PATIENT TRANSFER AGREEMENT BETWEEN _________________________________________
AND
_________________________________________
THIS PATIENT TRANSFER AGREEMENT (“Agreement”) dated ___________ (“Effective Date”) is entered into by and between __________________ (“_______”) and _________________________________ (“__________________”).
WITNESSETH
WHEREAS, _____________ and _______________ share a mutual desire to ensure the continuity of care and treatment appropriate to the needs of each patient in their respective institutions; and
WHEREAS, the purpose of this Agreement is to provide for the orderly transfer of acutely ill patients from the Transferring Facility to the Receiving Facility when the Receiving Facility provides services more appropriate for the patient level of medical need based on the Receiving Facility’s more extensive medical resources, as well as the return or transfer of patients whose condition no longer requires an acute level of medical care to the Transferring Facility;
NOW, THEREFORE, in consideration of the foregoing, the undersigned parties agree as follows:
1. TERM. The term of this Agreement shall be for a period of three (3) years from the
Effective Date set forth above. This Agreement shall automatically renew for successive one (1) year terms.
2. TERMINATION. This Agreement may be terminated by either party at any time and for
any reason upon at least sixty (60) days prior written notice and by ensuring the continuity of care to patients who already are involved in the transfer process. This Agreement shall automatically terminate upon the occurrence of any of the following:
a. either institution has its license revoked or suspended; b. either institution loses its accreditation;
c. either institution is destroyed to such an extent that the patient care provided by such institution cannot be carried out adequately;
d. either institution no longer is able to provide the services for which this Agreement is sought;
e. either institution is excluded from federal health care programs;
f. either institution is in default under any of the terms of this Agreement.
3. TRANSFERRING VS. RECEIVING FACILITY. For purposes of this Agreement, the
patient shall be called the “Receiving Facility.” The definition of “Transferring Facility” includes the main hospital campus and all of its off-campus departments.
4. DUTIES OF THE TRANSFERRING FACILITY. The Transferring Facility shall:
a. Ensure that the Receiving Facility is appropriately qualified, licensed and equipped, by way of bed capacity and resources, to accept, care for and meet the patient's medical needs.
b. Ensure that all transfers are consistent with promotion of the health and safety of the patient as determined by the patient’s physicians and health care professionals. The Transferring Facility shall obtain the consent of the patient or of a legally authorized individual prior to initiating transfer, except that in emergency situations efforts to obtain consent need to be documented by the physician responsible for the patient. c. Comply fully with all applicable laws, regulations and accreditation standards,
including the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); 10A NCAC 13B.3302; 10A NCAC 13B.4101; 10A NCAC 13B.4109.
d. Prior to the transfer, coordinate the transfer with the Receiving Party to ensure a smooth transfer of the patient and his/her records.
e. At the time of transfer, provide the Receiving Party with all pertinent medical information necessary to maintain a continuum of care. Typically, this will include the patient’s name, address, a copy of the patient's history, physical examinations, name of the treating physician, physician progress notes, laboratory reports, x-ray reports, discharge summary and transfer form, among others. The Transferring Facility is responsible for obtaining all necessary medical releases for the release of pertinent medical information.
f. Be responsible for all patient charges incurred until the transfer is completed, including transportation costs.
g. When transferring patients with a known infectious condition, notify the Receiving Facility and take all reasonably necessary and medically appropriate precautions to prevent the spread of disease.
h. Ensure that the patient is sufficiently stabilized for safe transfer. This means that no material deterioration of the patient's condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient.
1. The patient or the patient's legally authorized agent, after being informed of the Transferring Facility’s obligation to provide treatment and of the risks of transfer, in writing, requests a transfer to the Receiving Hospital; or
2. A physician or other qualified medical personnel at the Transferring Facility has signed a certification that, based upon the reasonable risks and benefits to the patient, and based upon the information available at the time of transfer, the medical benefits reasonably expected from treatment at the Receiving Hospital outweigh the increased risks to the patient.
j. Provide the Receiving Facility with reasonable prior notice of the patient transfer. k. Use qualified personnel and transportation equipment including the use of necessary
and medically appropriate life support measures to ensure the timely and safe transfer of patients.
l. Arrange for the provision of security and accountability of patient’s personal effects on transfer.
m. If medically appropriate, accept patient back at the Transferring Facility for further care and treatment.
n. Transfers shall be based upon the recommendation of the transferring physician who has assessed the patient and determined that the transfer is medically appropriate and the acceptance of the transfer by the receiving physician who concurs that transfer to a higher level of care is required, who concurs transfer is medically appropriate, and who reasonably believes that appropriate facilities and staff are not available at the Transferring Facility.
o. To arrange for the transfer of the patient to the Receiving Facility, and to accept and arrange for the transfer of the patient back to the Transferring Facility, when the patient no longer requires the specialized capabilities of Receiving Facility.
5. DUTIES OF RECEIVING FACILITY. The Receiving Facility shall:
a. Comply fully with all requirements of EMTALA.
b. Comply with all applicable laws, regulations, and accreditation standards, including the requirements of the Joint. Commission on Accreditation of Healthcare Organizations (JCAHO).
6. INSURANCE. Each party shall maintain general and professional liability insurance with
7. HOLD HARMLESS. To the extent permitted under North Carolina law, each party on its
behalf, and on behalf of its employees and agents agrees to indemnify and hold harmless other party from any and all claims, demands, damages or any other financial demands (including without limitation attorneys’ fees and expenses) due to any actions or omissions of the other party, its employees or its agents pursuant to this Agreement.
8. INDEPENDENT CONTRACTORS. The parties are independent contractors who shall
have no liability or obligation for the acts or omissions of the other.
9. NONEXCLUSIVE. Nothing in this Agreement shall be construed as limiting the rights of
either party to affiliate or contract with any other hospital or health care provider while this Agreement is in effect.
10. PATIENT REFERRALS. This Agreement does not require either Transferring or
Receiving Facility to refer patients or enter into any other arrangement for the provision of any item or service offered for which Medicare or Medicaid payments may be made.
11. NON-DISCRIMINATION REGARDING PATIENTS. Neither party shall differentiate
or discriminate in the treatment of any patient because of the patient’s race, color, national origin, ancestry, religion, health status, sex, marital status, age, the source or amount of payment available, or the ability of the patients to pay for medical services.
12. BILLING. The parties shall coordinate as necessary to insure that billing of third party or
government payors pursuant to this Agreement is consistent with all applicable legal requirements.
13. ASSIGNMENT. This Agreement may not be assigned by either party without the prior
written consent of the other party.
14. ENTIRE AGREEMENT. This Agreement contains the entire understanding between the
undersigned parties and supersedes any and all prior agreements or understandings, whether oral or written, relating to the subject matter of this Agreement. This Agreement may not be amended, changed or modified except by written agreement executed by both parties hereto.
15. GOVERNING LAW. This Agreement shall be deemed to have been made under and shall
be construed and interpreted in accordance with the laws of the State of North Carolina.
16. CHANGE IN LAW. It is the intention of the parties to comply with all Medicare/Medicaid
renegotiation of this Agreement in order to effect compliance. If such notice is given and the parties are unable within thirty (30) days thereafter to reach an agreement with respect to restructuring of the Agreement, then this Agreement shall automatically terminate.
17. THIRD PARTY BENEFICIARY. The parties do not intend to confer any rights,
privileges or benefits upon any other individual(s) or entity(ies), not signatories to this Agreement, arising out of this Agreement. The parties agree that nothing in this Agreement shall be construed or interpreted to confer any such rights, privileges or benefits upon any individual or entity not a signatory to this Agreement.
18. FORCE MAJEURE. The parties understand and acknowledge that neither shall be liable
for any loss, damage, detention, delay or failure to perform in whole or in part resulting from causes beyond their control including, but not limited to, act of God, fire, hurricanes, strikes, insurrections, riots, embargoes, shortages of motor vehicles, delays in transportation, and inability to obtain supplies of raw materials or requirements or regulations of the United States government or any other civil or military authority.
19. COUNTERPARTS. This Agreement may be executed simultaneously in two or more
counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument.
20. NOTICE. Any notice required or permitted to be given hereunder shall be in writing and
shall be deemed to have been given when delivered personally or three (3) days after being mailed by certified mail, return receipt requested, postage prepaid to the following addresses, or at such other address as either party may designate in a manner in compliance with this Section:
___________________ ____________________
___________________ ____________________
___________________ ____________________
21. ACCESS TO RECORDS. The parties agree that, until the expiration of four (4) years after
the furnishing of services pursuant to this Agreement, the parties shall make available, upon written request, to the Secretary of the Department of Health and Human Services or the Comptroller General of the United States, or any of their duly authorized representatives, this Agreement and any books, documents and records that are necessary to certify the nature and extent of the cost of services provided pursuant to this Agreement.
22. FREE CHOICE AND MEDICAL JUDGMENT. This Agreement is not intended to
influence the free choice of the patient in his or her ability to select facilities or services, nor is it intended to influence the independent judgment of the medical staff of either party.
23. HEADINGS. The headings and numbers of sections and paragraphs of this Agreement are
24. DEFICIT REDUCTION ACT. To the extent it is required by 42 U.S.C. 1396a(a)(68), as it
relates to the provision of services under this Agreement, each party adopts and acknowledges having received the other party's written policies regarding compliance with the federal False Claims Act, 31 U.S.C. 3729-3733, administrative remedies for false claims and statements, 31 U.S.C. Chapter 38, state laws pertaining to civil or criminal penalties for false claims and
statements, and whistleblower protections under such federal and state false claims laws, as well as detailed information regarding the other party's policies and procedures for detecting and preventing fraud, waste, and abuse. To the extent there is a conflict between any of the policies of either party or between either party's policies and any applicable law, the more restrictive provision in the relevant policy shall apply to allow compliance of both parties with the requirements as set forth under 42 U.S.C. Section 1396a(a)(68).
IN WITNESS WHEREOF, the undersigned parties have caused this Agreement to be executed by their duly authorized officers as of the Effective Date set forth above.
______________________________ ____________________________
