Prescheduled Call Intake Form

CONFIDENTIAL PATIENT INFORMATION

*All fields are required to scheule transport

* = required field

Scheduler Information

Date of Call *

Scheduler *

Phone *

Fax *

Facility Information

Facility Name *

Phone *

Email *

Facility Address *

City *

State *

Zip code *

Patient Information

Patient Name *

Date of Birth *

Patient Height *

Patient Weight *

SSN *

*Medical diagnosis AND justification for stretcher support *

*"Weakness", "frail", "unable" or any other "symptoms" are NOT approved reasons for stretcher.

Doctor authorizing transport for patient *

NPI # *

Stretcher support REQUIRES that a patient has a MEDICAL CONDITION which prevents them from being transported by any other means.

Treatment & Destination Information

Destination Name *

Floor/Suite *

Room # *

Destination Address *

City *

State *

Zip Code *

Treatment Reason for THIS visit *

Date of Appointment *

Appointment Time *

Pick Up Time *

Equipment/Special Requirements

Specify if "Other" selected

Is a portable O2 device available? *

DIAGNOSED Reason for Oxygen *

Vent. Settings *

Pump or Drip Medciation(s) *

Insurance Information

Insurance Type *

Insurance # *

Private

2nd Insurance Type *

2nd Insurance #

Private

A completed PCS MUST be on file with transport company PRIOR to transporting a patient. *

By clicking this button you are confirming a valid PCS has been completed and sent.

Type the characters shown in the picture below *