MexCare logo
 

Forms | Transfer Agreement

Print
MexCare® Transfer Agreement

I, _________________________, am a patient at ____________________. I hereby acknowledge that I have read, understand and agree to the following:

__________________ has offered to refer me to a hospital in ___________________ to continue my medical care.

__________________ has an agreement with MexCare to refer patients to a private hospital network in _______________ for care and treatment.

I agree to voluntarily be transferred to __________________, __________ where I agree to receive the balance of my medical care.

I understand the prescribed care will be provided free of charge and ______________________ will compensate MexCare for all medical services related to my admission.

MexCare, through its agents, will assume responsibility to provide care as prescribed by ______________________ and will compensate the foreign hospital and physicians for all treatment delivered related to my admission.

I understand I do not have to accept the referral proposed in this agreement to MexCare or any doctor, hospital or medical provider in _______________________________.
I, hereby certify that I have read and understand this document. I am voluntarily agreeing to my transfer to a medical facility in ________________________________________.

_________________________________________
PATIENT'S SIGNATURE

____________________
DATE

_______________________________________________________________________
PRINT NAME

_______________________________________________________________________
WITNESS
____________________
DATE

top
Print
MexCare® Memorandum of Understanding

This Memorandum of Understanding (herein referred to as "MOU") is made and entered into as of _____________________, by and between MexCare L.L.C. (herein referred to as "Provider") and ___________________________ (herein referred as "Facility").

For valuable consideration given, the adequacy of which is acknowledged, the parties agree to the following:

1. Term: This MOU shall commence on the date set forth above and shall continue in effect for _____________ days.

2. Services: Provider agrees to provide medical management of the patient for a period not to exceed ________ days. In the event patient requires additional services, written authorization from facility must be obtained prior to delivery of such.

3. Compensation: Facility agrees to compensate provider the amount of $_________ dollars per day for ________ days and our ambulance fees of $_________. Provider agrees to reimburse facility the full day rate for unused days after the initial 30 day period.

4. Provider agrees to seek payment only from facility. Provider agrees to accept payment from facility as payment in full for those health services determined by Provider to be authorized, covered services. Under no circumstances will Provider seek payment from patient.

5. Invoice Submissions: Facility agrees to prepay for ________ days of care and our ambulance fee for a total amount of $_______. In the event patient stay is longer than ________ days, MexCare will bill for additional days up to but not to exceed ________ days.

"Provider" "Facility"

By: _______________________ By: _______________________


Authorized Agent MexCare L.L.C. Authorized Agent

Date: _____________________ Date: _____________________

 

top
Print
MexCare® Acuerdo Para Ser Trasladado(a)

Yo, _____________________ soy paciente de _________________ y por medio de la presente doy fe de que he leído, entendido, y aceptado lo siguiente:

___________________ ha ofrecido trasladarme a un hospital en __________ para continuar mi atención médica.

___________________ tiene un acuerdo con MexCare para trasladar a pacientes a un hospital privado en __________________.

Por mi propia voluntad acepto ser trasladado(a) a el hospital en ____________, __________ donde estoy de acuerdo en recibir el resto de mi atención médica.

Tengo entendido que la antención médica ordenada se me proveerá sin ningún costo a mí y que ____________________ reembolsará a MexCare por todos los servicios médicos relacionados a mi hospitalización.

MexCare, a través de sus agentes, asumirá toda responsabilidad de proveer la atención médica tal como lo ha ordenado __________________ y reembolsará al hospital y médicos extranjeros por todo servicio médico rendido relacionado a mi hospitalización.

Entiendo que no tengo la obligación de aceptar el traslado tal como lo propone este acuerdo con MexCare o cualquier médico, hospital o proveedor de atención médica en ____________________________.

Por medio de la presente hago fe de que he leído y entendido este documento. Por mi propia voluntad acepto ser trasladado(a) a una instalación médica en _____________________________.

________________________________________________________________
FIRMA DEL PACIENTE

____________________
FECHA

_________________________________________________________________
NOMBRE DEL PACIENTE (EN LETRA DE MOLDE)

_________________________________________________________________
TESTIGO

____________________
FECHA

arriba