Transfer Out Form

Receiving Facility

__________________________________

162724 Health facility name

Transfer-Out Date (Date transfer-out takes effect)

␣␣-␣␣-␣␣␣␣ 📆

160649 Date transferred out

Transfer-out Verified***

🔘 Yes

🔘 No

🔘 Unknown

VerificationDone Verification Complete

797e0073-1f3f-46b1-8b1a-8cdad134d2b3

• 1065 Yes

• 1066 No

• 1067 Unknown

Date verification done

␣␣-␣␣-␣␣␣␣ 📆

160753 Date of event

Notes

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165095 General patient note