You will need to use the front and back side of a standard size 8 1/2 x 11 sheet of paper for all data shown below
Patient Name:_______________________________Run/Vehicle No:______________Date:___________
Phone:_(_______)________________________Date of Birth:______________________Male / Female
Race: W - B - O Social Security Number:_________________________________
Insurance Company:_________________________ Address:_____________________________________
Policy #_______________ Group #______________
Responsible Party: (if other than patient):______________________________________________
Relationship to Patient: Self - Spouse - Child - Other
Billing Address (if other than above )___________________________________________________
Work Related: Y-N Accident:Y-N MVA: Y-N ALS vehicle: Y-N Round Trip: Y-N
Transported From: [ Residence [ Scene [ Nursing Home Other_______________________________________
Transported To:____________________________________________Loaded Miles:_________________
Chief Complaint/probable diagnosis_______________________________________________________
Check all Special Services Performed and abnormal conditions
| __IV Therapy | __ Medication | __Spinal Immob | __CPR |
| __Bleeding control | __ Defib/Cardiovert | __Suctioning of Airway | __EKG |
| __ Maintain Airway | __ Oxygen Therapy | __ LOC Monitored | __Bedridden |
| __ Stabilize Poss FX | __ Treat Shock __MAST | __ TreatCVA/Drugs/poison | __ CPR |
| ___________ % Pulse OX | _______Glucose reading | ____/____Blood Pressure | __ Restraints |
NON-EMERGENCY Transports
To justify ambulance transport we ***MUST MUST MUST*** prove that the patient could not be transported by Automobile/Van/Wheelchair if these were available.
| ___ | Patient could not sit for duration of transport |
| ___ | Patient required stabilization in a certain position to reduce pain/possible injury |
| ___ | Other reason ambulance required |
| IF ANY BLOCKS ABOVE WERE CHECKED, SPECIFICALLY AND EXACTLY EXPLAIN BELOW |
The undersigned agrees to: Release all information for filing claims; If assignment is accepted, reimbursement is directly to the ambulance company; if Medicare, Medicaid, Insurance rejects due to medical necessity, eligibility, or other reasons, that the patient is responsible for payment; if legal/collection agencies are required, patient is responsible for fees.
Medic 1___________________________________ EMT-P EMT-I EMT-B (circle one)
Medic 2___________________________________ EMT-P EMT-I EMT-B (circle one)
Medic 3___________________________________ EMT-P EMT-I EMT-B (circle one)
Check all that apply -- required in Alabama -- helpful in all states