Hospital Request for EMS Documentation

Please complete the information below. Your request for information will be sent to the EMS Service Director or their designee via e-mail. Please do not include any medical information (i.e. diagnoses, injuries,etc) about the patient in this communication.

Transporting Agency*
Do you have the Requesting Agencies run number?*
- Yes
- No
Requesting Agency Run Number*
Patient's Name*
Transport Date*
MM slash DD slash YYYY
Docuementation we are missing includes: (check all that apply)
- entire run report
- 12 lead ECG
- other - see comments below
missing documents
Hospital Completed By:*
Completed By:*
First Last
Phone - please call if you have any questions
Email*
Fax Number for requested records (###)###-####*

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