Get Impacted Hospital Program Form

This guide provides step-by-step instructions for completing the Impacted Hospital Program Form online. Whether you are a healthcare provider or a patient, this resource will help you navigate the form's various components with ease.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the EMS report form sequence number in the designated field to track the enrollment request. Make sure to include the time and date this form is being submitted.
3. Provide the EMS incident location or the home address of the patient, ensuring to fill out the street, city, and zip code accurately.
4. Input the hospital name where the patient is being treated, this should reflect the facility linked with the enrollment.
5. Fill out the patient information including last name, first name, middle initial, sex, and date of birth. This section is crucial for identifying the individual in medical records.
6. Record the date and time the patient was admitted to the emergency department. This helps establish the timeline of care.
7. Note the admit diagnosis which describes the patient’s condition upon arrival at the emergency department.
8. Enter the contact information for the hospital utilization review nurse. Include their telephone and fax numbers for any necessary follow-up.
9. Indicate the patient's disposition by checking the appropriate box. You may select options like 'Admitted to hospital,' 'Treated and released from ED,' or provide details for transfers to another facility.
10. For the emergency medical services agency’s use, complete the PTIS number and any other required fields, ensuring all information is accurate.
11. After completing the form, ensure to review it for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your documents online today for a streamlined process.