| Entry ID | 189 |
|---|---|
| eOrder Submission Date | 04/26/2024 |
| eOrder Submission Time | 14:19 PM |
| Requester Information | |
| Ordering Facility | Providence St. Jude Plaza Radiation Oncology |
| Requester Department | RADIATION ONCOLOGY |
| Requester Phone | 7144465632 |
| Requester Email | Email hidden; Javascript is required. |
| Service Needs Information | |
| Service Level | EMT Basic Life Support |
| Trip Type | Wait and Return |
| Bariatric Patient? | No |
| Ambulance Transfer Reason(s) |
|
| Trip Schedule Information | |
| Pickup Date | 04/29/2024 |
| Response Type | Scheduled Transport |
| Pickup Time | 07:20 AM |
| Appointment Time | 08:00 AM |
| Standing Order | Yes |
| Standing Order Details | TUESDAY 4/30 PICKUP AT 7:20 AM WEDNESDAY 5/1 PICKUP AT 7:20 AM |
| Pickup Location Information | |
| Pickup Location | Providence St. Jude Medical Center |
| Pickup Location Department/Unit Name | 5N |
| Pickup Location Patient Room/Bed No. | 4109 |
| Pickup Location Department Phone | 714992-3000 EXT. 7520 |
| Drop Off Location Information | |
| Drop Off Location | Providence St. Jude Plaza Radiation Oncology |
| Drop Off Receiving Department/Unit Name | RADIATION ONCOLOGY |
| Drop Off Patient Room/Bed No. | SUITE 1500 |
| Drop Off Receiving Department Phone | 7144465632 |
| Drop Off Receiving Contact Name | JUAN ANTHONY TORRES |
| Reimbursement Information | |
| Patient Information | |
| Patient Name | JAMES LEIBLIC |
| Patient Sex | Male |
| Patient Date of Birth | 02/07/1948 |
| Patient Age | 76 |
| 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 |
|
| Accompanying Documents | Please upload accompanying transfer documents. |
| Order Submission Certification | |
| Signature | |
| eOrder Submission Date | 04/26/2024 |