Region III MHOAC Hospital Patient Transfer Assistance Form

Purpose

The purpose of this form is to assist hospitals in completing the necessary steps and providing the required information to request MHOAC/RDMHS assistance with transferring patients to other hospitals pursuant to the August 16, 2021 CA State Public Health Officer Order. Hospitals are expected to exhaust their normal patient transfer process prior to requesting MHOAC/RDMHS assistance. Completion of this form does not guarantee bed availability or patient transfer. Bed transfers are done as medically appropriate.

Requesting/Transferring Hospital Information

Transfer Details, Necessity & Steps Taken

Patient Information