Providence eOrder – Ambulance Transport Order Portal

Providence Ambulance eOrder

An ambulance order placement form for requesters to place ambulance transport orders with our communications center electronically.

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

This field is hidden when viewing the form

eOrder Submission Time

{today:format:H}

{today:format:i}

Requester Information

Requester Name*

Requester First Name Requestor Last Name

Ordering Facility*

Requestor Title

Other Requestor Title

If your title is not listed in the drop down list, please enter your title here.

Requester Department*

Requester Phone*

Requester Email*

Service Needs Information

Service Level

EMT Basic Life Support

Paramedic Advance Life Support

AMI-Stroke Stat Transport

Nurse-Staffed Specialty Care Transport

RT-Staffed Specialty Care Transport

NICU Transport

Trip Type*

One-Way

Round Trip

Wait and Return

Will Call

Bariatric Patient?*

Yes

Indicate Yes if the patient’s weight exceeds 299 lbs.

Patient Weight

Please enter a number from 0 to 1999.

Patient Height

Ex. 5′ 10″

Ambulance Transfer Reason(s)*

In-patient inter-campus transfer.

Services required not available at sending facility, patient being transferred for out-of-facility services but will remain an in-patient of sending facility.

Services required not available at sending facility, patient being discharged and admitted to another facility.

HMO Authorized Service

Patient requires admission to a locked unit.

Other

Check one or more applicable reason transport by ambulance is needed.

Other Transfer Reason

Enter other ambulance transfer reason.

Trip Schedule Information

Pickup Date*

Response Type

Next Available – Patient Ready Now

Stat Transport

Scheduled Transport

Pickup Time*

Appointment Time

Return Pickup Date

Return Pickup Time

Standing Order

Yes

Describe the number of trips, frequency, days and times in the adjacent Standing Order Details field.

Standing Order Details

Pickup Location Information

Pickup Location*

Other Pickup Location

Other Pickup Address

Street Address City California ZIP Code

Pickup Location Department/Unit Name*

Pickup Location Patient Room/Bed No.*

Pickup Location Department Phone*

Pickup Location Contact Name

First Last

Drop Off Location Information

Drop Off Location*

Other Drop Off Location Name

Other Drop Off Address

Street Address City California ZIP Code

Drop Off Receiving Department/Unit Name*

Drop Off Patient Room/Bed No.

Drop Off Receiving Department Phone*

Drop Off Receiving Contact Name

First Last

Reimbursement Information

Primary Insurance Carrier

Member ID No.

Payor Authorized?

Yes

Payor Authorization No.

Patient Information

Patient Name*

First Middle Initial Last

Medical Record No.

Patient Sex*

Male

Female

Patient Date of Birth*

Patient Age*

Spoken Language*

Interpreter Required?*

Yes

Patient Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Medical Information

Isolation Precaution*

Yes

COVID-19 Status

Negative

Positive

Other Contagious Condition

Describe reason for Isolation Precaution.

Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance

Describe the patient’s current medical condition / diagnosis at the time of ambulance transport that supports the medical necessity reason for transport by ambulance.

Medical Necessity Certification

Is Patient Bed-confined?*

Yes

To be “bed confined” the patient must satisfy all three of the following criteria: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair.

Ambulance Medical Necessity Reason(s)*

Check one or more applicable reason transport by ambulance is medically necessary.

Other Ambulance Medical Necessity Reason

ICD-10 #1

ICD-10 #2

ICD-10 #3

ICD-10 #4

Medical Needs During Transport

Required Equipment and Care*

Number of IV Drips

Please enter a number from 0 to 9.

Other Needed Equipment or Services

Other Comments / Notes

Accompanying Documents

Please upload accompanying transfer documents.

Authorization Form

Accepted file types: pdf, tff, jpg, png, Max. file size: 100 MB.

Face Sheet

Accepted file types: pdf, tff, jpg, png, Max. file size: 100 MB.

Physician Certification Statement

Accepted file types: pdf, tff, jpg, png, Max. file size: 100 MB.

Order Submission Certification

Signature

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