Transfer Out Form

Questions	Concepts
Receiving Facility __________________________________	161562 Name of where the patient was referred to
Transfer-Out Date (Date transfer-out takes effect) ␣␣-␣␣-␣␣␣␣ 📆	160649 Date transferred out
Transfer-out Verified 🔘 Yes 🔘 No 🔘 Unknown	169465 Transfer out verification complete 1065 Yes 1066 No 1067 Unknown
Date verification done ␣␣-␣␣-␣␣␣␣ 📆	169466 Datetime of verification
Notes __________________________________	160632 Free text general