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Model Transfer Agreement for Trauma Care
What Transfer Agreements
Your Hospital Will Need
This model agreement is a sample only. You should consult your own attorney
before finalizing a transfer agreement and may wish to consider adding other provisions such as an
indemnification clause and provisions relating to your own trauma protocols.
This Transfer Agreement (“Agreement”) is made by and between [Insert name of hospital
referring patients to the trauma center] (hereinafter referred to as "Hospital"), located at [Insert address and city] and [Insert name of the
trauma center] (hereinafter referred to as "Trauma Center"), located at
[Insert address and city] and is effective on [Insert effective date].
Hospital is a provider of hospital services and from time to time
receives patients who are in need of specialized trauma care and services not available at Hospital.
Trauma Center, as of the
date of this Agreement, been verified as a [Insert as appropriate Level I, II, III, or IV and whether
pediatric or adult]
trauma center by the
American College of Surgeons, or has received provisional status as a [Insert as
appropriate Level I, II, III, or IV and
whether pediatric or adult] by the
Ohio Department of Health, and is able, willing and qualified to accept and
provide patient care services to appropriate trauma patients consistent with
its verified or provisional level.
Hospital and Trauma Center do mutually agree as follows:
I. GENERAL TRANSFER PROCEDURES
When the attending physician determines that a patient
should be transferred from Hospital, Trauma Center agrees to admit the patient as promptly as possible,
provided customary admission requirements are met, State and Federal laws and regulations are met, and
Trauma Center has the capacity to treat the patient. Notice of the transfer shall be given by
Hospital as far in advance as possible. Trauma Center shall give prompt confirmation of whether it can
provide trauma care appropriate to the patient's medical needs.
The patient's condition will be assessed by the
attending physician or the emergency department physician of Hospital using trauma criteria developed
by Hospital. In those cases where the attending physician or emergency department physician of
Hospital concludes that the patient's condition requires the services of Trauma Center,
the appropriate physician will initiate the transfer to Trauma Center.
To initiate the transfer, Hospital will call the emergency department designated
individual taking calls for trauma service of Trauma Center. The Hospital will contact Trauma Center
prior to the transfer of the patient and provide a brief report to Trauma Center
regarding the patient's condition which shall include, but not be limited to, the following:
name
age
medical history
mechanism and identification of injury
current condition
mode of transport
estimated time of arrival
Hospital, consistent with its obligations under the Emergency
Medical Treatment and Active Labor Act ("EMTALA"), will provide medical personnel to assess
and stabilize trauma patients who come to the Hospital's emergency department.
Patients not stabilized cannot be transferred unless the patient (or responsible person acting on the
patient's behalf) requests the transfer or a physician from Hospital certifies in
writing that, based upon reasonable risks and benefits to the patient and the
information available at the time, the medical benefits of transfer to Trauma Center
outweigh the increased risks to patient's medical condition from the transfer.
Hospital will assume primary
responsibility for arranging appropriate medical transport services to Trauma Center.
The medical condition of the patient will determine the mode of transportation used in
transfer. The emergency department physician or the attending physician of Hospital will determine the
appropriate transportation and life support equipment. The Hospital shall consult the emergency department
physician or designated trauma physician at Trauma Center in regards to arrangements and details of the
transfer, including transportation to ensure optimal care of the patient.
Hospital agrees to send with each patient, at the time of transfer, whatever
records (including copies of results of diagnostic studies or telephone reports of the studies) available at the
time of transfer and all medical records related to the patient's condition requiring the transfer.
Test results that become available after the patient's transfer should be telephoned to Trauma Center.
Records that become available after the patient is transferred, such as hard copies of test results or relevant
records of earlier admissions, should be sent to Trauma Center.
All patient information shall be transferred to the Trauma Center
in accordance with all federal and state privacy mandates
Hospital shall be responsible for the transfer or other appropriate
disposition of any personal belongings of the patient.
Hospital shall be responsible for obtaining the patient's consent to the transfer.
In non-emergent cases, this consent shall be obtained prior to the patient's transfer. If the patient is not
competent to consent to the transfer, Hospital shall obtain the consent of the patient's legal guardian or
representative. If a guardian or representative has not been appointed, the transferring institution shall
obtain the consent of a family member or other appropriate individual.
II. TRANSFER OF PATIENTS FROM TRAUMA CENTER TO HOSPITAL
Where applicable, when a patient previously transferred to Trauma Center
from Hospital is
ready for discharge from Trauma Center, Hospital agrees to promptly accept transfer of the
patient back to Hospital or to assist Trauma Center with the appropriate discharge alternative
of the patient. All federal and state transfer laws shall be followed with
respect to transfers back to Hospital upon a patient’s discharge from the
Trauma Center.
III. TERM AND TERMINATION
The term of this Agreement shall commence as of the
Effective Date, and shall be for a term of one (1) year therefrom, unless terminated in accordance with the
provisions set forth in paragraph III(b) herein, or unless extended as provided herein.
Thereafter, this Agreement shall automatically be renewed for an additional period of one (1) year unless either party
terminates this Agreement in accordance with the provisions set forth in paragraph III(b) herein.
To the extent that this Agreement is automatically renewed, each such renewal term shall be upon the
same terms and conditions of the immediate, preceding renewal term.
This Agreement may be
terminated by either party for any reason by written notice to the other party of at least
thirty (30) days, or upon mutual agreement evidenced in writing. In the event Trauma Center ceases to be a trauma center, either
through lose of its verification or provisional
status as a trauma center, this Agreement will terminate immediately upon such loss of verification or
provisional status.
It is explicitly recognized that in the
event of termination of this Agreement by either party,
neither party shall have any further obligation hereunder except for obligations accruing prior
to the date of termination, and for obligations, promises, or covenants contained herein which are
expressly made to extend beyond the term of this Agreement.
IV. MISCELLANEOUS PROVISIONS
Each party
certifies that it will use best efforts to comply with all applicable Federal and
State laws prohibiting discrimination against persons on account of race, sex, color, age,
religion, national origin, or disability.
The transfer or receipt of patients in need of
emergency care shall not be based upon the patient’s inability to
pay for the services rendered by the transferring or receiving
facility.
Each party to this Agreement shall be
responsible for billing and collecting from the patient, third party payer, or other
responsible party for the items and services rendered to the patient by such party. Neither
party shall be liable to the other for such charges.
Nothing in this Agreement shall be
constructed as limiting the right of either party to affiliate or contract
with any other entity, on either a limited or general basis, while this
agreement is in effect. Multiple transfer agreements may be entered
into by each party based upon the type or level of medical
services available at other trauma centers and health care entities.
The terms of this agreement shall be construed
and governed by the laws and regulations of the State of Ohio and
the United States of America.
Neither party may assign this Agreement without prior
consent of the other.
Notices under this agreement shall be in writing and hand
delivered or mailed by certified mail, return receipt requested, to the
parties at the addresses set forth below, or to such other addresses
as the parties may designate to the other in writing.
NOTICE TO HOSPITAL
[Insert name, address of person to receive notices]
NOTICE TO TRAUMA CENTER
[Insert name, address of person to receive notices]
In
transferring patients pursuant to this
agreement, both parties shall comply with the federal Emergency
Medical Treatment and Active Labor Act of 1985 (“EMTALA”),
contained in 42 U.S.C. Section 1395dd, as may be amended, and
all related federal and state regulations.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date.
HOSPITAL
By:______________________________________
Name:____________________________________
Title:___________________________________
Date:____________________________________
TRAUMA CENTER
By:______________________________________
Name:____________________________________
Title:___________________________________
Date:____________________________________
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