The Irish Ambulance Patient Care Report form is a comprehensive document used by ambulance services to record vital details during emergency response situations. It includes various sections such as agency name, incident number, response times, and personnel involved, ensuring a structured approach to documenting the complexity of care provided. The form captures all aspects of the incident, from the initial dispatch call through to the patient's arrival at the destination, including response information like the number of patients, any mass casualty incidents (MCI), and details on the attending crew. Additionally, it provides space to record critical patient information, medical history, incident specifics, initial assessment, treatments administered, and the eventual patient outcome. This thorough record-keeping aids in continuity of care, facilitates accurate billing, and ensures compliance with regulatory requirements. It also helps in reviewing the response to incidents for quality improvement purposes. The integration of factors affecting care, such as environmental conditions and potential barriers to patient care, alongside detailed records of any pre-existing conditions, medications, and allergies, underscores the form's role in fostering patient-centered care in emergency medical services.
Question | Answer |
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Form Name | Irish Ambulance Patient Care Report Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | 1099 reporting non reporting chart, patient care report template, printable ambulance report, ambulance patient care report form |
Ambulance Patient Care Report
Agency Name |
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Date of Incident |
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Call Number |
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Incident Number |
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Response Times |
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Response Information |
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Personnel |
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Driver |
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PSAP Call |
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Arrive Scene |
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In Service |
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PCR Number |
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Starting Mileage |
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Attendant |
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To Scene |
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To Dest. |
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Dispatch Notified |
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Arrive Patient |
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Unit Cancelled |
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# of Patients |
MCI |
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At Scene Mileage |
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Attendant |
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To Scene |
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Yes |
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To Dest. |
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No |
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Unit Dispatched |
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Leave Scene |
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In Quarters |
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Responding Unit |
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Dest. Mileage |
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Attendant |
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To Scene |
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To Dest. |
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Enroute |
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Arrive Dest. |
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Crew Number |
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Ending Mileage |
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Attendant |
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To Scene |
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To Dest. |
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Incident Information |
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First Responder Agencies |
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Incident Address |
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Room/Apt |
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Factors Affecting Care |
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Amb. Crash |
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Safety |
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City |
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County |
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Zip Code |
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Amb. Failure |
Extrication |
Traffic |
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Crowd |
HazMat |
Weather |
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Type of Location |
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Directions |
Language Barrier |
None |
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Airport |
Home/Residence |
Mine or Quarry |
Residential Institution Other |
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Distance |
Staff Delay |
Other |
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Farm |
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Industrial Place |
Place of Sport |
Street or Highway |
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Healthcare Facility Lake, River |
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Public Building |
Trade or Service |
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Destination/Hospital Name |
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Facility Diverted From |
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Response Request |
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To |
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Response Mode |
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From |
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Disposition |
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Response (Scene) |
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Lights and Siren |
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Treated: |
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Interfacility Transfer |
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No Lights or Siren |
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Transported by EMS |
Destination Determination |
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Closest Facility |
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Specialty Resource Ctr. |
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Medical Transport |
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Transferred Care |
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(Scheduled) |
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Initial No Lights and Siren |
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Released |
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Protocol Guideline |
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Law Enforcement Choice |
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Standby |
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Upgraded to Lights and Siren |
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Patient/Family Choice Diversion |
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Intercept |
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Cancelled |
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Initial Lights and Siren |
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Destination Type |
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Mutual Aid |
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Patient Refused Care |
Hospital |
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Ground Ambulance |
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Downgraded to No Lights and Siren |
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Dead at Scene |
Home |
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Police/Jail |
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Medical Office/Clinic |
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Morgue |
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Patient Information |
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Nursing Home |
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Other |
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Last Name |
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First Name |
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M.I. |
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Air Ambulance |
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Primary Role of Unit |
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Address |
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Room/Apt |
ALS Ground |
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BLS Ground |
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Other Transport |
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Critical Care Ground |
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Rescue |
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City |
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County |
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State |
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ERU |
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Rotor Craft |
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Fixed Wing |
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Supervisor |
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Zip Code |
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Phone Number |
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KG |
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Gender |
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Dispatch Reason |
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LB |
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M / F |
Abdominal Pain |
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Heart Problem |
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Allergies |
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Heat/Cold Exposure |
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Social Security Number |
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DOB |
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Age |
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Animal Bite |
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Hemorrhage/Laceration |
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Assault |
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Industrial Accident |
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Patient Physician |
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Guardian Name |
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Back Pain |
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Ingestion/Poisoning |
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Breathing Problem |
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MCI |
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Burns |
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Medical Transport |
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Race |
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Ethnicity |
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Cardiac Arrest |
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Pain |
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American Indian or Alaska Native |
Asian |
Hispanic or Latino |
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Chest Pain |
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Pregnancy/Childbirth |
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Black or African American |
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White |
Not Hispanic or Latino |
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Choking |
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Psychiatric Problem |
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Hawaiian or Other Pacific Islander |
Other |
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CO Poisoning/Hazmat |
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Sick Person |
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Convulsions/Seizure |
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Stab/Gunshot Wound |
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Prior Aid (Select All That Apply) |
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AED - ERU |
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Airway: |
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Performed By |
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Outcome/Condition |
Diabetic Problem |
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Standby |
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AED - First Responder |
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BVM |
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EMS Provider |
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Improved |
Drowning |
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Stroke/CVA |
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AED - Public Access |
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Combitube |
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Law Enforcement |
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Worse |
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Electrocution |
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Traffic Accident |
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CPR |
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Nebulizer Treatment |
Lay Person |
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Unchanged |
Eye Problem |
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Traumatic Injury |
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Extrication |
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Spinal Immobilization |
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Oxygen |
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Other Healthcare Provider |
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Fall Victim |
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Unconscious/Fainting |
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Splinting |
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Suction |
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Patient |
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Headache |
Unknown Problem/Man Down |
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Provider Impression - Primary/Secondary (Select One For Each) |
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P S |
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P S |
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P S |
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P S |
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P |
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AAA |
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CHF |
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Hypotension |
Other CNS |
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Seizure |
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Abdominal Pain/Prob. |
Dehydration |
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Hyperthermia |
Other Endocrine/Metabolic Sexual Assault / Rape |
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Airway Obstruction |
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Diabetic hyperglycemia |
Hypothermia |
Other General Urinary |
|
Smoke Inhalation |
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Allergic Reaction |
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Diabetic hypoglycemia |
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Hypovolemia / Shock |
Other Illness/Injury |
|
Stings / venomous bites |
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Altered LOC |
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Electrocution |
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Inhalation Injury |
Other OB/Gyn |
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Stroke / CVA / TIA |
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Asthma |
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ETOH Abuse |
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(toxic gas) |
Pain |
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Substance Drug Abuse |
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Behavioral / Psych |
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Fever |
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OB Delivery |
Poisoning / drug ingest. |
Syncope / fainting |
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Bowel Obstruction |
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GI Bleed |
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OB/Pregnancy/Labor |
Respiratory Arrest |
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Traumatic Injury |
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Cancer |
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Headache |
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Obvious Death |
Respiratory Distress |
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Unconscious Unknown |
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Cardiac Arrest |
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Heat Exhaustion/Stroke |
Other Abdominal/GI |
Rhythm Disturbance |
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Vaginal Hemorrhage |
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Chest Pain/Discomfort |
Hypertension |
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Other Cardiovascular |
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Patient Chief Complaint |
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Patient Chief Complaint |
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Primary Organ |
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Description |
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Onset Date / Time |
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System Affected |
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Cardiovascular |
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Signs & Symptoms (Select All That Apply) |
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CNS/Neuro |
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P S |
Abdominal Pain |
P S |
Chest Pain |
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P S |
Fever |
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P S |
Palpitations |
Endocrine/Metabolic |
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GI/Abdomen |
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Back Pain |
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Choking |
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Malaise |
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Rash/Itching |
Global/Other Illnesses |
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Behavioral/Psych |
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Death |
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Mass/Lesion |
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Swelling |
Musculoskeletal/Injury |
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Bleeding |
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Device/Equipment Problem |
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Nausea/Vomiting |
Weakness |
OB/GYN |
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Breathing Problem |
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Diarrhea |
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None |
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Wound |
Psych/ Behavioral |
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Change in Resp |
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Drainage/Discharge |
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Pain |
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Respiratory |
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Renal/GU Problems |
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Cause of Injury (Select One) |
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Skin |
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Injury Present |
Aircraft Crash |
Machinery Accidents |
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||||||
Yes |
|
Assault |
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Mechanical Suffocation |
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Injury Description |
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No |
|
Bicycle Crash |
MV, |
Identify the area of injury with |
|
|||||||
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Bites |
|
MV, Traffic Crash |
|
the following numbers |
|
|||||
Injury Intent |
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Chemical Poisoning |
Motorcycle Crash |
|
1 |
Amputation |
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||||||
Intentional, Other |
Child Battering |
|
2 |
|
||||||||
(Assaulted) |
Drug Poisoning |
Pedestrian Traffic Crash |
3 |
|
||||||||
Intentional, Self |
Drowning |
|
Radiation Exposure |
4 |
Burn |
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|
|||||
Unintentional |
Electrocution |
5 |
Crush |
|
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|||||||
|
|
Excessive Cold |
Smoke Inhalation |
|
6 |
Dislocation/Fracture |
|
|||||
Mechanism |
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||||||||||
Excessive Heat |
Stabbing/Cutting (Assault) |
7 |
Gunshot |
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|||||||
Blunt |
|
Falls |
|
Stabbing/Cutting (Accidental) |
8 |
Laceration |
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|
||||
Burn |
|
Fire and Flames |
Strike Blunt/Thrown Obj. |
9 |
Pain without swelling/bruising |
|
||||||
Other |
|
Firearm Assault |
Unarmed Fight/Brawl |
10 Puncture/Stab |
|
|||||||
Penetrating |
Firearm Injury (Accidental) |
Venomous Stings |
|
11 Soft Tissue swelling/bruising |
|
|||||||
|
|
Firearm (Self Inflicted) |
Water Transport Crash |
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Lightning
|
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Initial Assessment |
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||
Level of Responsiveness |
Airway |
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Breathing |
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Circulation |
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|||||||
Alert |
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Patent |
|
Rate |
|
Quality |
L |
Lung Sounds |
R |
|
Color |
|
Temp |
|
Condition |
Cap Refill |
||||||
Verbal |
|
|
Non Patent |
< 10 |
|
Normal |
|
Clear |
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Normal |
|
Normal |
Normal |
< 2 sec |
|||||||
Painful |
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Action taken: |
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Labored |
|
Wet |
|
|
|
Cyanotic |
Hot |
Diaphoretic |
2 - 4 sec |
|||||||
Unresponsive |
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> 24 |
|
Fatigued |
|
Wheezes |
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Pale |
|
Cool |
Dry |
> 4 sec |
||||||
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Apneic |
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Absent |
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Diminished |
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Flush |
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Cold |
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Absent |
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Not Assessed |
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Absent |
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Alcohol/Drug Use |
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Glasgow Coma Score |
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Pupils |
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Barriers to Patient Care |
|||||||
Alcohol/Drugs |
Eye Opening |
|
Verbal |
|
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Motor |
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Time |
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L |
|
|
R |
Developmentally |
|
|||||
4 Spontaneous |
5 Oriented |
|
6 Obeys Commands |
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Impaired |
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|
||||||||||
at Scene |
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Reactive |
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Hearing Impaired |
|
||||||||||||||||
Patient Admits |
3 To Speech |
|
4 |
Confused |
|
5 |
Localized Pain |
|
|
|
Score |
|
Sluggish |
|
|
||||||||
Alcohol Use |
|
2 To Pain |
|
3 |
Inappropriate |
4 |
Withdraws to Pain |
|
|
|
|
|
Constricted |
|
Language |
|
|||||||
Patient Admits |
1 Not at All |
|
2 |
Words |
|
3 |
Flexion to Pain |
Time |
|
|
|
|
Physically Impaired |
||||||||||
Drug Use |
|
|
|
|
Inappropriate |
2 |
Extension to Pain |
|
|
|
|
|
Dilated |
|
Physically Restrained |
||||||||
Smell of Alcohol |
|
|
|
|
Sounds |
|
1 None |
|
|
|
|
Score |
|
Nonreactive |
|
Speech Impaired |
|
||||||
None |
|
|
|
|
1 None |
|
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|
|
Unattended or |
|
|||||
Allergies NKA |
|
|
Patient’s Medications |
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|
|
Unsupervised (Including |
|||||||
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|
|
Minors) |
|
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|||||||
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|
Unconscious |
|
||
|
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|
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|
|
|
|
|
|
|
|
|
None |
|
|
|
Time |
BP |
|
Pulse |
Resp |
|
Rhythm |
SpO2 |
Procedures |
|
# Attempts |
Success |
Medication |
Dose |
Route |
Response |
Crew # |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
Improved |
|
||
|
|
|
|
|
|
|
|
|
|
|
|
No |
|
|
|
|
|
|
|
Worse |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
N/A |
|
|
|
|
|
|
|
Unchanged |
|
Cardiac Arrest Information
Cardiac Arrest
No
Yes:
After EMS Arrival
Prior To EMS Arrival
Etiology
Drowning
Electrocution
Presumed Cardiac
Respiratory
SIDS
Trauma
Other
Resuscitation Attempted
No:
Circulation Restored by First Responder
DNR Orders
Obvious Death
Yes:
CPR Only
Defibrillation
Time of Arrest Before EMS
Unknown
Witnessed By
Not Witnessed
Healthcare Provider
Lay Person
Return of Circulation
No
Yes:
Prior to ED Arrival Only
Prior to ED Arrival and at the ED
Resuscitation Discontinued
Time :
Reason Discontinued
DNR
Medical Control Order
Obvious Death
Policy Requirements Completed
Return of Circulation
First Cardiac Rhythm |
|
|
|
|
|
|
Asystole |
Normal Sinus Rhythm Ventricular Tachycardia |
Unknown AED |
Other |
|||
Bradycardia |
PEA |
Ventricular Fibrillation |
Unknown AED Shockable Rhythm |
|
||
|
|
|
|
|
||
Cardiac Rhythm At Destination |
|
|
|
|
||
12 Lead ECG: |
|
Atrial Fibrillation/Flutter |
Left Bundle Branch Block |
Right Bundle Branch Block |
Torsades de Pointes |
|
Anterior Ischemia |
AV Block: |
Normal Sinus Rhythm |
Sinus Arrhythmia |
Ventricular Fibrillation |
||
Inferior Ischemia |
1st Degree |
Paced Rhythm |
|
Sinus Bradycardia |
Ventricular Tachycardia |
|
Lateral Ischemia |
2nd |
PEA |
|
Sinus Tachycardia |
Unknown: |
|
Septal Ischemia |
2nd |
Premature: |
|
|
AED |
|
Agonal/Idioventricular |
3rd Degree |
Atrial Contractions |
Supraventricular Tachycardia |
AED Shockable Rhythm |
||
Artifact |
|
Junctional |
Ventricular Contractions |
|
Other |
|
Asystole |
|
|
|
|
|
|
Patient Past Medical HIstory
Narrative
Medical Control Method
Standing Orders
On Scene
Written Orders (Patient Specific)
|
|
Airbag Deployment |
|
HIPAA |
||
|
|
|
||||
Airbag Deployed Front |
Airbag Deployed Other |
Airbag Not Present |
Notice of HIPAA Privacy Practices |
|||
Airbag Deployed Side |
Airbag Not Deployed |
|
|
given to patient per agency guidelines |
||
|
|
|
|
|
|
EMD Performed |
|
|
Safety Equipment |
|
No |
||
Child Restraint |
Helmet Worn None |
Personal Floatation Device |
Protective |
Yes, With |
||
Eye Protection |
Lap Belt |
Other Protective Clothing Gear |
Shoulder Belt |
Yes, Without |
||
|
|
|
|
|
|
|
|
|
|
|
Signatures |
|
Receiving RN/MD
Guardian
I Refuse Treatment/Transport (Also See Back)
Technician
Continued On Supplement
Disclaimer: This page is provided for optional use by the ambulance provider; it is not required by the Minnesota EMS Regulatory Board.
|
Billing Information |
|
|
|
|
Medicare Number |
Medicaid Number |
Other |
Primary Insurance
Company Name |
|
Insurance Number |
|
|
Group Number |
|
|
|
|
|
|
|
|
|
|
|
|
Insured Last Name |
Same as Patient’s |
Insured First Name |
Same as Patient’s |
M.I. |
|
Relationship To |
Self |
|
|
|
|
|
|
|
|
Patient |
Spouse |
|
|
|
|
|
|
|
|
Parent/Guardian |
Address |
Same as Patient’s |
City |
County |
State |
Zip Code |
|
Home Phone |
Secondary Insurance
Secondary Insurance Company Name |
Secondary Insurance Number |
|
|
|
Group Number |
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
Insured Last Name |
Same as Patient’s |
Insured First Name |
|
Same as Patient’s |
|
M.I. |
|
Relationship To |
Self |
|||
|
|
|
|
|
|
|
|
|
|
Patient |
Spouse |
|
|
|
|
|
|
|
|
|
|
|
|
|
Parent/Guardian |
Address |
Same as Patient’s |
City |
|
County |
|
State |
|
Zip Code |
|
Home Phone |
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Type of Insurance |
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|||||||
|
Private Insurance Workers Comp Medicare |
Medicaid |
HMO/PPO |
Contract Services |
|
Authorization For Billing
I authorize the release to the Social Security Administration and Centers for Medicare and Medicaid Services, any HMO/PPO, other private or public insurance, or their agents, fiscal intermediaries or carriers or an independent agency performing billing or collection functions on behalf of the ambulance service, any personal, medical or billing information needed for this or a related claim. I understand I will be responsible for any services that are not paid/covered by my insurance. A copy of this authorization shall be valid as the original and shall remain in effect until revoked in writing by the patient/insured. I request payment of medical insurance benefits either to me or to the ambulance service.
Signature
Date
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I was provided with a copy of the ambulance services “Notice of Privacy Practices.”
Signature |
Date |
|
|
|
|
Name Printed |
Relationship To |
Self |
|
Patient |
Spouse |
|
|
Parent/Guardian |
Waiver of Liability
I refuse treatment and/or transportation by the providing ambulance service. I assume responsibility for my own, my child’s, or any family member’s medical treatment. I have been advised to seek the atten- tion of a physician. I release the providing ambulance service, its employees, officers and directors from liability resulting from my own, my child’s, or any other family member’s refusal of medical treatment or transportation.
Signature
If Signing For A Minor
Date
Signature |
Date |
|
|
|
|
Name Printed |
Relationship To |
Parent/Guardian |
|
Patient |
|
Patient’s Belongings
Patient’s Belongings
Location of Belongings
Who Belongings Were Left With