Providence Ambulance eOrders – Ambulance Transport Order Portal

Entry ID	113
eOrder Submission Date	09/27/2023
eOrder Submission Time	10:02 AM
Requester Information
Ordering Facility	Providence St. Jude Medical Center
Requester Department	ER
Requester Phone	(310) 111-1111
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	09/27/2023
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	ER
Pickup Location Patient Room/Bed No.	13
Pickup Location Department Phone	(310) 000-0000
Drop Off Location Information
Drop Off Location	Providence St. Jude Medical Center
Drop Off Receiving Department/Unit Name	ER
Drop Off Receiving Department Phone	(031) 000-0000
Reimbursement Information
Patient Information
Patient Name	TEST PATIENT
Patient Sex	Male
Patient Date of Birth	09/02/1980
Patient Age	35
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
eOrder Submission Date	09/27/2023