Providence Ambulance eOrders – Ambulance Transport Order Portal

Entry ID	114
eOrder Submission Date	09/27/2023
eOrder Submission Time	10:14 AM
Requester Information
Ordering Facility	Providence St. Jude Medical Center
Requester Department	ER
Requester Phone	(310) 000-0000
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	09/29/2023
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.	ER
Pickup Location Department Phone	(111) 111-1111
Drop Off Location Information
Drop Off Location	Providence Mission Hospital Mission Viejo
Drop Off Receiving Department/Unit Name	ER
Drop Off Receiving Department Phone	(310) 000-0000
Reimbursement Information
Patient Information
Patient Name	TEST PATIENT
Patient Sex	Male
Patient Date of Birth	09/01/1942
Patient Age	82
Spoken Language	English
Interpreter Required?	No
Patient Medical Information
Isolation Precaution	Yes
COVID-19 Status	Negative
Medical Necessity Certification
Is Patient Bed-confined?	No
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