Get Arha Ems New Item Request Form - Akron Regional Hospital ... - Arha

This guide provides step-by-step instructions on how to accurately fill out the ARHA EMS New Item Request Form for the Akron Regional Hospital. Whether you are submitting a new item request or a request for a replacement, this overview ensures a smooth and efficient process.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to download and access the ARHA EMS New Item Request Form in your preferred editing format.
2. Begin by entering the EMS name and address in the designated fields to identify your department.
3. Provide the EMS phone number and email address for communication purposes.
4. Select whether the request is for a new item or a replacement item by checking the appropriate box.
5. If it is a replacement item, specify which supply or pharmaceutical it is replacing in the provided space.
6. Indicate whether the new item request is for a supply or a pharmaceutical by checking the relevant box.
7. Clearly state the name of the requested item in the designated area.
8. Specify the unit or dosage request, including any relevant details such as units or gauge.
9. Enter the cost per unit or dosage to provide a clear understanding of the financial implications.
10. Include a medical justification for the request, supported by any written documentation outlining its benefit to patients.
11. Indicate the number of patients who have or would have benefited from the new item over the last six months, including the total number of patients transported.
12. Enter the name of the person submitting the form along with their phone number and email address.
13. Add the date of submission to track when the request was made.
14. Ensure that the form is signed by the Chief of Department and the Medical Director, along with their respective approval dates.
15. Include any additional comments or information in the designated area to provide context for the request.
16. Once completed, save changes to the document, and consider downloading, printing, or sharing the form as necessary.

Submit your request online to ensure timely processing.