| Entry ID | 3 |
|---|---|
| eOrder Submission Date | 01/16/2023 |
| eOrder Submission Time | 20:08 PM |
| Requester Information | |
| Ordering Facility | Providence St. Jude Medical Center |
| Title | Case Manager |
| Requester Department | ED |
| Requester Phone | (714) 336-0212 |
| Requester Email | Email hidden; Javascript is required. |
| Service Needs Information | |
| Service Level | EMT Basic Life Support |
| Trip Type | One-Way |
| Bariatric Patient? | No |
| Trip Schedule Information | |
| Pickup Date | 01/17/2023 |
| 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 | ED |
| Pickup Location Patient Room/Bed No. | 123 |
| Pickup Location Department Phone | (714) 336-0212 |
| Pickup Location Contact Name | Jim Karras |
| Drop Off Location Information | |
| Drop Off Location | Providence St. Jude Medical Center |
| Drop Off Receiving Department/Unit Name | 12 |
| Drop Off Patient Room/Bed No. | 4B |
| Drop Off Receiving Department Phone | (714) 336-0212 |
| Drop Off Receiving Contact Name | Jane Doe |
| Reimbursement Information | |
| Patient Information | |
| Patient Name | John Doe |
| Medical Record No. | 123456 |
| Patient Sex | Male |
| Patient Date of Birth | 10/23/1961 |
| Patient Age | 61 |
| Spoken Language | English |
| Interpreter Required? | No |
| Patient Home Address | 123 Any Street Orange, California 92866 United States Map It |
| Patient Medical Information | |
| Isolation Precaution | No |
| Description of Patient's Current Chief Complaint/Medical Condition Requiring an Ambulance | Test |
| Medical Necessity Certification | |
| Is Patient Bed-confined? | No |
| Ambulance Medical Necessity Reason(s) |
|
| Medical Needs During Transport | |
| Required Equipment and Care |
|
| Accompanying Documents | Please upload accompanying transfer documents. |
| Order Submission Certification | |
| Signature | |
| eOrder Submission Date | 01/17/2023 |