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Get WI F-47489 2015-2024

Ulance service providers to comply with Chapter DHS 110, Wis. Admin. Code as it applies to documentation of ambulance runs by completing and providing patient care information to the receiving facility when the patient is delivered to the facility. This form is not intended to become part of the patient’s medical record. INSTRUCTIONS: Print legibly. Complete all sections of this worksheet. A copy of this worksheet or the ambulance run report must be completed and left with every patient delive.

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