HPMC Ambulance eOrders – Ambulance Transport Order Portal

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Entry ID	132
Submitted by:	Joey Diaz
eOrder Submission Date	12/28/2023
eOrder Submission Time	10:20
Requester Information
Ordering Facility	CHA - Hollywood Presbyterian Medical Center
Requester Name	Joey Diaz
Title	Case Manager
Requester Department	Test
Requester Phone	(310) 644-5300
Requester Email	Email hidden; Javascript is required.
Service Needs Information
Service Level	EMT Basic Life Support
Trip Type	One-Way
Bariatric Patient?	No
Ambulance Transfer Reason(s)	In-patient inter-campus transfer.
Trip Schedule Information
Pickup Date	12/28/2023
Response Type	Next Available - Patient Ready Now
Standing Order	No
Pickup Location Information
Pickup Location	CHA - Hollywood Presbyterian Medical Center
Pickup Location Department/Unit Name	Test
Pickup Location Patient Room/Bed No.	Test
Pickup Location Department Phone	(310) 644-5300
Pickup Location Contact Name	Joseph Diaz
Drop Off Location Information
Drop Off Location	CHA - Hollywood Presbyterian Medical Center
Drop Off Receiving Department/Unit Name	Test
Drop Off Patient Room/Bed No.	Test
Drop Off Receiving Department Phone	(310) 644-5300
Drop Off Receiving Contact Name	Joseph Diaz
Reimbursement Information
Patient Information
Patient Name	Joseph Diaz
Medical Record No.	12345
Patient Sex	Male
Patient Date of Birth	01/02/2000
Patient Age	23
Spoken Language	English
Interpreter Required?	No
Patient Medical Information
Isolation Precaution	No
Medical Necessity Certification
Is Patient Bed-confined?	Yes
Medical Needs During Transport
Required Equipment and Care	Oxygen
Accompanying Documents	Please upload accompanying transfer documents.
Order Submission Certification
Signature