordinate an efficient, HIPAA-compliant transfer of care.

The form captures comprehensive patient identification, including name, date of birth, phone, email, and address, followed by the current provider's practice name, physician name, phone number, fax, and address. A parallel section collects the same details for the receiving provider or facility. The records-requested section allows patients to specify exactly which portions of their medical record they need transferred: complete medical chart, visit summaries, lab and imaging results, immunization records, medication history, surgical reports, mental health records, substance abuse treatment records, or a custom selection. Patients indicate the preferred transfer method (electronic health record exchange, secure fax, encrypted email, physical mail, patient portal) and the urgency level (routine, urgent, or expedited for upcoming appointments).

The insurance information section captures the patient's current coverage so the receiving provider can initiate verification before the first visit, reducing delays in care continuity. The consent for release section is structured to meet HIPAA authorization requirements under 45 CFR 164.508, including the specific information to be disclosed, the purpose of the disclosure, an expiration date, and the patient's right to revoke authorization. This patient transfer form is essential for primary care practices, multi-specialty groups, hospital discharge planning departments, and any healthcare organization that regularly coordinates care transitions between providers.