2016-697 Emergency Svc - First Choice Medical Transport - Application for Service Franchise

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FIRST CHOICE MEDICAL TRANSPORT = Patient Care Report(PCR) < TRIP# = PREMIS# DATE OF TRANSPORT / / SERVICE TYPE BLS,Non-Emergency UNIT# PT.NAME,LAST,FIRST,MI DOB / / AGE ADDRESS:ST CITY STATE ZIP PHONE( Gender Race Weight Physician Certification Statement Present(PCS) ❑Male ❑White ❑Black ❑Hispanic ❑American IndianlAlaska Native ❑lbs ❑ YES ❑ NO ❑Female ❑Asian Pacific!Pacific Islander ❑Other ❑kg SS# MEDICARE MEDICAID OTHER INSURANCE POLICY# GROUP# ADV DIRECTIVE DURING TRANSPORT: ❑State DNR Form ❑Other Healthcare DNR ❑Family Request DNR (no form) ❑None ❑ Other TRIP INFO HRS:DISPATCHED: ENROUTE ON SCENE DEPART SCENE ARRIVAL DEST REASON FOR TRANSPORT(per PCS): PICK-UP LOCATION ST CITY STATE ZIP DROP-OFF LOCATION ST CITY STATE ZIP STARTING MILEAGE ENDING MILEAGE TOTAL MILES TYPE TRANSPORT: ❑Dialysis ❑Inter-facility Transfer ❑Hospital Admission ❑Hospital Discharge OMedical Appointment ❑Other: APPT.ARRIVAL TIME: APPT.DEPARTURE TIME: TOTAL WAIT TIME: ALLERGIES: ❑NKDA MEDICATIONS:DNA ISOLATION: [None [Contact [Airborne[Droplet (Type Isolation): PATIENT MEDICAL HX:DNA PATIENT VITALS&OBSERVATIONS: AT FACILITY: TIME HRS P R BP I ; 002 LPM SPO2 RA: ENROUTE: TIME HRS P R BP I ; 002 LPM SPO2 RA: 2ND SET(if applicable): TIME HRS P R BP I ; 002 LPM SPO2 RA: LOC=A&O X RESPIRATORY EFFORT EYESNISION VERBAL NEUROLOGICAL MENTAL STATUSIBEHAVIOR ❑Normal❑Person OPERRL Illegally Blind ❑A PPro riate ❑Moving all Ext DAppropriate/Coherent riate/Coherent OLabored ONon-Reactive OCataracts ❑Incomprehensible OSensory Intact ❑Incoherent flume ❑Fatigued ❑Constricted OGlaucoma OBaseline ❑Baseline ❑Intermittent Consciousness ❑Situation ❑Absent ODilated ❑None ❑Other ❑Combative ONot Assessed INITIAL POSITION OF PT AT SCENE: OSEMI-FOWLER'S; OFOWLER'S; OSUPINE; ❑PRONE; OTRENDELENGBURG; OSITTING; ❑OTHER PT FOUND IN: OBED; OGERI CHAIR; OMEDICAL RECLINER; ❑FLOOR; ❑CHAIR; ❑OTHER PATIENT CONDITION AT ARRIVAL STATUS: ❑UNCHANGED(NO COMPLICATIONS) ❑IMPROVED [NORSE OUNKNOWN EQUIPMENT USED TO INITIATE TRANSPORT: [STRETCHER; ❑STAIRCHAIR; 002; ❑NR; ❑NC; ❑SUCTION;❑OTHER PPE USED: ❑ GLOVES ❑GOWN ❑MASK ❑GOGGLES ❑ OTHER NARRATIVE:[Transport Uneventful OPT Stable During Transport CAREGIVER SIGN PRINT TITLE EMT DATE I 1 DRIVER SIGN PRINT TITLE EMT DATE 1 / FACILITY REP SIGN PRINT TITLE DATE i 1 AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST:I certify that the transportation services)listed above were received and request that payment for these services be made on my behal authorize any pertinent medical or other information about me to be released to the Division of Medical Assistance and Healthcare Services andlor the Social Security Administration and Financing Administrath andlor its authorized agents,Intermediates or carriers,and/or the billing agent First Choice Medical Transport LLC any information needed for this claim or a related Medicare I Medicaid I Private Insurance I Priv Claim now and in the future. I permit a copy of this authorization to be:used in place of the original and request payment of medical insurance benefits to either myself or the party who accepts assignment. I REQUEST THAT MY PHYSICIAN PROVIDE A LETTER OF MEDICAL NECESSITY. I hereby acknowledge services rendered. I authorize use of this original or a copy and permit payment for same via assignment i medical insurance to First Choice Medical Transport LLC. Responsible party agrees to pay collection cost and if a suit is filed,reasonable attorney fees,and court costs. Patient SignaturelMark- DATE / 1 ❑Patient Unable to Sign;Reason Patient is physically or mentally incapable of signing:. Representative/Witness Signature Print Relationship