(b) A physician and surgeon who performs a scheduled medical procedure outside of a general acute care hospital, as defined in subdivision (a) of Section 1250 of the Health and Safety Code, that results in the transfer to a hospital or emergency center for medical treatment for a period exceeding 24 hours, of any patient on whom that medical treatment was performed by the physician and surgeon, or by a person acting under the physician and surgeon’s orders or supervision, shall report, in writing, on a form prescribed by the board that occurrence, within 15 days after the occurrence. The form shall contain all of the following information:

1. (1) Name of the patient’s physician in the outpatient setting.
2. (2) Name of the physician with hospital privileges.
3. (3) Name of the patient and patient identifying information.
4. (4) Name of the hospital or emergency center where the patient was transferred.
5. (5) Type of outpatient procedures being performed.
6. (6) Events triggering the transfer.
7. (7) Duration of the hospital stay.
8. (8) Final disposition or status, if not released from the hospital, of the patient.
9. (9) Physician’s practice specialty and ABMS certification, if applicable.