| Entry ID | 14 |
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| eOrder Submission Date | 06/23/2023 |
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| eOrder Submission Time | 14:59 PM |
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| Requester Information | |
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| Ordering Facility | Providence St. Jude Medical Center |
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| Title | Other |
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| Other Title | AmbuServe Communications Manager |
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| Requester Department | Dispatcher |
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| Requester Phone | (310) 749-6141 |
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| Requester Email | Email hidden; Javascript is required. |
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| Service Needs Information | |
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| Service Level | EMT Basic Life Support |
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| Trip Type | Round Trip |
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| Bariatric Patient? | No |
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| Ambulance Transfer Reason(s) | - In-patient inter-campus transfer.
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| Trip Schedule Information | |
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| Pickup Date | 06/23/2023 |
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| Response Type | Scheduled Transport |
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| Pickup Time | 06:00 PM |
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| Appointment Time | 06:30 PM |
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| Return Pickup Date | 06/23/2023 |
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| Return Pickup Time | 08:00 PM |
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| Standing Order | No |
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| Pickup Location Information | |
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| Pickup Location | Providence Mission Hospital Laguna Beach |
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| Pickup Location Department/Unit Name | ED |
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| Pickup Location Patient Room/Bed No. | 16 |
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| Pickup Location Department Phone | (310) 749-6141 |
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| Pickup Location Contact Name | Joseph Diaz |
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| Drop Off Location Information | |
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| Drop Off Location | Providence St. Jude Medical Center |
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| Drop Off Receiving Department/Unit Name | ICU |
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| Drop Off Patient Room/Bed No. | 406 |
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| Drop Off Receiving Department Phone | (310) 749-6141 |
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| Drop Off Receiving Contact Name | Joseph Diaz |
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| Reimbursement Information | |
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| Patient Information | |
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| Patient Name | Joseph P. Diaz |
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| Medical Record No. | 5628678148 |
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| Patient Sex | Male |
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| Patient Date of Birth | 01/02/1985 |
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| Patient Age | 38 |
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| Spoken Language | English |
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| Interpreter Required? | No |
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| Patient Medical Information | |
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| Isolation Precaution | No |
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| Medical Necessity Certification | |
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| Is Patient Bed-confined? | Yes |
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| Medical Needs During Transport | |
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| Required Equipment and Care | |
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| Accompanying Documents | Please upload accompanying transfer documents. |
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| Order Submission Certification | |
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| Signature |  |
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| eOrder Submission Date | 06/23/2023 |
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