NHI Transfer Agreement

1. I understand that I am allowed only one transfer per calendar year.
2. I confirm that I have not transferred to another clinic within the past 12 months.
3. I hereby provide a valid reason for my transfer request.
4. I understand that this transfer may affect my current care arrangements and that it is my responsibility to ensure continuity of care.
5. I authorize the release of my medical records from my current PCP to the new PCP to ensure continuity of care.
6. I understand that this transfer is subject to approval and processing by the relevant health authorities.

By signing below, I certify that I have read, understood, and agree to the terms outlined in this consent form.