Providence Ambulance eOrders – Ambulance Transport Order Portal

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Entry ID	111
eOrder Submission Date	09/27/2023
eOrder Submission Time	09:54 AM
Requester Information
Ordering Facility	Providence Mission Hospital Mission Viejo
Title	Physician's Assistant
Requester Department	TEST
Requester Phone	(121) 345-5879
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. Services required not available at sending facility, patient being transferred for out-of-facility services but will remain an in-patient of sending facility.
Trip Schedule Information
Pickup Date	09/01/2023
Response Type	Next Available - Patient Ready Now
Standing Order	No
Pickup Location Information
Pickup Location	Providence St. Jude Medical Center
Pickup Location Department/Unit Name	R
Pickup Location Patient Room/Bed No.	R
Pickup Location Department Phone	(323) 456-2356
Pickup Location Contact Name	ROD NEY
Drop Off Location Information
Drop Off Location	Providence St. Jude Medical Center
Drop Off Receiving Department/Unit Name	1
Drop Off Patient Room/Bed No.	2
Drop Off Receiving Department Phone	(323) 456-2345
Drop Off Receiving Contact Name	ROD NEY
Reimbursement Information
Patient Information
Patient Name	RODNEY OCHOA
Medical Record No.	000123456
Patient Sex	Male
Patient Date of Birth	05/05/1990
Patient Age	33
Spoken Language	English
Interpreter Required?	No
Patient Medical Information
Isolation Precaution	Yes
Medical Necessity Certification
Is Patient Bed-confined?	Yes
Medical Needs During Transport
Required Equipment and Care	Airway Monitoring Oxygen Cardiac Monitoring
Accompanying Documents	Please upload accompanying transfer documents.
Order Submission Certification
Signature
eOrder Submission Date	09/27/2023