| Entry ID | 181 |
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| eOrder Submission Date | 04/22/2024 |
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| eOrder Submission Time | 12:34 PM |
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| Requester Information | |
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| Ordering Facility | Providence St. Jude Plaza Radiation Oncology |
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| Title | Other |
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| Requester Department | Radiation Oncology |
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| Requester Phone | 7144465632 |
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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 | Wait and Return |
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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 | 04/22/2024 |
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| Response Type | Scheduled Transport |
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| Pickup Time | 02:00 PM |
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| Appointment Time | 03:00 PM |
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| Standing Order | No |
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| Pickup Location Information | |
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| Pickup Location | Providence St. Jude Medical Center |
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| Pickup Location Department/Unit Name | 4415 |
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| Pickup Location Patient Room/Bed No. | 4415 |
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| Pickup Location Department Phone | 7144469000 ext:6251 |
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| Drop Off Location Information | |
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| Drop Off Location | Providence St. Jude Plaza Radiation Oncology |
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| Drop Off Receiving Department/Unit Name | radiation oncology |
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| Drop Off Receiving Department Phone | 7144465632 |
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| Reimbursement Information | |
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| Patient Information | |
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| Patient Name | Leiblic R James |
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| Medical Record No. | 20015092064 |
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| Patient Sex | Male |
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| Patient Date of Birth | 02/07/1948 |
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| Patient Age | 76 |
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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? | No |
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| Medical Needs During Transport | |
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| Required Equipment and Care | |
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| Other Needed Equipment or Services | will be given pain meds |
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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 | 04/22/2024 |
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