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Home My WebLink AboutMINUTES - 07311984 - 1.7 (2) -- l 7 CUUM BOARD OF SUPERVISORS OF COMM Oo6TA COONTY, QUMORNIA BOARD AMON Claim Against the County, or District ) TO CLAIMANT July 31, 1984 governed by the Board of Supervisors, ) The copy of th s docum-en F- ---! I'--., -err• s Routi Endorsements, and Board j . i by 1._.___. ng ) notice of the action taken on your claim by the , Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warninnggs". Claimant: Anna Marie Abraham Bishop County (Aunsei Attorney: Ryan L. Werner J U L 0 3 1984 Gordon & Rees Address: 601 Montgromery Street Martinez, CA 94553 San Francisco, CA 94111 Hand delivered - Anount: Unspecified By delivery to clerk on June 27, 1984 Date Received: June 27, 1964 By mail, postmarked on I. nm Clerk of the Board ot Supervisors County Ccunsel Attached is a copy of the above-noted claim. Dated. June 27, 1984 J.R. OLSSON, Clerk, By Deputy Jo ene Edwards II. FROM: County Counsel IM: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: 17- </- t By: Deputy County Counsel III. FROM: Clerk of the Hoard TO: County,Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDER By unanimous vote of Supervisors present ( X ) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e n i DuBois Dated: 7-31 -84 J. R. OLSSON, Clerk, By,' ; Deputy Clerk MEJING (Gov. Code Section 913) Subject to certain exceptions, you have only six. (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. - FROM: Clerk of the Board 70: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DAs: 7-31 -84 J. R. OLSSON, Clerk, By _6,4�_ algia-� , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000008 CLAIM U6A1111 Tv; BOARD OF SUPERVISORS OF CONTRA rmrapplication to: ' . Instructions to ClaimantClerkof Uw Board P.O.rBeeoxx 911 53 A. Claims relating to causes of action for death or for Incjliury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Maims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1068 County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County,-the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, .Penal Code Sec. 72 at end of this form. RE: Claim by )Reserved fo k's f ling stamps ANNA MARIE ABRAHAM BISHOP ) RECEIVED J >' 1984 UN Against the COUNTY OF CONTRA COSTA) J.R. OLSSO. CLERK BOARD OF SUPERVISORS or A.C. Transit DISTRICT) oN ACOSTA o. (Fill in name ) BY) o�M The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ See -attached letter. and in support of this claim represents as follows: . ------------------------ -------------- ----=-------- ----- --- 1. When did the damage or injury occur? Give exact date ani hourf See attached letter. occurcl::de city and courty� See Item 3, below.- 3. How did the damage or injury occur? GiveuIS �etai�s, use extra sheets if required) This is a claim for indemnity and contribution. Plaintiff John Baker has filed Alameda Superior Court Civil Action No. 58389-5 against Keys, Bishop, and others for damages resulting from a bus/bicycle/automobile collision on Solano Avenue between Colusa and Fresno Avenues, City of Albany, County of Alma. 4. What particular act or omission on .the .pazt of county or district officers, servants or employees caused the injury or damage? See attached letter. (over) 0G00c9 t S. What are the names of county or district officers, servants -or employees causing the damage or injury? Eugene laespicio; others presently unknown. �:" What c'�amage or"3n2uries �o you claim resulte�7 ZG�ve �uiY extent of injuries of damages claimed. Attach two estimates for auto damage) Claimants assert that to the extent they may be liable for plairitiff's injuries, the County of Contra Costa is obligated to hold thein hannless and assure that liability, or to contribute for their proportional share of fault. 7. now Was the amount claimed above computed? 7Inc1u3e the est=aM amount of any prospective injury or damage. ) Not applicable. See attached letter. --------------------- - ---s- --------- ------ ------------------ �� Names and addresses of witnesses, doctors and hospitals. Not applicable. See attached letter. ------------- you ------------you made on account of this accent or �n2ury: I�TE,M AMOUNT Not applicable. See attached letter. i Govt. Code Sec. 910.2 provides: 'The claim signed by the claimant SEND NOTICES TO: (Attorney) or / some person on his behalf. " Name and Address of Attorney % 4. P. GEPJiARDZ' ZA= Claimants Signature RYAN L. VERNIER See Attached letter for claimant's 601 Montgcaery Street, Fourth Floor Address San Francisco, California 94111 address & telephone number. Telephone No. (415) 986-8041 Telephone No. NOTICE Section 72 of the Penal Code provides: •Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, 7or to any county, town, city district, ward or village board or officer; authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony.' 0000 .0 . LAIN OFFICES STUART M,GORDON DONALD W REES GORDON & BEES TELEX 6771151GRSF UW P.GERHARDT ZACHER JAMES MOUSHEGIAN FOURTH FLOOR TELECOPIER(415)9868041 DOUGLAS B.HARVEY JAMES M HANAVAN JACK B MCCOWAN JR MITCHELL L.FORSTER' 601 MONTGOMERY STREET JAMES PATRICK CASTLES P.KURT PETERSON SAN FRANCISCO,CALIFORNIA 94111 OF COUNSEL DONALD K.BUSSIERE WILLIAM A.ROBLES (415)966_6041 ARTHUR L.LANTZ JR. NANCY HUDGINS WILLIAM C.WILKA CRAIG A.BESTWICK ELIZABETH B SANDZA DIANE CROWLEY GREGORY W.JARRETT June 2 7 1984 MICHAEL T.LUCEY H.SCOTT SIRLIN / S.MITCHELL KAPLAN DANIEL J HERLING THOMAS CROSBY HOLLY HELMUTH KENNETH B TISHGART THOMAS A PACKER WILLIAM J.PETERS ALEXANDER M.WEYAND IRENEK GREENBERG JOHN HUGHES RYAN WERNER MARK ABRAMSON 'A PROFESSIONAL CORPORATION Clerk of the Board Board of Supervisors County of Contra Costa P.O. Box 911 Martinez , California 94553 Re: Claim for Indemnity; and Claim for Contribution in Connection with Alameda Superior Court Civil Action No. 583890-5: John Baker v. Alameda- Contra Costa Transit District, Anna Marie Abraham Bishop, Robert W. Keys, Jr. , Eugene Respicio To whom it may concern: This office represents Robert W. Keys, Jr. and Anna Marie Abraham Bishop in the above-referenced civil action. On behalf of Mr. Keys and Ms. Bishop, we hereby present claims for indemnity and contribution pursuant to California Govern- ment Code Sections 910-910. 2 : 1 . The names of the claimants are Robert W. Keys, Jr. and Anna Marie Abraham Bishop. Mr. Keys ' address is 6982 Brighton Drive, Dublin, California 94568 . Ms. Bishop' s address is 3200 62d Street, Apt. 35, Emeryville, California 94608 . All correspondence directed to claimants should be sent to P. Gerhardt Zacher, Ryan L. Werner, Gordon & Rees, 601 Montgomery, 4th Floor, San Francisco, California 94111 . 2 . The injuries of which plaintiff in the above- referenced civil action complains occurred on August 26 , 1982 at 5:40 p.m. Plaintiff filed suit in Alameda County Municipal Court on January 13, 1983 . On March 29, 1984 plaintiff ' s Motion to Amend his Complaint and transfer it to Alameda County Superior Court was heard and granted. Claimants Keys and Bishop voluntarily appeared in the Superior Court Action on April 25, 1984 . The Alameda-Contra Costa Transit District has also been named as a defendant and made party to plaintiff ' s suit. Claimants Keys and Bishop make this claim against the Counties of Alameda and Contra Costa in connection with plaintiff ' s suit. �no0 Page Two Clerk of the Board June 27, 1984 Claimants are informed and believe, and based upon such information and belief allege, that the injuries and damages complained of by plaintiff, if any, were caused by the Alameda- Contra Costa Transit District and the Counties of Alameda and Contra Costa, through their negligent and careless operation, control, construction, design, planning, building, maintenance, management, supervision, inspection, alteration and repair of the location, instrumentalities, equipment, and personnel which caused the injuries to plaintiff as alleged in the complaint. 3 . With the exception of Eugene Respicio, the driver of the A.C. Transit bus involved, the identities of the persons employed or connected with the entities to which this claim is addressed who were responsible for the activities listed above are unknown to these claimants at this time. 4 . The amount of damages sustained by claimants are presently unknown. Claimants are seeking indemnity and contribution. We await your response to this claim. Very truly yours, GORDON & REES By G.. RYAN L. WERNE Z' 00C'O CLAIM BOARD•OF SUPERVISORS OF CORMA COSTA COUNTY. CALIlWTIA BOARD AMON Claim Against the County, or District ) NOTICE TO CLAIMANT July 31, 1984 mWerned by the Board of Supervisors, ) The cope of th s document ma ed to you is ye— Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Sandra Brown County counsel Attorney: Annie Evans 89 Bruno JUN 2 8 1984 Address: Pittsburg, CA 94565 Martinez, CA 94553 Amount: Unspecified By delivery to clerk on - Date Received: June 28, 1984 By mail, postmarked on June 27, 1984 - I. FRCM: Clerk of the Board of Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: June 28, 1984 J.R. OLSSON, Clerk, By Deputy Jo ene ar s II. FROM: County Counsel T0: Clerk of the Board of Supervisors (Check only one) (X) This claim complies substantially with Sections 910 and 910.2. ( ) Zriis claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: Co - Z - By: Deputy County Counsel III. FROM: Clerk of the Board 70: (1) amty Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDER By unanimous vote of Supervisors present (XX) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e e n i DuBois Dated: 7-31 -84 J. R. OLSSON, Clerk, By , Deputy Clerk MRNING (Gov. Code Section 913) Subject to certain exceptions, you have only six. (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FRCM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leavenio uesent Bois a late claim was mailed to claimant. DATED. -31 -84 J. R. OLSSON, Clerk, By _� , Deputy Clerk cc: County Administrator (2) County Counsel (1) 0 Q 0 013 CUUM CLAIM AGAINST THE CITY OF PITTSBURG, ITS AGENTS AND EMPLOYEES: AND THE COUNTY OF CONTRA COSTA, ITS AGENTS AND EMPLOYEES : SANDRA BROWN presents a claim for damages against the City of Pittsburg and the County of Contra Costa, and their agents and employees . Notices sent with respect to this claim should be directed to SANDRA BROWN, c/o ANNIE EVANS, 89 Bruno , Pittsburg, CA 94565. PARTIES RESPONSIBLE: Claimant does not know the names of the officers complained of, except that Deputy Sheriff Olson was present at the scene along with at least one other deputy sheriff, and more than two Pittsburg police officers , whose names are not known to Claimant, at the time of the filing of this claim. One of the Pittsburg Police officers had a badge number 37168. The other Pittsburg Police officer's badge number was not clearly viewed, but the numbers 2122 appeared on the badge, though that may not have been the complete badge number. ACTS COMPLAINED OF: On or about March 20, 1984, in the evening, more than two officers of the Sheriff' s Department of the County of Contra Costa, and more than two officers of the Pittsburg Police Department, arrested SANDRA BROWN, who was at 36 Mountain View, .Apt. A. , in the area of Contra Costa .County, known as West Pittsburg. Other people were arrested in addition to Claimant. At the time of the arrest of other individuals in one part of the above- mentioned apartment, Claimant was taking a shower and was without clothes. During the commotion, she left the shower, put a towel CEIVED JUN 01984 000)014 J. R. OLSSON -1- CLERK BOARD OF SUPERVISORS 0NTRA TA CO. around her body and went where she could see what the cause of the noise in the apartment was . Sheriff's officers saw her and Pittsburg Police Officers then arrested her. One of the Sheriff's , officers forcibly removed the towel from her body and all of the officers looked at her naked figure. Then* the officers informed her they were going to take her into custody. They also notified her they were going to take her into custody naked, because they had found her in that condition. Claimant requested an opportunity to put on at least underwear, but was denied. Officers then handcuffed her. While Claimant was handcuffed, she was unable to . cover her breasts or her pubic area. The officers all continued to gaze upon Claimant in this condition and escorted her from the house to the street in this same naked condition. Then officers placed Claimant in a car. The police had .also brought a purported victim of a crime and a witness to this purported crime to the scene to identify some of the people being arrested. Police dis- played the naked body of Claimant to the "witness" and the "victim". The police then transported claimant in the nude displaying her to the gaze of casual onlookers and neighbors and others who were able to see her in this condition at different points of travel on the way to the Pittsburg Police Department at 55 Civic Avenue in the City of Pittsburg. The officers then walked Claimant still nude, from the car into the police department where employees of the police department were allowed to gaze upon her naked body. After entry into the , police department clothes, which relatives of the Claimant had been urging the police to allow her to g g p put on throughout this entire humiliating sequence, were then given to Claimant by police officers 000015 -2- with the remark: "Now you can put on your clothes ." When it appeared that the police were going to take Claimant under arrest in the nude and the police continued to gaze upon her body, after having torn away the towel, one of her relatives brought in some underwear for her to put on. One of the officers grabbed the underwear, threw it in .a corner of the room in a gesture obviously intended to mean that the Claimant was not going to be allowed to put it on, and turned to the person who brought the underwear and said "you are under arrest too . " DAMAGES : Damages are impossible to estimate, however, Claimant is obviously entitled to damages for this egregious behavior. Claimant requests the sum of $ 1 ,000,000.00 in damages . The exact basis of such damages is difficult to state with precision. Obviously, Claimant, who is a 24 year old black woman, has witnessed many things in her life which are badges of the former conditions of servitude of her race . It is obviously not a new fact to her that the police may see her and her relatives as people who are less than the equals of the majority white community. However, this depraved, unnecessary, and humiliating experience must serve to deeply alienate her and all those who saw this even further from white society. This lack of fundamental decency speaks volumes as to the officers' attitude toward her and her race and shows their lack of consideration for her as a person. That each officer would want to. gratify his own lust by gazing on her body is unworthy of .an official charged with en- forcing the law and serving in that capacity on this evening. That peace officers should seek to publicly expose Claimant and -3- 000016 l humiliaterher goes beyond their own motives of individual lust and shows a depraved and sick state of mind, which should justify the imposition of exemplary damages against the officers individually in the amount of $ 1,000,000.00 a piece. This is especially true of those officers in charge of the operation at the scene. Dated: Apr+i- 1984. SANDRA BRO14N Claimant Q.OQ©1 7 -4- / CUM BOARD OF SUPERVISORS OF MMA COSTA COURrY, allM NIA BOARD ACTION Claim Against the County, or District ) CT AIMAW July 31, 1984 �� governed by the Board of Supervisors, ) The copy or tnis aument mailed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all 'wtFulyjounsel Claimant: Cadillac Ambulance Service, Inc. 4601 Nevin Avenue jUL 0 3 1984 Attorney: Richmond, CA 94805 Address: Martin94553 ez, CA Amount: $31,347.89 By delivery to clerk on ,Tune 29. 1984 Date Received: June 29, - 1984 By mail, postmarked on I. FROM: Clerk of the Board at upervisors County Counsel Attached is a copy of the above-noted claim. Dated: June 29,1 984 J.R. OISSON, Clerk, By 9dz-,,e- 6 Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) (x This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: - - By: Deputy County Counsel III. FROM: Clerk of the Board TO: ) County Counsel, (2) Canty Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD Q}2DER By unanimous vote of Supervisors present (XI This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e e n i Dubois Dated: 7-31 -84 J. R. OLSSON, Clerk, By - ,� . Deputy Clerk SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You'may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's ocipy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DATED: 7-31 -84 J. R. OLSSON, Clerk, By , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000018 C UUM CLAIM,TO: -BOARD OF SUPERVISORS"OF CONTRA "*Q Yapplication to: I Instructions to ClaimantClerk of the Board i P.O.Box 911 Martinez Califomia94553 i A. Claims relating to causes of action for death or for Injury to person or to personal property or growing crops must be presented 1 not later than the 100th day after the accrual of the cause of action.' ; Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building; 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of-tTliis form. RE: Claim by )Reseryed for !„B,. ng stamps CADILLAC AMBULANCE SERVICE TNC_ C f--y ? I �--� 4601 Nevin Avenue ) Richmond, CA 94805 ) Against the COUNTY OF CONTRA COSTA) a�� or DISTRICT) (Filln name The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 31,347.89 and in support of this claim represents as follows: I. When did the damage or �n3ury occur? Give exact date ani hour] JULY, 1983 --- SEE ATTACHED '�. W�iere ds� tie damage or �n3ury occur? ZInc1ude city and countyS Contra Costa County --- SEE ATTACHED 3. How did the damage or in�ury occur? �G1ve �uII-�etalls, use extra . sheets if required) Cadillac Ambulance Service, Inc. , was requested by a. Contra Costa County Agency to provide ambulance service. Cadillac Ambulance Service, Inc. has not received full reimbursement for the ambulance transportation provided. At the time of the requested -service, there was no written contract in effect between Cadillac Ambu-' lance Service, Inc. and Contra Costa County. Thus each request for ambulance service was 'a ----------- T--- ----- 4. What particular act or omission on the part o county or aistr�ct officers, servants or employees caused the injury or damage? •_ Contra Costa County requested ambulance service which was provided by Cadillac Ambulance Service, Inc. and full payment for the service has not been made. (over) 000019 -, 5: What are the names of county or district officers, servants or employees causing the damage or injury? Unknown, but SEE ATTACHED 6. W�iat damage or �n�uries �o you clam resu�te�7 ZG�ve �u�l extent of injuries or damages claimed. Attach two estimates for auto damage)-- Loss of Income --- SEE ATTACHED -----------=---------------------------------- ------ ---- --- . How was the amount claimed above computed? Include the est mate amount of any prospective injury or damage. ) The private ambulance rates in effect on the date of the requested service less any payments received. ------------------------------------------------------z- - --------------- 6. Names and addresses of witnesses, doctors and hospitals Employees of Cadillac Ambulance Service, Inc. , 4601 Nevin Avenue, Richmond, California, 94805 --- SEE ATTACHED 1S. List the expenditures you made on account of this accident or �n3ury: DATE ITEM AMOUNT JULY, 1983 AMBULANCE TRANSPORTATION Cost of doing business Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney VN mant s Signa re GARY HURSH 46n Avenue 6825 Fair Oaks Blvd. , Suite 103 Address Carmichael, CA 95608 Richmond, CA 94805 Telephone No. (916) 481-9426 Telephone No. (415) 231-0190 •**�*�*•*Rt***t�****•�r�*it�t*,��***�sr►*�t*ter*�*tt*ate**:***��R*w��w�*tR**�*** NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer,,-, or to any county, town, city district, ward or village board or officer, authorized to allow or pay . the same if genuine, any false or fraudulent claim, bill, account, voucher', or writing, is guilty of a felony.` 000020 NAME DATE OF SERVICE AMOUNT . FLOWERS, Jennifer L. 07/01/83 $ 184.50 LONN, Vogie Y. 07/01/83 274.50 TOIBETT, Ray 07/01/83 159.50 HEHIR, Kenneth 07/01/83 184.32 WOOLEY, Mike 07/01/83 177.32 NELSON, Nancy 07/01/83 177.32 WATSON, Ethel 07/01/83 236.00 DEHAL, Gurcharan 07/02/83 280.00 CASTILLO, Pedro 07/02/83 153.00 LEWIS, Lloyd 07/03/83 183.00 GALLOWAY, David L. , Jr. 07/03/83 199.50 KENHOFFER, Robert 07/03/83 239.50 CORDOVA, Frankie 07/03/83 269.00 ARCHER, Rodney B. 07/03/83 274.00 ARCHER, Rodney B. 07/03/83 241.00 PARKINSON, Tim 07/03/83 239.50 MCGILL, Alphonso 07/04/83 168.66 HOLLIE, Lianette 07/04/83 219.52 TALBOT, George 07/04/83 321.50 DEMARS, Eddie 07/04/83 193.00 TRAVIS, Betty Anne 07/04/83 199.50 MCCRARY, Eula 07/04/83 29.00 BRENNAN, Walter, Jr. 07/04/83 232.00 ' ROBINSON, Alice B. 07/04/83 61.00 MURRAY, Kimberly 07/04/83 336.00 TATE, Derrick 07/04/83 294.00 MCCOY, Dean Harold 07/04/83 196.00 WELLS, Steven Ed. 07/05/83 204.38 FARMER, Arthur 07/05/$3 50.00 COLE, Carmen 07/05/83 316.00 HOCK, Karen 07/05/83 244.00 ASHTARI, Sophia 07/05/83 228.00 NAME DATE OF SERVICE AMOUNT EVERSON, RANSOM 07/06/83 $ 224.50 MALONEY, Linda E. 07/06/83 277.50 PROCTOR, Kim 07/06/83 212.50 COE, Melvin 07/06/83 341.00 MATSON, Ellis 07/06/83 407.50 HYMES, Ethel 07/06/83. 159.50 DOWD, Cirstie Mae 07/06/83 219.50 VAUGHN, Ivory 07/06/83 264.50 BLANCHFIELD, Daniel 07/07/83 254.50 VAN BRUNT, Larry, Jr. 07/07/83 167.25 VAN BRUNT, Richard 07/07/83 167.25 MENEWEATHER, Thomas 07/07/83 261.00 BARNETT, Patricia 07/07/83 74.20 VIGIL, Jesus 07/08/83 228.00 SABO, George 07/08/83 271.50 WHITE, Edna 07/08/83 241.50 COURTWAY, Robert 07/08/83 209.00 LAMLIN, Mike 07/09/83 177.25 MCHUGHES, Carl 07/09/83 167.25 DICHOV, Vsevolod A. 07/09/83 307.50 HOOPER, George J. 07/10/83 189.50 LENNOX, Lionel 07/10/83 194.50 BROWNE, Robert 07/11/83 220.00 DRY RUN 07/11/83 50.00 WHITE, Ann 07/11/83 201.00 DRY RUN 07/12/83 50.00 FLYNN, Brad 07/12/83 50.00 DEFRIES, John 07/12/83 216.50 ZERNITT, Zeola 07/12/84 50.00 HINDS, Samuel 07/12/84 50.00 FASANO, Alfred 07/12/83 272.00 HOLLIE, Lianette 07/12/83 236.00 DASHNIER, Ruth 07/12%83 124.00 DRY RUN 07/12/83 50.00 -2- 000022 NAME DATE OF SERVICE AMOUNT WOZNIAKOWSKI, Waldekmar 07/12/83 $ 271.00 PARKER, Noel 07/12/83 314.00 JARED, Billie L. 07/13/83 75.00 HENDERSON, CARL 07/13/83 224.50 CANCIMELLO, John 07/13/83 213.00 HUNT, Frank 07/13/83 367.50 DRY RUN 07/13/83 50.00 DELGADO, Salvador 07/13/83 159.50 DE EAIRIE, Lorraine 07/13/83 50.00 MUNSON, Michele 07/13/83 301.50 COSTELLO, Bessie 07/14/83 93.00 MCCAN, Anthony 07/14/83 153.00 GREENE, Rick R. 07/14/83 351.00 HOYDAL, Hilda 07/14/83 73.00 DRY RUN 07/15/83 50.00 DRY RUN 07/15/83 50.00 MARTINEZ, Debra 07/15/83 272.00 STEPHENS, Linzie 07/15/83 71.00 GIBBONS, Timothy M. 07/15/83 212.50 GUILLORY, Edna 07/15/83 373.00 WALLECO, La Tomya 07/15/83 50.00 AGNITSCH, Julie 07/15/83 223.00 DRY RUN 07/15/83 50.00 OVIATT, Cathy 07/15/83 198.50 POLA, Betty J. 07/15/83 195.65 ARNOLD, Marlin 07/15/83 189.50 DRY RUN 07/16/83 50.00 SAUERS, Charles 07/16/83 183.00 BRADDY, Veronica 07/16/83 139.80 CRUMMIE, Stella 07/16/83 50.00 SCHOPPE, Olivia 07/16/83 176.50 SIMMERSON, Rex 07/16/83 244.50 DRY RUN 07/16/83 50.00 -3- 000023 NAME DATE OF SERVICE AMOUNT SCHMIT, Errol 07/16/83 $ 172.50 DRY RUN 07/16/83 50.00 ABALOS, Anna 07/17/83 371.50 MACKEY, Marilyn 07/17/83 263.50 LATUS, Edwin H. 07/17/83 237.00 GARCIA, Juanita 07/18/83. 229.50 DRY RUN 07/18/83 50.00 DRY RUN 07/18/83 50.00 FRANKLIN, Kathryn 07/18/83 64.00 OSBORN, Olden 07/18/83 147.00 BORDEN, Sylvia 07/18/83 31.40 JARED, Billie 07/18/83 64.00 BORDEN, Sylvia 07/18/83 40.00 DRY RUN 07/19/83 50.00 DRY RUN 07/19/83 50.00 DRY RUN 07/19/83 50.00 BROWN, Michael Shane 07/19/83 222.00 MARK, Gilbert 07/19/83 35.00 ADAMS, Milton 07/19/83 166.00 DRY RUN 07/19/83 50.00 CISSON, Ken 07/19/83 223.00 GARCIA, Elizabeth 07/19/83 275.50 DRY RUN 07/20/83 50.00 MOLLOY, Peter M. 07/20/83 116.32 DRY RUN 07/20/83 50.00 BUDDY, Christina 07/20/83 50.00 DRY RUN 07/20/83 50.00 DRY RUN 07/20/83 50.00 DRY RUN 07/20/83 50.00 JOHNSON, Sarah Jane 07/20/83 288.00 DRY RUN 07/20/83 50.00 DRY RUN 07/20/83 50.00 DRY RUN 07/20/83 50.00 -4- 000024 NAME DATE OF SERVICE AMOUNT IRVING, Diem 07/21/83 $ 263.50 DRY RUN 07/21/83 50.00 HYMES., .Ethel 07/21/83 159.50 PETERS, Larry 07/21/83 .388.:50 DRY RUN 07/21/83 50.00 GREEN, Donna 07/22/83 303.00 DRY RUN 07/22/83 50.00 DRY RUN 07/22/83 50.00 DRY RUN 07/22/83 50.00 CARD, John 07/22/83 186.50 SANDOVAL, David 07/22/83 50.00 WYNNE, Brian 07/22/83 207.50 ROSE, Tina 07/22/83 223.00 ROGERS, David 07/22/83 308.00 DRY RUN 07/23/83 50.00 DRY RUN 07/23/83 50.00 TRAYNOR, Emmett 07/23/83 196.00 DRY RUN 07/23/83 50.00 WOODSON, Quincy Lee 07/23/83 275.50 MACK, Barbara 07/23/83 193.00 PRESTEGARD, Louise 07/23/83 130.00 DRY RUN 07/23/83 50.00 BYRTUS, Judith 07/24/83 163.00 DRY RUN 07/24/83 50.00 DRY RUN 07/24/83 50.00 . BROWN, Michael 07/24/83 159.50 DUARTE, Dennis 07/24/83 186.00 DRY RUN 07/25/83 50.00 WOODS, Eva 07/25/83 183.00 DRY RUN 07/25/83 50.00 ROBINSON, Jennifer • 07/26/83 399.00 BROWN, Hilda 07/26/83 181.50 BEIERLE, Mark 07/26/83 108.50 ALLGOOD, TROY Dale 07/26/83 183.00 DRY RUN 07/27/83 50.00 DRY RUN 07/27/83 50.00 000025 -5- NAME DATE OF SERVICE AMOUNT SCOTT, Jimmy Ray 07/27/83 $ 213.00 CALEY, Michael 07/28/83 280.50 BRINKERHOFF, Kurtis 07/28/83 60.00 HORDAHL, Olga 07/28/83 64.00 STEWART, GARY 07/28/83 228.00 , WADE, Beverly 07/28/83 229.50 DRY RUN 07/29/83 50.00 HAWK, DEREK 07/29/83 186.50 MODICA, John 07/29/83 51.00 ROARCH, DALE 07/29/83 219.00 WALKER, Thomas 07/29/83 60.00 DRY RUN 07/29/83 50.00 HOLDEN, Daryl 07/30/83 50.00 DRY RUN 07/30/83 50.00 DANBAE, Sidney 07/30/83 127.00 JORDAN, John 07/30/83 284.50 STILLWAGON, Robert 07/30/83 301.50 WILSON, Leatha 07/30/83 35.00 DRY RUN 07/30/83 50.00 DRY RUN 07/30/83 50.00 MCGILL, Yolanda S. 07/30/83 302.00 JOHNSON, Robert 07/30/83 50.00 HART, Donald E. 07/31/83 172.00 MARIANI, Richard 07/31/83 365.00 000026 -6- CONTRA COSTA COUNTY AMBULANCE raj PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 ��7 v CHECK OR FILL IN'APPROPRIATE SPACES DATE: 3 j PATIENT'S NAME=.`CU'..,QS�.j,.Sln�yl_TQC'�,._ ❑ M Id F. COMPANY N •r 3 � � �y'"' ADDRrESS tit AGE �, 114 2L CITY-t- ;�.L __ STATE C. ZIP LI_.�_I�— DOB AL 1D(-1o1 O Sn O M O T O W O Th VF; 0 S. DRIVER'S LICENSE q .. .. ...... PHONEFS30.-.S'C?>9-- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- P.S.O. CALL RECEIVED -3 T . O P.D. TIME 10.8 L :-_L j PATIENT DESTINATION: FROM SCENE r1 ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: //� 13OTHER/PVT TIME 10-7 -e END SJ �� TIME 10-98 DOCTOR _ _. PMD/ER START— TIME 10-22 .1 HOW CHOSEN: TOTAL - z(,� STANDBY TIME e NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME y; ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COMPANY: CAS I i PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: 5 RESPONSE ZONE 14 YES Cl NO WAL',ED Cl GUERNEY ❑ OTHER _ �O 1 PATIENT CONDITION. DRIVER t C_ 7-10 j TECHNICIAN_. ct:s Xj ,1 PARAMEDIC Hx.C1�_----.----_-_._-_-- --_--_-- DISPATCHER: 3Et,EC*LL 004 CHIEF COMPLAINT: RLf��?++a��l(_��L, rtjflk0iS,� DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES gNO NO. OF PATIENTS: � mp pz. S.S. a _ PRIVATE INS. CO.: BASE RATE: .� . KAISER a: MULTIPLE PTS.BASE RATE _ L , BLUE CROSS k: TOTAL MILES: X MEDICARE 4: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) 1/0•dU CCHP/PPHP M: EMERGENCY RUN: 3p.•u I MEDI-CAL#: CODE 2/3 40 aU J }-Q OTHER: OXYGEN: (PER TANK _ _�04l0 _ �J P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATO . DATES BILLED: _ _ STANDBY: (OVER 15 MO /I ?i.cam EPIS NEAREST RELATIVE/RESPONSIBLE PARTY: EADMIN.*ADMIODE) (�`,� � DRUGS: (PER ADMIN.) R RELATIONSHIPI_SL �li"W E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) + CITY: __._— STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE nn WORK PHONE VET: nQ DRY RUN: (AUTHORIZED) EMPLOYEF�fS-Rf)!UVi OCCUPATIQN: — OTHER: - - ADDRESS:LI�L'_��sli�> CITY:C` lr-Lnr\, STATE:C'A- ZIP: � ,� � ♦ p — COMMENTSRI( nx� ni-i't �K1L�� \?Ate C11� ��`T •J[�- �O �• s.. TOTAL:- 00 OTAL:-00 _ _— PATIENT RECEIVED BY:X' s( (SIGNATURES © (�.(3 py as-I Prividrr rr:aio7 c it, ;r: Icr.. r�74 h.tLr: Yr..':r ,-a, !�t" uk.+n til ink �J U1[ �" CONTRA rO.^.TA COUNTY �> AMBULANCE �(��62 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# ' CHECK OA FILL IN APPROPRIATE SPACES N ` ` ' DATE:- PATIENT'S NAME_ _ `_f' ..- �Gl lam_ _ _ _ / M OF COMPANY S9 ___.. 6ADDRESSKtn ✓–C* De1Wiz; 'go.3 ten � �� V) ^ ZCOCITY �jj-- -A:rF: SDO O Sn O M O•T O W O Th 1dF. O S- ;� Cl 535' DRIVER'S LICENSE# ___.._ Q+L , 1 -r TYPE OF TRANSPORT: AMBULANCE[] OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED �-_ ❑ P.D. TIME 10-8 7 PATIENT DESTIN TION FROM SCENE O FIRE TIME 10-97 / Q� I�L. ❑ PSAP TIME 10-49-!��Z s: 3 1 k � MILEAGE: O OTHER/PVT TIME 10.7 J ? I END J TIME 10-98. Of DOCTOR _ 1):1��`� PMD STAR —�- TIME 10-22 HOW CHOSEN TOTAL -`L—_ STANDBY TIME O NEAREST FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT 11 OTHER CALL BACK#: AMBULANCE CpyPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �.In RESPONSE ZONE ❑ YES O..NO ❑ WALYED KGUERNEY O OTHER PATIENT CONDITION. DRIVER_ VlSSl1Yl U),0 0 Q EMT-tA - TECHNICIAN�• h _VAJ-1/it U� PARAMEDIC Hx: Jj (-) II- DISPATCHER: 004 T " , CHIEF DRY RUN: ❑ YES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4 PATIENT REFUSED SERVICES: (SIGNATURE) X____.—._: (� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 4�J jc3 �I \ S.S. #- 4 Ll �t— PRIVATE INS. CO.:— __ BASE RATE: '�'�!•� / KAISER#: _ —__—_ MULTIPLE PTS.BASE RATE '•7 \� BLUE CROSS# ] �[�_ TOTAL MILES: v X J �� -•I MEDICARE#: 1E.O.B. ATT. ROUND TRIP: ❑ YES O NO ' O YES ❑ NO NIGHT: (19:00-07:00) \ CCHP/PPRP#: —_ EMERGENCY RUN: V` MEDICAL#:—__ CODE 2/3 f _S y�y G' of `50XYGEN: (PER TANK) U JJ P.O.E. STICKER YES ❑ NO Cl�c C-77 (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) :; \ �c�'r �•`� �� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: ( I.V.: (PER ADMIN.) X �•�j !••y�11(�; DRUGS: (PER ADMIN.) X ��'r✓ NAME:.— � � RELATIONSHIP E.O.A.: (IF NOT REPLACED) - ADDRESS _ J-..'.7_� C� ►L► .�C _,_�Z(�. _ ORAL AIRWAY: (IF NOT REPLACED) 1 CITY STATE.__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE __ ..____._ WORK PHONE Q DRY RUN: (AUTHORIZED) EMPLOYER _. _._ _.___ _._ OCCUPATIQN:J� OTHER: ADDRESS:-- --.-----...- - --- — / & /�✓ cJ' /7 CITY: —.—. STATE: ZIP: -- COMMENTS:— I z _ 27 N.So ------...-- ---- — — — TOTAL: --,:' 7 / ((��jj ---__-- -. PATIENT PECEIVED BY 1 CONTRA COSTA COUNTY A MBULANCE �• PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION IV /D Cf Sg CHECK OR FILL IN APPROPRIA rF SPACES DATE: PATIENT'S NAME. +3 .1 M ❑ F COMPANY# ADDRESS-[ S �. .SF1 I� e ---t�� / /P�� -- AbE CITY' )- �C� _ STATE__ ZIP nit DOB' O Sn O M O T O W `O Th Q os .�� A \ DRIVER'S LICENSE a PHONE _..____. NATURE OF DISPATCH CLS TYPE OF TRANSPORT: AMBULANC 61OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR�SXS.O. CALL RECEIVED OTO SCENE. P.D. TIME 10-8 f I PATIENT DESTINATION: FROM SCENE- 13 FIRE TIME 10.97 � ❑ PSAP TIME 10-49 ill�I �'�C, ► 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 END Lp TIME 10-98 ; DOCTOR .--.— _ PMO/ER START TIME 10-22 .. HOW CHOSEN: ANDBYTIME TOTAL I ' T - . O � S ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER "� CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: s 1^ RESPONSE ZONE ES ❑ NO ❑ WAL'�ED ERNEY ❑ OTHER PATIENT CONDITION: DRIVER__1�'d� •l�_ 2?S MT-1 �/-- TECHNICIAN PARAMEDIC ' Hx:'f-{ �Q .- –_ - – - DISPATCHER: I r .,_. , ` CHIEF COMPLAINT: C77 C_) �� DRY RUN: ❑ YES NO •-hEASON FOR DRY RUN AUTHORIZATION FOR Y RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X,--- MEDICAL .-- MEDICAL_COVERAGE: INDUSTRIAL ❑ YES � NO NO. OF PATIENTS: • S.S. # _i,4 s _4�g7 . PRIVATE INS. CO.: BASE RATE: 1- 1 KAISER#: MULTIPLE PTS. BASE RATE ` X ` J / BLUE CROSS#:--- TOTAL MILES: -• j MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO :" f:- OYES :'❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY HUN: - S MEDT-CAL W CODE 2/3 _ J OTHER: OXYGEN: (PER TANK) :, � P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1• ��' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) " ' NEAREST RELATIVEESPONSIBLE P Y: I.V.: WER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: —off -FG� RELATIONSHIP:4_f► E.O.A.:(IF NOT REPLACED) 11 ADDRESS: s`._� Z�C <. ORAL AIRWAY: (IF NOT REPLACED) CITY: IS YV.. �_ G _ - STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 9 2 S_ WOW PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _ OCCUPATION: OTHER: ADDRESS: CITY STATE: ZIP: COMMENTS: / TOTAL: -_ PATIENT RECEIVED BY:X Puider retcwhitr h, (SIGNATURE)OO 000029"s CONTRA COSTA COUNTY r "� AMBULANCe HV� PRE- �1c0l•rAl r-ARE FORM I UNIT (�� AUTHORIZATION-7 (-y'�n^hJ CHECK OR FILL W APPROPRIATE SPACES DATE:. © ` -O I - " ` ) �� PATIENT'S.NAME-,//;Z,# /..ti V eor_�me- -_..___ VM ❑ F COMPANYN_ 2- ADORE ADORE AGE , 4 I / CITY STATE ZIP DOB DOBQQ______ O Sn ❑M ❑ T /O W O Th VIF Ds DRIVER'S LICENSE N -. ._...-_ _ PHONE -_72.4-lI.U_S__ NATURE OF DISPATCH 1 f7c) TYPE OF TRANSPORT: AMBULANCE O OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE 0P.D. TIME 0-8 RECEIVED PATIENT DESTINATION: FROM SCENE- n a FIRE - TIME 10.97 2,10 H03. , PSAP TIME 10-49 {' MILEAGE" -,�'7 ❑ OTHER/PVT TIME 10-7 11 `sCI END TIME 10-98 DOCTOR .4'• . " �l �� ; PMD/ER START69.0__ TIME 10.22 HOWPIOSEN: TOTAL STANDBY TIME NEAREST O FAMILY 13 TRANSFER WAIT TIME ❑ PATIENT O DIRECT 11 OTHER CALL BACK N: AMBULANT CRMPANY: ' ( J PT. MBULATORY? ,P.AA ENT TAKEN TO AMBULANCE: 5 RESPONSE ZONE _''• R[YES ❑ NO �WAL"ED ❑ GUERNEY ❑ OTHERONO (� PATIENT CONDITION: DRIVER-1^ EMT-IA— TECHNICIAN P AMEDI i (/ Hx: ' DISPATCHER: CHIEF COMPLAINT: _ DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE UNL Y) :. t PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL O"YES ONO NO. OF PATIENTS: S.S.N i I PRIVATE INS. CO.:— _ BASE RATE: !- KAISER R:��T/��U�G:. S�7`1��,Z� }r MULTIPLE PTS. BASE RATE � 3•• BLUE CROSS N: TOTAL MILES: ^t X MEDICARE C E.O.B: ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C ��'� EMERGENCY RUN: MEDT-CAL C . CODE 2/3� �,OTHER: OXYGEN: (PE'R"TANK).'� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR)% '°"" DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V:: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ 6TATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: __ OCCUPATION? OTHER 7 ADDRESS: �` ��"-?�•"'� Ao� CITY: STATE: ZIP: CO ENTS: NOy 1 IMP-0,_AVAIL, TOTAL 00 � �_ l ` -1. L._^:. J. PATILNT RLCf'IVFt7 BY X a CONTRA COSTA COUNTY � � AMBULAtsICE �L PRE-HOSPITAL CARE FORM I I UNIT AUTHORIZATION# -7/ //F3 CHECK OR fILL INAPPROPRIATE SPACES .DATE: ^! PATIENT'S NAME V��_ __ 1 1 0 O M F COMPAN # ? �' 1 PADDPESS �� AG Y STATECA_ ZIP__ DO 1 ❑ Sn ❑ M ❑ T ❑ VII O Th 0 $ n1 NATURE OF DISPATCH 1_ DRIVER'S LICENSE# _�"ZC� PHON�� ' TYPE OF TRANSPORT: AMBULANCE Wr OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQ TED BY: TIME— (24 HOUR CLOCK) Ccp� 1 r TO SCENE ❑ S.O. CALL RECEIVED U'J P.D. TIME 10-8 r�^ ' PATIEN�IN TION: FROM SCENE- ❑ FIRE TIME 10.97 ':.�_' 1 N 3 (lc� — ❑ OTHER/PVT TIME 10-49 - _�.��_ MILEAGE: ❑ OTHER/PVT TIME 10-7 ` END_ TIME 10-98 -_22J DOCTOR PM /E START_ TIME 10-22 ' HOW CSEN: TOTAL _ _ STANDBY TIME I NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AAWE COMPANY: PT MBULATORY? PATI T TAKEN TO AMBULANCE: 5 1O RESPONSE ZONE 1 YES ❑ NO AL!-,ED ❑ GUERNEY ❑ OTHER f � PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN, 2 _L3 Z PARAMEDIC �( H. .j\kSSA._ -eDISPATCHER: ' CHIEF COMPLAINT: DRY RUN: ❑ YES t1fro REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ") lI • PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVER INDUSTRIAL ❑ YES D<o NO.OF PATIENTS: -r- ,n�" I PRIVATE INS.CO.: BASE RATE: �� •' KAISER w MULTIPLE PTS.BASE RATE " BLUE CROSS# I^ TOTAL MILES: I X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES O ❑ YES ❑ NO NIGHT: (19:00-07:00) �" (p d _ :,�r„�r-•.i ! �P CCHP/PPRP#: EMERGENCY RUN: IJ r/d MEDI-CAL#: CODE 2/3 J10,vv ) ._..__•I OTHER: OXYGEN: (PER TANK _ P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) L,�r-3`� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) DRUGS: (PER ADMIN.) X NAME:_ _ RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ?— ADDRESS: —._` ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE __. _"._ WORK'PHONE _ DRY RUN. (AUTHORIZED) EMPLOYER: ___�_...___ _ OCCUPATIOtl: OTHER: ADDRESS: —-- CITY: STATE: ZIP: COMME —_ -�v . _p—,,,,,,�ma�c I 1 • 3 1�I� TOTAL:—,, —_ 00 PATIENT RECEIVED BY-'X Pn,vidrr "ri., W'_"f(• mr.' Ii• a 4rtdr' Vn•- n (SIGN TUBE) CONTRA COSTA COUNTY AMBULANCEC PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 _ 'GCJ `-�—� 7 ^y/ CHECK OR FILL IN APPROPRIATE SPACES � y DATE: { ^ _ (, _r f PATIENT'S NAME _ GV�J�j [VV�. . O M �F COMPANY# I _ ?v ADDRESS(, �1'�.Lv_-C>� :.,-- _ _ AGE ` CITY._�(�JE� i` STATE 71P94564l_ . DOBj57 15 ❑ Sn ❑ M ❑ T o w ❑Th b(F Ds _ �_� DRIVER'S LICENSE# ___. __ __._.._._.._.__—_ PHONE__- 2'`'1._-. _f5_ _ QNATURE OF DISPATCH 11-7 TYPE OF TRANSPORT: AMBULANCEgTd OTHER❑ j INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) O SCENE- z 04 S.O. — CALL RECEIVED I S c EAST N W Y �O �C��t'f'i � J ❑ P D. TIME 10 8 --- - -- PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 i 2 ❑ PSAP TIME 10-49 'v Y MILEAGE: ❑ OTHER/PVT TIME 10-7 ^(-1 1 ENDTIME 10-98 .� DOCTOR _ 1 PMD/ER START 1Q,k TIME 10-22 HOWOSEN: TOTAL — �i! STANDBY TIME eG NEAREST ❑ FAMILY ❑ TRANSFER — WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ' . CALL BACK#: AMBULANCE OMPANY: I 1 PT/AMBULATORY? PA TENT TAKEN TO AMBULANCE: c RESPONSE ZONE ® YES ❑ NO WAL':ED ❑ GUERNEY ❑ OTHER _ 1� I — PATIENT CONDITION: DRIVER ROVOCALM: 610 EMT-1A TECHNICIAN- 3 P AFn Hx: .____L� _J_._____. t_�—_ - DISPATCHER: 1 n( ( C CO 1PLAINT: _. _. Ctiiz!"•��._ f F� �bRUN: ❑ YES O R AS6N FOR DRY RUN / /V� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE)X I MEDICALCOVER . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S # _ nGE� 7_927b_--- PRIVATE INS. CO.:— BASE RATE: _ KAISER#: MULTIPLE PTS. BASE RATE ^` •"j i BLUE GROSS#: - TOTAL MILES: X Z MEDICARE#: E.OIB. ATT. ROUND TRIP: ❑ YES ❑ NO DYES ❑ NO NIGHT: (19:00-07:00) E `a.�,,� / CCHP/PPRP#: EMERGENCY RUN: N Sd.Od / 1 MEDI-CAL#: _ CODE 2/3 1 °-moo, ,ifd.0 r ( OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) /713-115 V.- *t) DATES BILLED: STANDBY: (OVER 15 MIN.) / E.K.G.: (PER-EPISODE) �� ✓� I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: -_ ORAL AIRWAY: (IF NOT REPLACED) CITY: _— ___..____ .. . ...- STATE__ZIP:_.___ C-COLLAR: (IF NOT REPLACED) PHONE: WOFjK PHONE: DRY RUN: (AUTHORIZED) I EMPLOYER: OCCUPATION: .— OTHER: ADDRESS: CITY: STATE: ZIP:— %4- COMMENTS: IP: %4- COMMENTS: my zNS, '-T,I ' ? — — TOTAL: r PATIENT RECEIVED BY:X (gl NATURE) 0 O ^ Provider rets:r• 6�1 i!c rr.J Pi..: ropg Act— Yr::vw :-.)py !• EM.z uticn til ti OSS-1 i CONTRA COSTA COUNTY `' AMBUL CE ^ PRE-HOSPITAL CARE FORM 1 \ UNIT AUTHORIZATION If /t CHECK OR FILL IN APPROPRIATE SPACES ( �' ' )',E ATE: PATIENT'S NAMEL � .� OM COMPANY- N_ ADDR -1 �\f(1 Na 3 — A f ', CITY 114 09 STATE ZlP ' DO*NATURE Sn O M 13 T ❑W O Th OF DRIVER'S LICENSE q ___._�____._.. _ _ PHON :* OF DISPATCH` 1`TJ3k2lw-1 TYPE OF TRANSPORT: AMBULANCE la4THERO INCIDENT LOCATION: RESPONSE CODE: ;E,OUUTTED BY: TIME- (24 HOUR CLOCK) ((� (` . TO SCENE- u+'S.0. CALL RECEIVED i � - rT ❑ P.D. TIME 10-8 2 j PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 c� O PSAP TIME 10-49 MIL O OTHER/PVT TIME 10-7 "7 END TIME 10-98 : DOCTOR _ PMD/& START �- TIME 10-22 ------ HOW CC SEN: TOTALI�s,,4,0?— STANDBY TIME y►'ly)rACREST ❑ FAMILY ❑ TRANSFER WAIT TIME ®/PATIENT ❑ DIRECT ❑ OTHER ) CALL BACK 4: ACjtj$NCE COMPANY: PT AMBO TORY? PATIENT TAKEN AMBULANCE:'" 5lo RESPONSE ZONE .� YES NO ❑ WAL':ED GUERNEY O OTHER \ l` `_ PATIENT CONDITION: DRIVER V_�Y�k 7--3?- EMT-1A TECHNICIAN ` •� >a�ctol0 PARAMEDIC -'• Hx: y"'�.: �` DISPATCHERo� : CHIEF COMPLAINT: �� t� DRY RUN: ❑ YES O RE S6FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X— jot_ i `S /� MEDICCOVE GE: I USTRIAL ❑ YES NO NO.OF PATIENTS: ��/� � ' PRIVATE INS.CO.: NOY= - BASE RATE: 7J'(jJ KAISER p: MULTIPLE PTS.BASE RATE BLUE CROSS p: TOTAL MILES: y X MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES O NO J- _ ❑ YES ❑ NO NIGHT: (19:00-07:00) !'.7�`��j CCHP/PPRP q: EMERGENCY RUN: 0-A ` MEDT-CAL N: CODE 2/3 _ { F OTHER: OXYGEN: (PER TANK) r t'� J I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) f� DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY:_ (/ % I.V.: (PER ADMIN.) X �,�T �.� DRUGS: (PER ADMIN.) X I NS_H_I+ E.O.A.: (IF NOT REPLACED) ADDRESORAL AIRWAY; (IF NOT REPLACED) CITY S ___._.._.. _._ ._.-._.. STATCJQI,.ZIP: C-COLLAR: (IF NOT REPLACED) 'ti PHONE- ��t7��7 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: ^ CITY: STATE: ZIP; la a COMMENTS: TOTAL: 36 PATIENT RECEIVED BY:X t Provider rota?r. "itr v.; J;•:: :•opp ivtumYr:uy .nrpy t EW. utlrrt EfI'inp SIGNATURE) a5�1 f CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL,CARE FORM I 1 UNIT AUTHORIZATION N �T ! L ' CHECK ON FILL IN APPROPRIATf SPACES DATE: PATIENTS NAME ��r.. TQ= ._..—_ ❑ F COMPANY# ADDRESS Ci ..CS-..-- AGE �' CITY CLA SATO tJ STATE ZIP r: _ _ DOB.diclo, ❑ Sn ❑ M ❑ T O W ❑ Th ❑ F�1'$ DRIVER'S LICENSE N _____ .. _ _.. .. .. PHONE 61'2-. 1�Z.. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. __ CALL RECEIVED is " r l C�- )t, 0 c, ----- 3�z' ❑ D._ TIME 10-8 , I ci.: PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 51 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 • I :.��.• END O TIME 10-98 DOCTOR �uL�LM !&O t PMD ER START_C4_ _ TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHERI J CALL BACK C AI BU�CE COMPANY: T. AMBULATORY9 PATIENT TA Ep TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL'CED UERNEY O OTHER _ .I PATIENT CONDITION. DRIVER�`�"��j ''C�� EMT-1A �j ,, 1 1 TECHNICIAN `" kiC'� PARAMEDIC LLC Hx: . �kr_Rrme�f ISJN� C_vk : r I c 1-1 DISPATCHER �,f� CHIEF COMPLAINT: DRY RUN: 11YES Qjl NO REASON FOR DRY RUN I— _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__� MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. # — — PRIVATE INS.CO.: BASE RATE: a KAISER#: MULTIPLE PTS. BASE RATE _ BLUE CROSS n0 �' a'�`�'re0�_ TOTAL MILES: ,' X MED ARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: 20•L MEDT-CAL#: CODE 2/,•3 OTHER: OXYGEN: (PER.-TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: TMb S RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: SA IA ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE_—ZIP:_.— C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: (2 0 f}jl ADDRESS: — . . - y lJ l!V 4 CITY: STATE: ZIP: COMMENTS: - - ---- IOTA aUr OtJ 00 _— - -_—'- --- . PATIENT RECEIVED[3Y X Pn n:.(.r r.I,r:•. :r ISIGNATURE) • (MC•I ��s U CONTRA COSTA COUNTY > AMBULANCE PRE-)HOSPITAL CARE FORM I, UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES I DATE: PATIENTS NAME 4�" �t l U , fir 1 r O OM ❑ F COMPANY N , z ADDRESS 1\'0AGEJ��y ,1 CITY _ STATE— — ZIP DOB (OSn OM OT ❑ W O Th ❑ FS DRIVER'S LICENSE# _____—. _.. PHONED. NATURE OF DISPATCH _. I , TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) - 3 rc� TO SCENE- ? ❑ S.O. CALL RECEIVED.' 0 'z� / ❑ P.U. TIME 10.8 _T , PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 } n E z ❑ PSAP TIME 10.49 MILEAGE: VOTHER/PVT ' TIME 10-7 yy END- TIME 10-98 DOCTOR�_L�.< s PMD/ START-ILd _ TIME 10.22 HOW CHOSEN: TOTAL 1 _ U STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER ^ WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER l CALL BACK#: AMBULANCE C MPANY: Eo AMBU TORY? PATIENT TAKE TO AMBULANCE: DRESPONSE ZO EYES NO ❑ WAL''ED GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER t� re— EMT-1A)< TECHNICIAN_ PARAMEDIC Hx: s f/>.c i y� __ DISPATCHER: CHIEF COMPLAINT: _ � DRY RUN: O YES4DRY NO REASON FOR DRY RUN AUTHORIZATION RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X._ (I / MEDICAL CC)V F3 A.GE:,S,_ INDUSTRIAL ❑ YES KNO NO. OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER IT: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X '> MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) --� CCHP/PPRP IT: EMERGENCY RUN: ` u!t . MEDI-CAL#: - CODE 2 13 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) NEAREST RELATIVE/RESPONSIBLE PARTY: �`} _X _X NAME. RELATIONSHIP: = - ADDRESS: CITY: _ tTATE—_ZIP: �y �' ,i E• PHONE: WORK PHONE:_ EMPLOYER: OCCUPATION: ^ ,� ADDRESS: 7 Il) �j:TI ...a...:1) CITY. STATE: ZIP: ,�^_—.Ct"_�i.1.l?.7 C,j TCITAL.lti,,S-.a 00 .. .. .. - IIA 111 PIT III rt I'll 1 111v X �� 1 I• '. R ��• ,*.� , CONIRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I \ 1 UNIT __ AUTHORIZATION M I0 _ � CHECK OR TILL IN APPROPRIATE SPACES DATE: u PATIENT'S NAME. G�`��S _ / L_L� �, IPM ❑ F COMPANY# ADDRESS --4 .5..� �`�7- AGE O ry CITY-- �eA'4f1 pSTATE 4�L ZIP _ DOB! ID 'y- 'S+* ❑ M ❑ T 0 W O Th 0 F O S DRIVER'S LICENSE # ___ -_ _ _._. PHONE NATURE OF DISPATCH 89LL U LI/V�f//n N_ TYPE OF TRANSPORT: AMBULANCHER❑ INCIDENT LOCATION: 7 RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) / TO SCENE- ❑ S.O. CALL RECEIVED • .D -_ ''cJ %� r.t ( ❑ P.U. TIME 10-8 a / ... PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 2�' • ❑ PSAP TIME 10-49 :a2 ,- MILEAG 1) OTHER/FC TIME 10-7 ;�� 11// END 6 • _~J TIME 10-98 DOCTOR PMDtV START D _ - y TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME t N AREST ❑ FAMILY ❑ TRANSFER l r / 7 WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULAN E COMPANY: EABULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSEZONEONO AL',ED ❑ GUERNEY ❑ OTHER 1�j� t PATIENT CONDITION: DRIVER _ �! TECHNICIAN __ �� r -s � PARAMEDIC ! DISPATCHER- CHIEF Cgh'PLAINT:. 's _ DRY RUN: ❑ YES BNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL 11 YES ❑ NO NO. OF PATIENTS: 73 PRIVATE INS. CO.:, BASE RATE: KAISER#: __. MULTIPLE PTS. BASE RATE BLUE CROSS#' TOTAL MILES: ( X �� -"'� �¢• .. MEDICARE#: ____. E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) - �� %/ CCHP/PPRP#:— EMERGENCY RUN: 1. { MEDI-CAL It: ✓D C'¢� CODE 2/3 I OATHER) OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: __ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME Lr--. "�T � RELATIONSHIPAeoZ1 E.O.A.: (IF NOT REPLACED) ADDRESS: f,,�..�!�L ORAL AIRWAY: (IF NOT REPLACED) CITY: __._..__. STATE__ZIP:__. C-COLLAR: (IF NOT REPLACED) PHONE: _ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: �"1- OCCUPATIOV: OTHER: [! ••• ADDRESS: - 0.00038 CITY: STATE: ZIP: COMMENTS: / TOTAL: d PATIENT RECEIVED BY:X `�• P 00 i..r tr r.:. •/•L .5i .. (SIGNATURE) t: rr'' t�• Lhr.. Li1'ihp d15-1 CONTRA COSTA COUNTY �; AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: �___ro l I PATIENT'S NA�M-E'7__( � l LC' Q /( .' �� ❑ F COMPANY M ADDRESS �! `--_..__�`�i_`_r�F�_�! AGE_�Z 1 CITY- 0__1 — ZIP_ DOBr� Sn ❑ M O T O W O Th O F O g, p .. DRIVER'S LICEAISE« PHONE __. 0._LV.C,. -- NATURE OF DISPATCH kA/VN-V- • - .� TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: EO TED BY: TIME— (24 HOUR.C� CK) I j ? �—� ) p I + TO SCENE- 1 S.O. CALL RECEIVED 1 —O- =�._1 P.D. TIME 10-8 ..//..] PATIENT DESTINATION: FROM SCEN O FIRE TIME 10 97 1 �— ❑ PSAPTIME 10-49 ,: I• 1 _ t- —____ MILEAGE: ❑ OTHER/PVT TIME 10-7 >� END_ `$__ TIME 10-9 8 :Q DOCTOR - _ S.c]� _ PM /E START_.O_t-S TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME kPO EAREST ❑ FAMILY ❑ TRANSFER �• WAIT TIME _ ATIENT ❑ DIRECT .❑ OTHER CALL BACK N: AMBULAN E OMPANY: T AMBULATORY? PATIENT T EN AMBULANCE: (' RESPONSE ZONE 1 ES ❑ NO ❑ WAL-EGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J \ i _-J! a_� E EMT-1A TECHNICIAN �� ARAMEDIC Hx: AA-Cr DISPATCHER: CHI COMPLAINT: __.(�<_C.,Z\eS- v=�+�1 DRY RUN: ❑ YESlz NO REASON FOR DRY RUN �•...____-__ ._..._____.___.___� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES' (SIGNATURE) X Ir. MEDICAL COVERAGE: _ INDUSTRIAL ❑ YES NO.OF PATIENTS: S.S. K__--_ _2�/� ��— ',I PRIVATE INS. CO.:— BASE RATE: `��4/ KAISER K: —__ _ _ MULTIPLE PTS.BASE RATE 1 BLUE CROSS It: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP p: _ _ EMERGENCY RUN: MEDI-CAL a: CODE 2/3 J / OTHER: __ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ? DRUGS: (PER ADMIN.) X NAME:YVIME 15 RELATIONSHIP: I_ E.O.A.:(IF NOT REPLACED) ADDRESS: __ ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE:�3S_-o�_I�WO PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: { Q 66CUPATIQN: OTHER: ADDRESS: { -If1. VV fill v CITY: STATE: ZIP• „ COIIMENTS4T+?. :i - U y1 _�� V [`j [. /� - .Z TOTAL:11�• 'ICJ - PATIENT RECEIVED BY:X S� 00 JL�•+ lmUi lr^ w7;/fr y Tir, v (SIGNATURE) EMS-1 .•:I:. •%�. ,• L'll« EI I 1.117 c/o ( 33!71 r CONTRA COSTA COUNTY ' AMBULANCE c PRE-HOSPITAL CARE FORM I UNIT l` AUTHORIZATION# CHECK OR Flll IN APPROPRIATE SPACES DATE: / PATIENT'S COMPANY NAME kEti iso `�'•Fl-t �GI F �Erm O F I = - _ -� -- --- # ADDRESS NOti fiE� L�N�_S , ��1ILI-LY—AGE -- Ir I .;., CITY c- 2 STATE _. ZIP __._.._._.__ DOB..��' e"� -Sn ❑ M ❑T ❑W ❑Th ❑ F 13 t1S DRIVER'S LICENSE# -.. ._.._.-..__ _ PHONE __ _.._____ NATURE OF DISPATCH__•SL J'ek,yl(-'F('LQ TYPE OF TRANSPORT: AMBULANCE.O OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REUESTEO BY: TIME- (24 HOUR CLOCK) ` TO SCENE- O. ___ CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-9771, ❑ PSAP TIME 10-49 /- aa� IC� J lon m MILEAGE. ❑ OTHER/PVT TIME 10-7 —L : END TIME 10-98 DOCTOR_ `W M E PMD/ER START A TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 09NEAREST O FAMILY ❑ TRANSFER WAIT TIME —_ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY. E . AMBULATORY? PATIENT TAKEN TO AMBULANCE: -] I RESPONSE ZONE S zz YES 11 NO ❑ WAL'CED01GUERNEY ZOTHER l�� UD t- J PATIENT CONDITION: DRIVERC!iZl�t_i1dd� JN EMT-1A ✓ TECHNICIAN 5 .(r. ARAMEDIC 1`7 Hx: Ll P-I DISPATCHER: CI jJ,EF COMPLAINT: •S eIn&l l ✓` -- DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN UJ -Z- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ i 1 l�j 40 MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 43Ole) 0 _ J S.S.# 1 PRIVATE INS.CO.: BASE RATE: =�. (�. KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: �- X 'J >,o MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO Il > ❑ YES ❑ NO NIGHT: (19:00-07:00) QCCHP/PPRP#: EMERGENCY RUN: 30, Q MEDT-CAL#: CODE 2/3 'VI OTHER:M kJl-/141- el(::& OXYGEN: (PER TANK) V� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �( DATES BILLED: STANDBY: (OVER 15 MIN.) Q E.K.G.: (PER EPISODE) I ^ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �J V, ��N N F� — n A � DRUGS: (PER ADMIN.)_ X NAME: CF IRfLAT10NSH P:� '�' E.O.A.: (IF NOT REPLACED) ADDRESS: J til ORAL AIRWAY: (IF NOT REPLACED) --- —CITY: f% _STATE-- IP: `tl) C-COLLAR: (IF NOT REPLACED) /�i� ,'i / # O PHONE: $2� S_S 7 WORK PHONE:}S DRY RUN: (AUTHORIZED) r EMPLOYER;SU J1 I h�OCCUPATION' i "► OTHER: o - -�4c�cr" ' r s� 6e ADDRESS:.��t�t%z- L�GcL.LI�� _� �.L�'O 0000- - CITY: N C STATE:-L&-&-ZIA5 Z j Z V RICTENTS: (^` ILI ,-- �I�L - -`C- �';�.IL�_tL _,U l i TOTAL:.OS.�J.-`' PATIENT RECEIVED BY. X (SIGNATIJRE) .. .. Eh.:.I � CONTRA COSTA COUNTY AMBULANCE , /�� PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N l CHECK OR FILL IN APPROPRIATE SPACES - DATE: 717, to - PATIENT'S NAM F COMPANY N ADDRESS /7 �2� AGE` CITY-IC-10C Kl� FDQ��,TATE ZIP ^' DOB Sn ❑ M OT OW O Th OF ❑S DRIVER'S LICENSE N _� __-_ PHONE_!`� J_.�__-- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ y INCIDE T LOCATION: 1 RESPONSE CODE: RESTED BY: TIME- (24 HOUR COCK) ' TO SCENE- 1 S.O. CALL RECEIVED / ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE-`,/ ❑ FIRE TIME 10.97 i Ir n :(nJL`` '..: �A ';;1," ❑ PSAP TIME 10-49 f - t'j MILEAGES-7 ❑ OTHER/PVT TIME 10-7 END L.7" - TIME 10-98 L; DOCTOR fl4JC!APMER LSTART._(�� TIME 10 22 HOWo-IOSEN: S STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANfF,COMPANY: PT. AMBU�LA�RY? PATIENT TAKEN TO A446Hir*MCC RESPONSE ZONE 4-t-, ❑ YES ENO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ,EMT-1A TECH NICIA PARAMEDIC `f Hz: �) �'A�'�CZ_r DISPATCHER: CHIEF COMPLAINT: 1]�SLcJ� DRY RUN: ❑ YES NO REASON FOR DRY RUN t/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I ( PATIENT REFUSED SERVICES: (SIGNATURE) X_ Ir `✓MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. n i PRIVATE INS.CO.: BASE RATE: �r�•G'� :5�RaOSS �� ) MULTIPLE PTS.BASE RATE N: TOTALMILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ONO NIGHT: (19:00-07:00) / 11 CCHP/PPRP N: EMERGENCY RUN: s GI MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) =�"�' •.Od �j: E.K.G.: (PEREPISODE) EARF$T RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X IDRUGS:A .n,,S (PER ADMIN.)_ X . 14AMkM 'T�1=1tDNSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: C �]"C ORAL AIRWAY: (IF NOT REPLACED) FIT": STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: P WORK PHONE: �^ DRY RUN: (AUTHORIZED) IEMPLOYEIKAA41:7- j 1CCUPATIOOTHER: / 00003 �• ADDRESS: CITY: STATE: ZIP: �✓�' - G '�` �� COMMENTS !C� _T� �tOTAI. G �' dY` o w►- o�► u 00--- .---- --- - -- - - PATIENT RECEIVED 13Y. X _... I•.rt,HAria r r r CONTFIA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I UNIT 21 AUTHORIZATION 0 Cf� CHECK OR FILL INAPPROPRIATE SPACES J DATE: __ ' PATIENT'S NAME r_G�_� �_ V✓ _ �f M ❑ F COMPANY# ADDR[SS ..1�✓9 /��..__I�ct ncpc�/��s r�_++_a�_ AGE 1-2013 � _ ORo CITY_ nCO�c1..._ STATE_�!� ZIP T�S� DOB 91.2.4 38 N S O M OT O W O Th OF I O S-'j . DRIVER'S LICENSE to N A_ ._ PHONE b1 1 7-0.867 NATURE OF DISPATCH 29 , j' 4 TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CSL CK) TO SCENE- ) •S.O. CALL RECEIVED - { /vlQ✓ Qh Ll�_ ❑ P.D. TIME to-8 PATIENT DESTINATION:' FROM SCENE- ❑ FIRECTIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 1 END_ 21� TIME 10-98 A 0 •:-;gj(-" j DOCTOR ._ (^.�L.J_c� PMD/ER START— TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBO ANCE COMPANY: ) PT AMBULATORY? PATIENT TAKEN TO AMBULANCE, RESPONSE ZONE - ❑ YES ❑ NO ❑ WAL':ED X GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �n EMT-tA�1- -I TECHNICIAN_ �/CI Q PARAMEDIC DISPATCHER: - L 11 1 ) CHIEF COMPLAINT: __ _ DRY RUN: ❑ YES 'M NO REASON FOR DRY RUN !�t, AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: `sG S.S. # PRIVATE INS. CO. BASE RATE: ' KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: _7 f > MEDI-CAL#: CODE 2/3 ._. 7 OTHER:/•_ �� /r, �' I'' t.'( 12 C I t (L/ h` ' OXYGEN: (PER TANK) �j.cv d P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) S DATES BILLED: STANDBY: (OVER 15 MIN.) /,',r \kip E.K.G.: (PER EPISODE) l NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X l ��`` DRUGS: (PER ADMIN.) X NAME: �J��1►�11—__ RELATIONSHIP: II_�l F�. E.O.A.: (IF NOT REPLACED) .� ADDRESS: �} _ ORAL AIRWAY: (IF NOT REPLACED) CITY: /_! — ..____ STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) -+- PHONE: ___ WORK PHONE:_ DRY RUN: (AUTHORIZED) Gi"olp1cn-JLAL� EMPLOYER: - a __ OCCUPATIO(V:PAimer OTHER: • • ADDRESS: •%G e CITY: STATE: ZIP: -- COMMENTS:__ TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) 00 f1•.-vi.irr rrt.:i- .�;f•. ..r.: j:. Srt:.r ..r,: rl•_ ch••- t in• rx$_l i CONTRA COSTA COUNTY (� AMBULANCE or PRE-HOSPITAL CARE FORM I UNIT Z , AUTHORIZATION# .., c- --z f '• � . • ,LK OR FILL IN APPAOPRfATE SPACES DATE: _ 1. fIENT'S NAME—._��`�'o_C_��_0. ' �l1ul �❑ F COMPANY M •�• �� "" ADDR S _i L�L`f—�/,�k (1�1- AGE O +' CITY STATE ZIP CL DOB /ZSn ❑ M ❑ T•O yy ❑Th ❑ F�❑S� DRIVER'S LICENSE#:_____.__._____—_____. _ PHONE .(� NATURE OF DISPATCH �1Cw TYPE OF TRANSPORT: AMBULANCE qFCTHER❑ !.Js.%-i INCIDENT LOCATION: RESPONSE CODE: �EOUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED vo ` ( ❑. P.U. TIME 10-8 -;� �• v � ❑ FIRE TIME 10-97, • �� •�_ •! PATIENT DESTINATION: FROM SCENE ❑ PSAP TIME.10-49 �_ . { f . . , T _ MILEAGE: ❑ OTHER/PVT TIME 10-7 END "` TIME 10.98 �2 . ^� DOCTOR - � PMD/ER START ( TIME 10.22 HOW CHOSEN: TOTAL_ STANDBY TIME ❑ NEAREST Cl FAMILY jT ANSFER WAIT TIME ❑ PATIENT ❑ DIRECT OTHER � CALL BACK#: AMBULANCE COMPANY: PTZONE—I,— AMBULATORY? PATIENT TAK N TO AMBULANCE: RESPONSE ZON YES ❑ NO ❑ W/,L'CEGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER C;2 06 EMT-1A � � •_ TECHNICIAN Sig PARAMEDIC " H. �COMPL�AINT DISPATCHER:(_1 CHI1r.1� G� 1 /(� ' � DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN , AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES: (SIGNATURE) X— j MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: -- S.S. # PRIVATE INS. CO.:— BASE RATE: . KAISER#: MULTIPLE PTS. BASE RATE �— BLUE CROSS#: TOTAL MILES: MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) r CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: APER TANK) _ _ P.O.E. STICK ER ❑ YES 13 NO NEONATAL: (INCUBATOR)- ��'+ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: LV,: (PER ADMIN.) ( (,� DRUGS:. (PER ADMIN.) X ?„ NAME: tc n_► — K�'t' RELATIONSHIP: " — E.O.A.: (IF NOT REPLACED) --- --�►r ADDR_F,_�S^^ C 3��(� i1C ORAL AIRWAY: (IF NOT REPLACED) . .f CITY: STATE_ ZIP C-COLLAR: (IF NOT REPLACED)-- PHONE: UHK PHONE: DRY RUN: AUTHORIZED s EMPLOYER: OCCUPATION OTHER: .. _...-..�fJF? - t--^-�+r. l.•, ADDRESS: Cf fJ V V 1 CITY: STATE- ZIP-- COMMENTS: IP•CO MENTS: --r TOTAL: PATIENT RECEIVED BY:X 00 - (SIGNATURE) „) Proviuer reiazr• Il/itr. :r.i T'2 JrL .RPILT+i Ye'Iow Dnp: j?t^when hii:.iag ° CON IIIA r.O STA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# � t CHECK OR FILL IN APPROPRIATE SPACES DATE: v .. PATIENT'S NAME '�_� .�_�.�-t,!�'i M J10 M ❑ F COMPANY# -- ADDRESS ;- 1 �� `T C c1 F✓} ��- AGE S 7 I ~ CITY—/-1 STATE__-_.— ZlP__ DOB-cq_!6 %�L) `® Sn OM OT Ow OTA OF O g DRIVER'S LICENSE# .. . _ PHONE_3_6 "G ?'s 8 NATURE OF DISPATCH /1-7 4 ' i '� TYPE OF TRANSPORT:* AMBULANCE, OTHER❑ - rte• INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR LQCK) TO SCENE- S.O.— CALL RECEIVED Zl,.n4. ,_3/:Z ❑ P.D. TIME 10-8 72- PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 7--,P_ • SS I Z ❑.PSAP TIME 10-49 t-;N: •� Y ��- l� — MILEAGE: ❑ OTHER/PVT TIME ID : END ,G'7- C� TIME 10-98 DOCTOR _s12�'1_V._�-T__— P� STARTS_ TIME 10-22 - ) HOW CHOSEN: TOTAL i STANDBY TIME --TI'NEAREST ❑ FAMILY ❑ TRANSFER �_ WAIT TIME _ ❑ PATIENT ❑ DIRECT ❑ OTHER �. �: � CALL BACK N: AMBULANCE COMPANY: EPT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Z YES ❑ NO 13WAL•,EDX GUERNEY 13 OTHER _- 1 PATIENT CONDITION: DRIVER_�%��I ( EMT-1A ~+ TECHNICIAN_&"'n ICL PARAMEDIC L I'J Hx: ----- -o.�._.O I r'.5. -----------.DISPATCHER: CHIEF COMPLAINT: —��_j_1. 5..�-APs L'� DRY RUN: ❑ YES-Ag-NO REASON•FOR DRY RUN • —__.___ _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) f PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: Std S.S. # / .. _.......) PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE -- BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: .s .=�y MEDT-CAL#: CODE 2/3 Z II� OTHER: OXYGEN: (PER TANK) r P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS:. (PER ADMIN.) X I • i NAME: RELATIONSHIP:Zb-C. E.O.A.: (IF NOT REPLACED) ADDRESS: 4-1/ ORAL AIRWAY: (IF NOT REPLACED) CITY: __ STATE-ILA ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: k1AZ C OCCUPATIQN:Am+kpe "H ADDRESS: CITY: STATE: ZIP- COMMENTS: �a ��-S-�.k►c, .KGcL ...... -- __ TOTAL: ' PATIENT RECEIVED BY:.X ) -- i --- tr. .:..• „.,.. . -- --' ---- __ _ - (SIGNATURE � i .qp 5.t:.r+ }•,. •.�•; nr^ uhrnhi7'ino DIS-1 CONTRA COSTA COUNTY AMBULANCE 1 .. PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N .9, . . 49 CHECK OR FILL IN APPROPRIATE SPACES DATE: .7_4_g3 PATIENT'S NAKAF _ ��.� 1 �'v F. COMPANY M <<. )__,._ __ AG j ADDRESS -1 I ` V 3; CITY JCk{M0N�_ STATE_�� ZIP 4 DOBJ-�� ❑ Sn M 13T ❑W ❑Th. E3F O S DRIVER'S LICENSE N . ._ -... ___.- PHONE-137--0442- NATURE OF DISPATCH 1� / TYPE OF TRANSPORT: AMBULANC OTHER❑ I- INCIDENT LOCATION: RESPONSE CODE: REgklESTED BY: TIME- (24 HOUR CLOCK) w TO SCENE krS.O. CALL RECEIVED :AI <l•n-. — 4�� Y,��l V� O P.D. TIME 10-8 PATIENT DESTINATION: -Som`' FROM SCENE- 2 O FIRE TIME 10-97 02 O PSAP TIME 10-49 2. MILEAGE 13OTHER/PVT TIME 10-7 c> rl� � END_L 1 ' TIME 10-98 (��L :E DOCTOR l� � PMD/ER START TIME 10-22 HOWW HOSEN: TOTAL —�� STANDBY TIME J� NEAREST O FAMILY ❑ TRANSFER - - WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ( _?\` CALL BACK N: AMBULANCE OPANY: PT AMBULATORY? PA TENT TAKEN TO AMBULANCE: S' RESPONSE ZONE ESt7 NO IWAL':ED 11GUERNEY O OTHER irV PATIENT CONDITION: DRIVER EMT-lAA-�, ) TECHNICIAN n RRAR MEDT 1 HV DISPATCHER: ,. --f-U C -• U (-P'j- 1 CHIEF COMPLAINT: _ DRY RUN: ❑ YES YJ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X.___-- MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ' J . o r I G-�)G� b� g S'S, PRIVATE INS. CO.: BASE RATE: KAISER p: MULTIPLE PTS. BASE RATE BLUE CROSS p'_ —_ TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO f ❑ YES ONO NIGHT: (19:00-07:00) r CCHP/PPRP q:_ EMERGENCY RUN: �! IEDI-CAL V Al(-- CODE 2/3 / OXYGEN: (PER TANK) LA f P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBA '1 1 DATES BILLED: - STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) --�- q�� / ,,�, DRUGS: (PER ADMIN.)_ X I NAME:LL/S-L LCiF��/ RELATIONSHIP: Q.O.A.: (IF NOT REPLACED) ADDRES _11113 ORAL AIRWAY: (IF NOT REPLACED) . -9 C-COLLAR: (IF NOT REPLACED) CITY �C�M��...____.____- STAT 21P •• IPHONE: __ WORK PHONE: DRY RUN: (AUTHORIZED) _ EMPLOYER: . — OCCUPATION: OTHER: ADDRESS: CITY- STATE:--ZIP:--. CgMMENTS:1[ TOTAL: - -- 00 _ PATIENT RECEIVED BY:X \\ Fy ui:rr rrt.r.'. W i, r .• ry ry ;.4�: 1'1 inp (SIGNA RLl DIS-1 U �+► iolz/�3 rs l.� CONTRA COSTA COUNTY AMBULANCE "PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION f't.� • ,: CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAMdul- Le- ❑ M F COMPANY p �r� �`rZit� ADDR S ` fj( AGF.!_L_ D�I JCITY .` _ 1 STA ZIP DOBf0 2=LV•1 ❑ Sn XM ❑ TII ❑ �Wf ❑ Th ❑ F OS-1 DRIVER'S LIC SEN _ PHONE_. _— NATURE OF DISPATCHl TYPE OF TRANSPORT: AMBULANCEZ OTHER❑ INCIDENT LOCATION:' :i RESPONSE CODE: REOUE,STED BY: TIME—(24 HOUR CLOAK) ! TO SCENE- b�.0/ CALL RECEIVED C fl-P.D. TIME 10-8 C1 'A ;I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 L�� - .I /1 L �j'7�1� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTORPMD/ R START h TIME 10-22 HOW CHOSEN: TOTAL f- STANDBY TIME NEAREST i❑ FAMILY ❑ TRANSFER ,r 'WAIT TIME 1 ❑ PATIENT ❑ DIRECT ❑ OTHER �_ i CALL BACK#: AMBULANCE COMPANY-4 1; PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE:/ SIV RESPONSE ZONE I , A YES ❑ NO ❑ WALKEDGUERNEY ❑ OTHER V PATIENT CONDITION:. I DRIVER ,d." p;; / TECHNICIAN iD� PARAMEDIC HX: DISPATCHER: I lJ CHIEF OMP INT: DRY RUN: ❑ YES NO REASON FOR DRY RUN qQ ` AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 2(` d 1 ( T T F�Et S SERVICES: (SIGNATURE) X -1✓ MEDICAL Q�ERA _ INDUSTRIAL ❑ YES J�NO NO.OF PATIENTS: S.S. a ,q4,22 C1 �.' PRIVATE INS. CO.: BASE RATE: - KAISER a: MULTIPLE PTS,BASE RATE 1 BLUE CROSS N: TOTAL MILES: X - ✓' MEDICARE It: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) m ��"✓, oW�," CCHP/PPRP C EMERGENCY RUN: MEDI-CAL#' CODE 2(3.-" OTHER: OXYGEN: (PER TANK) ��""� &V P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR)' v :; DATES BILLED: STANDBY: (OVER 15 MIN.) ` 1��i..i' E.K.G.: (PER EPISODE) � " , .__.NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' d G DRUGS: (PER ADMIN.) X t_hl_-.-NAME r RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) f�ev*'6 PHONE: 3 3 - 3 2 Z WORK PHONE: DRY RUN: (AUTHORIZED) C, _-EMPLOYER: OCCUPATION.'. OTHER: d ADDRESS: �� G `.CITY;" STATE:—ZIP:- 000044 COMMENTS: a z .�. TOTAL: _. PATIENT RECEIVED BY:X �!{ •' `—• L jo� ® Provider retain 4%itev.,f Ji., rnr ISIGNA*URE I rms-1 V CONTRA COSTA COUNTY AMBULANCE _ r^� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N D O ^ TTA CHECK OR FILL INAPPROPRIATE SPACES DATE: - 7 93 PATIENTS NAME L�y_L__ r J � . (�•--/�--�� •� � M �,J❑(�F COMPANY N• •/ ADDRESS �) 1` 6M 1 r lY?O/7T�. b r AGE�! CITY / _A STATE - L— ZIP DOB 0 Sn )qM O T Q W Q Th �O F•13 f5 DRIVER'S LICENSE# I�..___.__ PHONE Nv NATURE OF DISPATCH- U__ ISPATCH �I(o_ 1 Lr- TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ _ A INCIDENT LOCATION: RESPONSE CODE: i REQUESTED BY: TIME-(24 HOUR CLOCK) L . I I { A TO SCENE- S.O. CALL RECEIVED O P.D. TIME 10-81 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 :' R (� �` ` (� ❑ PSAP TIME 10-49 L- c �J `'' MILEAGE: ,/ ❑ OTHER/PVT TIME 10.7 a 1 4 ' END ~ ( r TIME 10.98 ;, t DOCTOR ��;U..U^C.l� PMD/o START TIME 10-22• _ HOW CHOSEN: TOTAL Z 9 STANDBY TIME ❑ NEAREST 13 FAMILY TRANSFER I WAIT TIME "1 ❑ PATIENT ❑ DIRECT ® OTHER S/SO �� CALL BACK#: AMBULANCE COMPANY PT. AMBULATORY? PATIENT TAK N TO AMBULANCE:ES ❑ NO ❑ WL,L':ED UERNEY 5 to RESPOySE ZONE /Q�� ❑ OTHER �--r T - . PATIENT CONDITION: DRIVER 110 EMT-1A ^5 ... • onff TECHNICIAN X7� PARAMEDIC C� �j _mw _r! ctu 'O_� I ' DISPATCHER: t�EL._e-LE- 004 .k J GHi1 F OA PC>Yttdi r ( 1 DRY RUN: 13YES M NO REASON FOR DRY RUN c Tl 24L . � UTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIEN REFUSED SERVICES: (SIGNATURE) X— ' MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO. NO.OF PATIENTS: y `✓- � -' S.S: # PRIVATE INS,CO.: BASE RATE: D' KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: X •��?/ i MEDICARE C - E.O.B.ATT. ROUND.TRIP: ❑ YES WNO ❑ YES ❑ NO NIGHT: (19:00-07:00) *- v CCHP/PPRP#: EMERGENCY RUN: _�17•cd a0 MEDI-CAL#: CODE(a 3 OTHER: OXYGEN: (PER TANK) _ P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) ' } DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: —I.V•: (PER ADMIN.) X' :: DRUGS: (PER ADMIN.) X. NAME: RELATIONSHIP: E.O.A.: (IF.NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED)' CITY: _ STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �_..•': ';; EMPLOYER: OCCUPATION•,__ OTHER: -~~- --~--�--'� ADDRESS: CITY: STATE: ZIP: I.% Cl/1E COMMENTS: Nttyv I f TOTAL: /•,�J -- — PATIENT RECEIVED BY:X :.. IGH TUBE dDIS-1 4 Pmuidrr retair• White Ud Pink rrpp FttuM YoNuLl noes �: 4tS ishan hil'inp �� 1 L�Qn . ..'. `.q ! CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Pn AUTHORIZA TIO M L iL-CHECK OR FILL INAPPROPRIATE SPACES DATE: ^ PATIENT'S NAME_,!�C1I'�AP�S_ �/ - � ❑ F COMPANY N I — - ADDRESS L S_ ` AGE Z '� C CITY__i�a ffw _ STATE • ZIP 9 go 612D BO Sn Xvl ❑ T O W O Th O F .0 S ) DRIVER'S LICENSE a PHONE__ , _ � NATURE OF DISPATCHrp �� TYPE OF TRANSPORT: AMBULANCE THER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK),-, TO SCENE- .O. CALL RECEIVED 741 is Sh - 3 f� . . -- -- ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-.�7 ❑ FIRE TIME 10-97 �C� !i O PSAP TIME 10-49 'LLL'' ! ' MILEAGE: O OTHER/PVT TIME 10-7 �— END _ _� TIME 10 98 DOCTOR Iz _. PM %ER START . a TIME 10-22 HOW CHOSEN: TOTAL_ STANDBY TIME rEAREST ❑ FAMIL ❑ TRANSFER .--- \ WAIT TIME PATIENT ❑ DIRECT ❑ OTHER (J�� 1 CALL BACK M: AMBULANCE COMPANY: _-r it PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 J^ RESPONSE ZONE L1 YES ❑ NOWALL"ED ❑ GUERNEY 11 OTHER PATIENT CONDITION: s }i�LC DRIVER j3Q 4'�OPARA EMT-1A TECHNICIAN L MEDIC H : _1�_I�L`/.�_1___._-..._ DISPATCHER: ,. �1-'� 00( CHIEF COMPLAINT: DRY RUN: ❑ VES O y REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.a 1 3-1-_.`_�� _ I PRIVATE INS. CO..— __ BASE RATE: U d� KAISER a: _ MULTIPLE PTS. BASE RATE BLUE CROSS M:_ TOTAL MILES: X J MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN: MEDT-CAL a: CODE 2/3 y O — OXYGEN: (PER TANK) (u,t_c P.O.E' STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:— STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X /j DRUGS: (PER ADMIN.) X NAME1RELATIONSHIP � E.O.A.: (IF NOT REPLACED) ADDRESS:..Z'_wql __ /� /1}?S�L�_ �� ORAL AIRWAY: (IF NOT REPLACED)CITY: � p------____.___._ STATE_�,_dZIP:_., C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _.. OCCUPATION: OTHER: ADDRESS: �- CITY: STATE' ZIP: COMMENTS: n I 1 TOTAL: s � (�O PATIENT RECEIVED BY:X � Zy } 21 (SIGNATURE) V 1 Provider rcta:r, White ,rd Pir, ,•app Return �e'Icn• rnpy t !�J� �hrn tc1'inu a5-1 • ONTRA COSTA COUNTY AMBUL CE 83 _ RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# v • - CHECK OR FILL IN APPROPRIATE SPACES DATE: K••� PATIENTS NAM ✓ _ J120 M }G - COMPANY M ADDRE6S 41 n . Y AGE% CITY STATE ZIP _ DOB. 7 0❑ S. ❑ T ❑ W ❑ Th ❑ F Os DRIVER'S LICENSE N -_ __._-- _--_ PHONE. S SNATURE OF DISPATCH s ci?ur r - TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED ( i ' � ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE-n ❑ FIRE TIME 10-97 .J ❑ PSAP TIME 10-49 –1� •= MILEAGE O OTHER/PVT TIME 10-7 END �� TIME 10-98 DOCTOR PMD/ v .START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER ,..� WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COM MY PT. AMB LATORY9 PATIENT TAKEN TO AMBULANCE: J�, RESPONSE ZONE ' ❑ YES NO ❑ WAL'<EDXGUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER r iJ�.� �` ' �2' 3 EMT-1A hbo TECHNICIAN�r ayid 1 ;4(I ' RAMEDIC Htt: 1111 ? � DISPATCHER: r L' 7 CHIEF COMPLA NT: l�_� DRY RUN: ❑ YES NO REASON FOR DRY RUN —f,1„1021.� _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERA E: It4DUSTRIAL ❑ YE$,JO NO. OF PATIENTS: ?�• �-� �� S.S.# PRIVATE INS. CO.: r.4SE RATE: ' KAISER a: _ MULTIPLE PTS. BASE RATE BLUE CROSSS'g� �IZk S�' TOTAL MILES: -� X �' ? •5J MEDICARE It: --5,4,/ C0r4 E.O.B. ATT. ROUND TRIP: O YES ❑ NO YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP R: EMERGENCY RUN: yyy MEDT-CAL M: CODE 2/3 yI� OTHER: _ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ------------- E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIB PARTY: EE.O.A.: V.: (PER ADMIN.) X � RUGS: (PER ADMIN.) X NAME: � '� TIONSHIP:. (IF NOT REPLACED). ADDRESS: SQ�.t ��• ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE__.. (71P:..__..__- C-COLLAR: (IF NOT REPLACED) PHONE: KPH 1 -S DRY RUN: (AUTHORIZED) EMPLOYER: U 111 �_� . ADDRESS-� CITY: Com • STATE:-ZIP: - COMMENTS: TOTAI.- -- - ---- - ------------ ..\ ' J 1J 0 ` 1 AIIF NI III LIVI-1) BY C CONTRA COSTA COUNTY AMBULANCE a ' ,/ PRE-HOSPITAL CARE FORM I UNIT (j�)� AUTHORIZATION M 1 IL!(t�.�a CHECK OR FILL IN APPROPRIATE SPACES DATE: kl PATIENT'S NAME ___-. _ O M f F COMPANY M L4U 'O ADD SSqu AGE CITY Aa STATE ZIP �q � DOB- ILW ❑ Sn VM OE W ❑Th OF O g , DRIVER'S LICENSE q __�________-__.__-_'PHONE ( _I71Q'�NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 1AOTHER0 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE` .0 S.O. CALL RECEIVED D P.U._ TIME 10-8 '• :��'•:.:;r.'.. PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1nn D PSAP TIME 10-49 lJ� MILEAGE. �,. I ❑ OTHER/PVT TIME 10-7 GEND TIME 10-98 DOCTOR P� START- t__; ` TIME 10-22 HOW CHOSEN: TOTAL , S.' STANDBY TIME. ❑ NEAREST 11 FAMILY ❑ TRANSFER WAIT TIME PATIENT D DIRECT ❑ OTHER `7 CALL BACK N: AMBULANCE COMPANY: E. AMBULATORY9 PATIENT TAKEN TO AMBULANCE: 5+`.� RESPONSE ZONE YES O NO WAL'(ED ❑ GUERNEY ❑ OTHER ;_ ! PATIENT CONDITION: DRIVER ) `� ` ClFMT—tA�� .;•, TECHNICIAN Aft PARAMEDIC '7 J Hx: [Ld ` — DISPATCHER: 7 HI C (PLAINT: 17� �� e DRY RUN: O YES 1-3NOREASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SI NATURE) X_�_— MEDICAL COVERAGE. INDUSTRIAL ❑ YESPI-NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER 4: MULTIPLE PTS.BASE RATE BLUE CROSS p: TOTAL MILES: MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES O NO OYES ONO NIGHT: (19:00-07.00) CCHP/PPHP EMERGENCY RUN: <LHnl-fezw: L>>S CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES. O-NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X �. DRUGS: (PER ADMIN.) X NAME: ` RELATIONSHIP � E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 01 t PATIENT RECEIVED BY• X nn 1'mVi IVr pvta".. whi t.. .,.:.I KPA irlum Y. I (SIGNATURE) oma' CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION It FL CHECK OR FILL IN APPROPRIATE SPACES DATE: Y PATIENTS NAME (j'AF., RC1 ll1s`_ ly'n,�NL)c, M O F COMPANY M ADDRESS A U (3 rN�k (- - AGE SA-6— CITY STATE -ZIP_ DOB— O Sn OM OT OW ❑ Th .O F OS DRIVER'S LICENSE M _..._ __—_ PHONE _._ _-- NATURE OF DISPATCH`,s'z klzL TYPE OF TRANSPORT: AMBULANC&C OTHER❑ ...__ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) '•, TO SCENE �;S.O. CALL RECEIVED r. s N, —+� ❑ P.D. TIME 10-8 / L PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 //�� ❑ PSAP TIME 10-49 zMILEAGE ❑ OTHER/PVT TIME 10-7 END .TIME 10-98 DOCTOR PMD/ER START Z7 _ TIME 10-22 HOW CHOSEN: TOTA _ ._ STANDBY TIME J 13NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT a(IOTHER CALL BACK M: AMBULANCE COMPANY: P,._.TAMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 f C RESPONSE ZONE :7 ,// < .YES ❑ NO ❑ WAL'.<ED '�(GUERNEY ❑ OTHER t PATIENT CONDITION: DRIVER r� 1,i=�__� �J rF► -1 a.: TECHNICIAN PARAMEDIC Hx: _ DISPATCHER: (� CHIEF COMPLAINT: DRY RUN: 11 YES NO REASON FOR DRY RUN (U C AUTHORIZATION FOR DRY RUN(EMS USE ONLY) X02 PATIENT REFUSED SERVICES: (SIGNATURE) X, 5� MEDICAL COVERAGE: INDUSTRIAL ❑ YES'% NO NO. OF PATIENTS: S.S. R `y PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BAS ATF BLUE CROSS R: c� TOTAL MILES: X ID...?zJ MEDICARE R: E.O.B. ATT. ROUND TRIP: Y O JI O YES O NO NIGHT: (19:00-07:00) i CCHP/PPRP#: EMERGENCY RUN: , d� MEDI-CAL#: CODE 2/3 7 v� OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATO'N, • DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY`. STATE: ZIP: _. COMMENTS:r � on Z-o. an6 Ly..-a 4 i, tq-T LD T1 TOTAL: 00 IE NT RECFIVFD BY X _-- .—' 4ryiFFl S CONTRA COSTA COUNTY AMBULANCE V PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 i : " r R Flll INAPPROPRIATE SPACES DATE:- NAME ATE:NAME 8061115OL1 ItCP I ❑ M COMPANYN SS 3 I 2_'S F cy ST, AGE 2 f i?,o D `r• GC C!Lku(Q"lbSTATE CC- ZIP95A3 g DOB_ IC ❑ Sn 6M 0 T 0 W 0 Th O F 0 S IVER'S LICENSE M -_. __.____-_ PHONE c NATURE OF DISPATCH 5k'�2 + TYPE OF TRANSPORT: AMBULANCE OTHER❑ - 1 INCIDENT LOCATION: RESPONSE CODE: RE9,,UES TED BY: TIME- (24 HOUR CLOCK) ., / TO SCENE- '? ;+J.O. CALL RECEIVED S - _� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10-97 0 PSAP TIME 10-49 ' vob MILEAGE- 0 OTHER/PVT TIME 10-7 �1 END TIME 10-98 (_• .~ , DOCTORT�IS MC/ER START TIME 10-22 HOW CHOSEN t4,e r r(C ��" ' TOTAL — Lam_ STANDBY TIME 0 NEAREST ❑ FAMILY 0 TRANSFER WAIT TIME Vr PATIENT ❑ DIRECT ❑ OTHER f � 1 CALL BACK q: AMBULANC CO —mss I PTBULATORY? PATIENT TAKEN TO AMBULANCE: �� ``- RESPONSE ZON YES ❑ NO ❑ WAl':ED J�rGUERNEY ❑ OTHER I i ah r PATIENT CONDITION: DRIVER- .._ (+'•l _ EMT-1A TECHNICIAN M ""Qi CC c "1 V•'`T 0.�c1 S .2 S 1 l PARAMEDIC 1 Hx:C � `''�� DISPATCHER: r � ` ( ��• � ,1 CHIEF COMPLAINT: SG (Z �!'L_ DRY RUN: ❑ YES §�_NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAt,COVER E:E: _ NDUSSTR IZ'❑ YES ❑ NO NO. OF PATIENTS: S.S. # Z J Z i PRIVATE INS. CO.: BASE RATE: 3tUI KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS d TOTAL MILES: X MEDICARE K: Cl _ ZQ E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO ❑ YES 0 NO NIGHT: (19:00-07:00) �1 CCHP/PPRP N: EMERGENCY RUN: ''�I G a� MEDT-CAL R: CODE 2/3 J� 0THER:I'/11I'fCd elMC�('iC'C,A C OXYGEN: (PER TANK) I P.O.E. STICKER 0 YES 0 NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.:. (PER ADMIN.) X ,�{ DRUGS: (PER ADMIN.) X NAMEV,prC` 1 , F'r�[ T_ RELATIONSHIFD-0.0 E.O.A.: (IF NOT REPLACED) ' ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) + EMPLOYER: OCCUPATION:,- OTHER: ADDRESS: CITY: A STATE:__ZIP: COMMENTS:UM - oG rci SZ_L(- -- TOTAL. u- ,4QS! 1315.c(.. S� --.._......_. PATIENT RECEIVED BY X (SIGNATIMI 1 U U Yn+w.(vr rC[air, Mhiti ,f / I ir,% •.q p ..l ra 7. ':..a / . nl a.la•'rr I•il i ,r CN' I ' Iti CON I RA COSI A COUN 1Y AMBULANCE .•�� Q9 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPAOPTf SPACES DATE: —/ •1 PATIENT'S NAMELA / .__..��.A/ !_ _- 0M ,52F COMPANY 1 ADDRESS �on. �' AGED D �- CITY V.j L_L6 STATE C•4 ZIP_9_1!1�� 700B!__7��❑ Sn ;YM O T O W O Th O F O g•;l DRIVER'S LICENSE k .__- .__ PHONE ..__ ZC` 3 NATURE OF DISPATCH�JIQ(�Q,L1f s�S-D TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REO VESTED BY:' -TIME- (24 HOUR CL C 0RECEIVED . K) I r 7 TO SCENE- 'S.O. CALL RECEIVED . 1��I ? -11� _�"� SLt�-� �- _ ❑ P.U. TIME 10-8 I' ' PATIENT DESTINATION: 'T,,1 I• FROM SCENE ❑ FIRE TIME 10 97 ❑ PSAP TIME 10-49 11 ��4:• 4` __[_�__ _-_ MILEAGE: O OTHER/PVT TIME 10-7 Z -� ` l� END Zz. .� TIME 10-98 DOCTOR _ �__-- _. PMq/ER', START_ _ TIME 10-22 HOW CHOSEN: ) TOTAL �� STANDBY TIME 13NEAREST _V?�MILY ❑ TRANSFER \\ WAIT TIME r ❑ PATIENT O DIRECT 'OTHER s'��! (all- / CALL BACK C AMBULANCE PTjAMBULATORY? TENT TAKEN TO AMBULANCE: 5 o ' [RESPONSE ZONE _y OYES ❑ NO ❑ GUERNEY O OTHER ---._ LI / ) PATIENT CONDITION: DRIVEF#?��LL'—=5 C, — E T-lA A'� 11 TECHNICIAN6.II RAMEDIC Hx �. CJ1.( - r- ------- DISPATCHER: 'l CHIEF COMPLAINT: DRY RUN: ❑ YES '13 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (� PATIENT REFUSED SERVICES: (SIGNATURE) X i /J MEDICAL COVERAGE INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. Is PRIVATE INS.CO.: BASE RATE: � KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: y X G ✓'�� , MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO i ' (� I 1 O YES ONO NIGHT: (19:00-07:00) - fp I CCHP/PPRP qC EMERGENCY RUN: . ..'dry 0 MEDT-CAL C CODE 2/3 _ OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X• NAME:. RELATIONSHIP: _ E.O.A.: (IF NOT REPLACED) ADDRESS: __ _ ___ ORAL AIRWAY: (IF NOT REPLACED) CITY ___._____.____...__..._ ... STATE-_ZIP:_. C-COLLAR: (IF NOT REPLACED) PHONE: - - WORK PHONE: DRY RUN: (AUTHORIZED) (}�--- a EMPLOYER: OCCUPATION: OTHER: v V k ADDRESS: CITY: STATE: ZIP: COMMENTS:_, TOTAL! 7 6 . PATIENT RECEIVED BY:X _ � Nttaki (SIGNATURE)OO . ENS-1 .I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITFrAUTHORIZATION# Ilz CHECK OR FILL INAPPROPRIATE SPACES DATE:- 7 PATIENT'S NAME h �M ❑ F -COMPANY ADDRESS —� lJ � _ AGE CITY��! h �K / S,/T�ATE ZIP_ DOB �d -'�J ❑ Sn )N ❑T ❑/W ❑�JTh 0 F, 0 S ALtTODR+tFER ICEiVSE k fr<�.f'/_&,�__-_ PHONE C - � _ NATURE OF DISPATCHT`�_ ' TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME-(24 HOUR C OC ) I TO SCENE- S.O. CALL RECEIVED , 6� ISL7"Yl P.U. TIME 10.8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 J' ❑ PSAP TIME 10-49 JAL MILEAGE: ❑ OTHER/PVT TIME 10-7 n / ,�-�S �! END _ TIME 10-98 DOCTOR _�_—� PM ER START __- TIME 10-22 HOW CHOSEN: TOTALZ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ��-- PATIENT ❑ DIRECT ❑ OTHER / CALL BACK#: AMBULA Cj�( "}' .7PANY: PT AMB LATORY7 PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WAL!,ED VGUERNEY ❑ OTHER _ PATIENT CONDITION. DRIVER_____ el E%/ oo EMT-tA :1 TECHNICIAN G , l�E%' /SCTvL" -'PARAMEDIC J�y,�.�b, _u Glr�h . r Hx: _ ___-__- DISPATCHER: �� ( I CHIEF COMPLAINT: _/!k'!/CLl.c' - /' /�e DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES O'NO NO.OF PATIENTS: J'"'`• ' S.S. #- -- ' PRIVATE INS, CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE f BLUE CROSS# TOTAL MILES: '/X -2 `-7• `/ MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO 11 . oS YES ❑ NO NIGHT: (19:00-07:00), I CCHP/PPHP#: EMERGENCY RUN: a� MEDI-CAL#: CODE 2/3 I OTHER: OXYGEN (PER TANK) YE STICKER P. .E. TI ❑ ❑ N NEONATAL: INCUBATOR O S C S O /) �r DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X / ,� / DRUGS: (PER ADMIN.) X l / ..:. NAME:_�_��_ Gt!' //��___^ RELATIONSHIP:�Y�t�l� E.O.A.: (IF NOT REPLACED) ADDRESS:S�v2G?""_/—��!_z 6�' #y ORAL AIRWAY: (IF NOT REPLACED) r CITY: G.clii/_.�_.)_ STATE-QZIP: C-COLLAR: (IF NOT REPLACED) - - PHONE: >� � �`7C_ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: —L�0uE,- OCCUPATION: OTHER: - ' ADDRESS: _ �` �,��• %=/ % . '��/ ��(/ y7 CITY:. _ STATE: ZIP: COMMENTS: (' S 1 l IN-1-_ ka 44 S L[O 101A L 00 2ty PATIENT DECEIVED 8N' X �._. •+�*rlMlvM►�A�� CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM I UNIT ® AUTHORIZATION 0 a`S /`1.,5�► CNECK OR FILL INAPPROPRIATE SPACES DATE: ZJLk L_ 93 N.PATIENTS NAME [_..._ _ ?'M ❑ F COMPANY R- •� `� �) ADDRES 3 A9-R�EvJ ST AGE _- J Z-- CITY _ STATE �++�� - ZIP__�.. � DOFI_:1�3 13 S. M ❑ T ❑ W ❑ Th 13F ❑ S DRIVER'S LICENSE M _;X U(4 Ylv(J__ _.. PHONEC-)Q&`S%79 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE J6 OTHER❑ _ ____-_....___.�_ .. INCIDENT LOCATION: RESPONSE CODE: R2OUESTED BY: TIME- (24 HOUR CLOCK)C r C '7O `ee S-rTO SCENE- ,O P.U. TIME a8 RECEIVEDS.O. CALL \ / .2 3 G 1 PATIENT DESTINATI N: FROM SCENE ❑ FIRE TIME 10-97 ML RIO V I �� 13PSAP TIME 10-49 = : •/ 11� MILEAGE: / - ❑ OTHER/PVT TIME 10-7 -� �3•� END— �`�'/ TIME 10-98 DOCTOR c 5Ak '2' PMD/Q START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER 711 WAIT TIME 0 PATIENT ❑ DIRECT ❑ OTHER (4 ) CALL BACK q: AMBULANCE COMPkN`Y- ` PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1(_) RESPONSE ZONE G 9f YES ❑ NO [IWALi:ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER '_' M -1A I ii TECHNICIAN Ld A-t d= 2.111 P MEDIC Hx: 0 V I C'7 ISPATCHER: LIRA - 1!:7 qp ^ CHIEF CnOMMPLAINT: � Zl&C p -� �� RY RUN: ❑ YES ❑ NO REASON FOR DRY RUN Gl `!lam I CAA_-� _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) // PATIENT REFUSED SERVICES:(SIGNATURE)X- j MEDICAL COVERAGE: IN U TRIAL ❑ YES 13 NO NO. OF PATIENTS: S.S. # SV•'•-' �-� P .• BASE RATE: ''•�� AISER R S. COMULTIPLE PTS.BASE RATE BL CROSS#: TOTAL MILES: X or) MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO d S ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP A: EMERGENCY RUN: " v MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK), { P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �D DATES BILLED: STANDBY: (OVER 15 MIN.) ' E.K.G-: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: � �(Alrzl� RELATIONSHIP:_ E.O.A.: (IF NOT REPLACED) ! 7 ADDRESS: ORAL AIRWAY: (IF NOT REPLACED /4 _ CITY: rZ ' STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) 11 i PHONE: �� g'VWORK PHONE`,_ DRY RUN: (AUTHORIZED) �f I' ( � } • EMPLOYER: OCCUPATION: OTHER: � � '1 •�, ��• , ADDRESS: . ( ►� CITY: STATE: ZIP: III .l COMMENTS: ---- TOTAL: _.. ..--- - - PATIENT RE rF IVF h By X '-� CONTRA COSTA COUNTY 11 AMBULANCE PRE-HOSPITAL CARE FORM I ` UNITp p- AUTHORIZATION IS CHECK ON FILL IN APPROPRIATE SPACES DATE: •• . PATIENT'SINAME ___ S� V ^IJ C—t'J IJ 0 F COMPANY M ADDRESS 3ST AGE CITY tv`T7" STATE `"�_ ZIP 5 S 3 DOB2_l-S_( O Sn ❑ M 4%KT O W O Th Of O S r. DRIVER'S LICENSE N L/ y ( -7 PHONEZ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O INCIDENT LOCATION: ) RESPONSE CODE: E ESTED BY: TIME-(24 HOUR CLOCK) ALA r I (z V fir? C�/P fjm0 �O SCENE- 3 !: CALL RECEIVED - [� A Fl A Y I TIME 10 B �; ,� '�= •... PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 ❑ PSAP TIME 10-49 Tl 1 MILEAGE: O OTHER/PVT TIME 10.7 S (Z END um ' S TIME 10-98 DOCTOR �y PMD/19 STAR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 9❑ EAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT AMBULATORY? XALKED ENT TAKEN TO AMBULANCE: '510 RESPONSE ZONE YES ONO ❑ GUERNEY ❑ OTHER f " hc( Q PATIENT CONDITION: � DRIYERA e�r— I �v5 EMT-1A •• TECHNICIAN�L PARAMEDIC (/ Hx. DISPATCHER:� W_ 4- r- � ` CHIEF COMPLAINT: _�"t h e4d nal., DRY RUN: O YES NO REASON FOR DRY RUN t.•- _ I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1.5' MEDICA COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 2 �� /C; S.S. a �2 Z_ `'1 ��,5 1C1 r PRIVATE INS.CO.: n o p e BASE RATE: KAISER K: MULTIPLE PTS.BASE RATE OCBLUE BLUE CROSS#: TOTAL MILES: - X _ Y�/ MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO 1 O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP q: EMERGENCY RUN; - MEDI-CAL a: hy h e CODE 2 Y 3 `jr ry• f I OTHER: OXYGEN: (PERTANK) 30 e9 P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBA o�7�•,�-U i DATES BILLED: STANDBY: (OVER 15 MIN.) - E.K.G.: (PER EPISODE �``2� L — s NEAREST RELATIVE/RESPONSIBLE'PARTY: I.V.: (PER ADMIN.) r�-�<�✓ c� DRUGS: (PER ADMIN.) NAMEG� ,SAX '¢ RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS 2r,4 4_ .7—_ n/ ORAL AIRWAY: (IF NOT REPLACED) - CITY:_C7_--s I STATEC&—ZIP: C-COLLAR: (!F NOT REPLACED) PHONE: Z�` I S ( ( WORK PHONE: -DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:-,— OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: V V �'v 47. TOTAL: -' PATIENT RECEIVED BY:X Provider retcir Mite and Pink copl, Rcturn YINOW copy to VV; when billing ( DtS-1 f►n CONTRA COSTA COUNTY ) AMBULANCE 3_ p S 3 PREHOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK ON FILL IN APPROPRIATE SPACES DATE:. 7/c9\ _�� 41`�y 3 Hy / PATIENTS NAME D IZ 1- IZ M L� F COMPANY N . 7 / ADDRESS1n_?� ✓ ✓� C/'/] � f AGE CITY/ tT Z STATE_ti+tl� ZIP__._—__._ DOB.._.._.;_ ❑ Sn ❑ M _BT ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE,N __—._ ___. PHONE _...._.. __ _. –_._ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEA OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: 'TIME– (24 HOUR CLOCK) ? c TO SCENE- .$S.O. _ CALL RECEIVED O P.U. TIME 10-8 _yam PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 - MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR J PMD/ER START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAFfEST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CQMPANY: 1 -s PT. AMBULATORY? PATIENT TAKEN T BULANCE: RESPONSE ZONE 'Z Al YES ❑ NO ❑ WAL':ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER__'- Ple,L1412% EMT-1A, TECHNICIAN I( PARAMEDIC �?•. �fI Hx: DISPATCHER: I L- p s CHIEF COMPLAINT: DRY RUN:)b YES ❑ NOI REASON FOR DRY RUN i 1 ! q _ THORIZATI DRY R I F UN(EMSp PATIENT REFUSED SERVICES: (SIGNATURE) �1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES:_ X �l MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO JJ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: J EDI-CA K/% G-rGQ CODE 2/3 V/ OTHER: V A OXYGEN: (PER TANK) I J P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ 6TATE--ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION OTHER: ADDRESS: --- CITY: STATE: ZIP: v MMENTS: Sr PrT?-=S we '-r i' -'KCfzTOTAl 0 PAT 11 NTIII'CfIVI0HY. x 000055 0 -- .. 1.. r �. r•.••_I'r i�., _ (�ilfiN{.il/11I I 1l �N• I CONTRA COSTA COUNTY 1 AMBU E `� PRE-HOSPITAL CARE FORM I \ UNIT AUTHORIZATION M • ' r' I v ►>> o' i ! CHECK OR FILL INAPPROPRIATE SPACES D TE: PATIENT'S NE�t-tC,a 1.1�1_� ��t_ ❑ M COMPANY N ADD 5 ogi CITY K. �� STATE� ZIP DOBII q1 Sn ❑ M ❑ W 13 Th D F O S DRIVER'S LICENSE q PHON :7.� 1 NATURE OF DISPATCZ0 TYPE OF TRANSPORT: AMBULANCE Er OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REO�ED BY: TIME— (24 HOUR C O K) TO SCENE-� yY5.0. CALL RECEIVED D P.U. TIME 10-8 : PATIENT D STINATION: FROM SCENE=c1 ❑ FIRE TIME 10-97 ' ► j• - -_ �Z ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME.10-7 I`v END TIME 10-98 M ' DOCTOR _ 1s.� _ _ E START _— TIME 10-22 HOW C EN' TOTAL STANDBY TIME E ST ❑ FAMILY ❑ TRANSFER 3Li WAIT TIME TIENT ❑ DIRECT O OTHER _� (I ` CALL BACK N: A NCE COMPANY: P,,,..T�AMBULATORY? PATIENT TAKEN TO LANCE: �, RESPONSE ZONE C1 ES ❑ NO ❑ WAL':ED ERNEY ❑ OTHER PATIENT CONDITION. DRIVER. Y� _ _I �� EMT-IA 1�- - TECHNICIAN ARAMEDIC ��+J Hx: 1 c' — -- L-' DISPATCHER: - CHIEF COMPLAI DRY RUN: ❑ YES REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGES: � INDUSTRIAL ❑ YES NO. OF PATIENTS: S.S. a -'snv q-Vj�`'' / �^ PRIVATE INS. CO.: � BASE RATE: , 5 •to KAISER a: MULTIPLE PTS. BASE RATE/z/ �,� f BLUE CROSS p TOTAL MILES: ` X 4�' I MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: o c MEDI-CAL r+: CODE 2/(3 ) OTHER: OXYGEN: (PERTANK) P.O.E. STICKER ❑ VES ❑ NO NEONATAL: (INCUBATOR) �p O / `Sv<rDATES BILLED: STANDBY: (OVER 15 MIN.) _LGll��L E.K.G.: (PER EPISODE) ---------- NEAREST NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' � � DRUGS: (PER ADMIN.) X ��'LD �� 3C) NAME mQjICZnnC. _.l.J__C—� RELA. ONSHIP:_ E O.A.: (IF NOT REPLACED) ADDRESS:___- p" ___. —__ ORAL AIRWAY: (IF NOT REPLACED) CITY:_.�__ STATE---ZIP:---- C-COLLAR: (IF NOT REPLACED) PHONEA33__DWORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER:. OCCUPATIQ_N: OTHER: ADDRESS: _ �'/,• %.1/ i �:�._ S.lJb �i CITY: STATE: ZIP:_ "Iola,et) COMMENTS: \A—P --- TOTAL: . DDVL . 00 PATIENT RECEIVED BY:X Pt+-vidrr rrtarc L?;i f. •-re .r (SIGNATURE) . n.• .t... :ar DIf-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N .. 0 CHECK OA FILL IH APPROPRIATE SPACES DATE: 7 J PATIENT'S NAME ._InL 1!1_.__-. .X �� _._. _.._.___ D M F COMPANY 0 ADDRESS —JL1� J-C _,.._ AGE._1 ._ `1r� -C a CITY STATE__—_—__ ZIP__�._.__._— .��_�� O Sn ❑ M PrlT ❑ W O Th 13 IF ❑S DRIVER'S LICENSE N —...__. ___ ._ PHONE _ NATURE OF DISPATCH _ )' V TYPE OF TRANSPORT: AMBULANCEVe OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME— (24 HOUR CLOCK) ' TO SCENE- VXS.O. _ CALL RECEIVED �- �� 00L3 ❑ P.U. TIME 10-8 -77� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1/� 2 D PSAP TIME 10.49 [(!�_ �y C' c c y _ MILEAGE:. �! ❑ OTHERiPVT TIME 10-7 END �— TIME 10-98 /y. DOCTOR PMD/ER START .9 TIME 10-22 HOW CHOSEN: TOTAL -L STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER i WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COCMPAtJ,Y:s PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' v,YES ❑ NO, X WAL'CED ❑ GUERNEY ❑ OTHER _- PATIENT CONDITION: DRIVER—. 1 �L��-S. EMT- > _ TECHNICIAN ln��{ i PARAMEDIC Hx: -�� DISPATCHER: 55 CHIEF COMPLAINT: _� DRY RUN: ❑ YES Q NO REASON FOR DRY RUN" AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES�iO NO. OF PATIENTS: ,• r S.S.a PRIVATE INS. CO.: BASE RATE: U•�� KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: ��'` X MEDICARE k E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO - ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: ...L"�G •`" \ MEDT-CAL M: COPE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE.PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:J/ C,VE� ��A)RELATIONSHIP: _ E.O.,A.: (IF NOT REPLACED) ADDRESS: Y 115�1Si �J ORAL AIRWAY: (IF NOT REPLACED) CITY: ��`�lll.�sx!. STATED ' ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 7_ ' WORK PHONE: DRY RUN: (AUTHORIZED) !� EMPLOYER: _ OCCUPATION: OTHER: .� ADDRESS: CITY: STATE: ZIP: .. _— COMMENTS: o'' •� 1 L/r11 F - ------ __- PATIENT RECEIVED 6Y X "r•••i.L•r rrt.ir! 1/L:•. r (SIGNATURE).-. PATIENT'S NAME: ASHTARI, Sophia ADDRESS: 981 Allview El Sobrante, CA DATE OF SERVICE: 07/05/83 AUTHORIZATION NUMBER: 83-10782 AMOUNT DUE: $ 228.00- INCIDENT LOCATION: 981 Allview, E1 Sobrante PATIENT DESTINATION: DHP 000058 �o ; PRE#r I IIIA COSTA COUNTY AMBULANCE HOSP)TAL CARE FORM I UNIT f� AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: • 'y C2 rl/n1 NjO Yom, / — PATIENT'S NAME.��C.. SCS N M 13F COMPANY# /L� W- L ADDRESS I/ /c C N (Z t� ._— /v AGE 52— 0 CITY_- to STATE ZIP 4 DOB 7-// 31 ❑ Sn O M ❑ T�w ❑ Th ❑ F ❑S j DRIVER'SLICENSE# __.__..__. ._.___ PHONE/_.. s_`./�� 'NATURE OFDISPATCH TYPE OF TRANSPORT: AMBULANCE MOTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY:. TIME— (24 HOUR gLO�CK) n TO SCENE - S.O. CALL RECEIVED C--j- 0❑ P.D. TIME 10-8 v 1.: PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 n r . /J , 13PSAP TIME 10.49 �x1SFS �/" I`_ MILEAGE ❑ OTHER/PVT TIME 10-7 QEND TIME 10-98 . Qct :�" DOCTOR _ PM ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ~ NEAREST 11 FAMILY .0 TRANSFER - WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER j CALL BACK#: AMBULANCE COMP NY' '..... . PT AM ULATORY7 PATIENT TAKEN TO AMBULANCE: S U ' RESPONSE ZONE �• I ❑ YES NO ❑ WAL`ED DF(�ERNEY ❑ OTHER PATIENT CONDITION. DRIVER_XlJ! T-1 TECHNICIAN -AINA 04•- 1 U PARAMEDIC Hx: �.+'n�_c.t Ir...p,T 3E_T__-_ —_—_ DISPATCHER: !y,' CHIEF COMPLAINT: _Ll�u 5�111v!� H�� DRY RUN: 13 YES>1�10REASON FOR DRY RUN 1( 1319"X,) ___-- `� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) � PATIENT REFUSED SERVICES: (SIGNATURE) XMTL _- vS� G AL COVERAGE: INDUSTRIAL ❑ YES O NO. OF PATIENTS: n c s -�� 7p �/I syr PRIVATE INS. CO.: BASE RATE: I KAISER#: MULTIPLE PTS. BASE RATE .0. BLUE CROSS#: TOTAL MILES: -J X ( MEDICARE E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO OS ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: A0.. 1 1 �. MEDI-CAL#: CODE 2/3 ` OTHER OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t DATES BILLED:. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X / DRUGS: (PER ADMIN.) X NAME: .`.'� __._..._ RELATIONSHIP: E.O.A.- (IF NOT REPLACED) -•-• ADQRESS: ORAL AIRWAY: (IF NOT REPLACED) ' 1+ CITY: _- )___ STATE._ ,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE. —_ WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: ____ OCCUPATION: OTHER: + ` 1~ > ADDRESS: 77 , /J c // CITY: STATE' ZIP:— COMMENTS: IP:COMMENTS: jn TOTAL: PATIENT RECEIVED �-0 O F'n vidrr rrt.ic whifc .. .. :•opl. :rt:r. ir'[.;. !Tf? Fit'i no (SIGNATURE) 34 -.�;: CONTRA COSTA OUNTY AMBULANCE / 2 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZAT ON asa CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME C L L I,VI d L- O M )kF COMPANY ADDRESS AZ} AGE o CITY STATE C' ZIP. ._ DOB L 7 _4/�O Sn O M ❑ T W �O Th ❑ F DS DRIVER'S LICENSE M PHONED 7. _-_ .! ATURE OF DISPATCH 2210 l-) TYPE OF TRANSPORT: AMBULANCE Pr OTHER❑ .- .-...._.:. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- XS.O. CALL RECEIVED ❑ P.U. TIME 10-8 PA TENT DESTINATION: FROM SCENE.- ❑ FIRE TIME 10-97 2 ❑ PSAP TIME 10-49 MILEAGE] O OTHER/PVT TIME 10-7 END— -- ` TIME 10-98 DOCTOF�u �� PMD R] START TIME 10-22 HOW CHOSEN: TOTAL_ STANDBY TIME ❑ NEAREST FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT O DIRECT ❑ OTHER Li CALL BACK#: AMBULANCE COMPANY: T AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL'CED ;( GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER`„_ '` '/ EMT-IA TECHNICIAN = '` PARAMEDIC Hx: DISPATCHER: CHIEF CHIEF CQMPLAINT: OYES >•-•i � #.. " L� DRY RUN: O YES ,W RE NO ASON FOR DRY RUN LlGq AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X d MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �v S.S. a 4 (7 -- — 2 PRIVATE INS. CO.: BASE HATE: GSL KAISER K: MULTIPLE PTS. BASE RATE TOTAL MILES: �� X l¢ Jif MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL#: CODE 2/3 �U OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X PDRUGS: (PER ADMIN.)_ X NAME: leq�� RFI DRUGS: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ,W RK PHONE: DRY RUN:.(AUTHORIZED) EMPLO l OTHER: ADDRECgS:7; � CITY: J�/1 T Ea IC STATE: ZIP: COMMENTS: 5�1 TOTAL: ./`QI t PATIENT RECEIVED BY: X.. .... .. v fi5' Provider stair• whirr vr.! i j, •I. .,.r:..•. (SIGNATURE) o •.�.. %�. r:. ir,; LMS-I �t CON f IIA COSI A COUNTY AMI1l1LANCE Pk-HOSPITAL CARE FORM I UNIT AUTHORIZATION N A CHECK OR FILL IN APPROPRIATE SPACESa�b �(J�p DATE: 1',(�TIFjdT'S NAME ..��OC1 O 1�1/►�._ _.__....___ O M F COMPANY N �'— AGE ADDRESS - )_J�l.t:� � AGE '- CITY 0' `4STATE ZIP_ __—©DOB._)_ r l"M� O Sn O M O T W O Th O F O$ .•I DRIVER'S LICENSE p _..5.. kv{t _- __...___ PHONE __ C)�g ��_I NATURE OF DISPATCH >tit lk"I �r1..n,1 '• TYPE OF TRANSPORT: AMBULANCE OTHER❑ ) t INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) t ^_ TO SCENE- S.O. — CALL RECEIVED ; �L.l.` L–\1�L�zL` -- P.U. TIME 10-8 PATIENT DESTINATION: Q,�� FROM SCENE O FIRE TIME 10.97 i ❑ PSAP TIME 10-49 +� / ►� D r��ta-.. ( �,J.�Q MILEAGE: O OTHER/PVT TIME 10-7 L : -z O Cd it )1, g J y END r_S% Z42 TIME 10.98 1�_DOCTOR - _._ PMD/ER START/ q _ TIME 10-22 j HOW CHOSEN: TOTAL <— STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER •j CALL BACK N: . AMBULANCE COMPANY,tA5 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ; l ❑ YES NO L7 WAL',ED GUERNEY O OTHER PATIENT CONDITION: DRIVERV- 31 EMT-tA TECHNICIAN PARAMEDIC-A---- Hx ___ PILL�'�?J DISPATCHER: X11 (( CHIEF COMPLAINT: S�rN�I '�_— DRY RUN:-WYES ❑ NO REASON FOR DRY RUN .. / I — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) X—__—_ 1'- MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. a . -- -- -- PRIVATE INS. CO.:-- BASE RATE: �\ KAISER x: MULTIPLE PTS. BASE RATE ! 1 c BLUE CROSS N: TOTAL MILES: X - \ MEDICARE# E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP N: _ EMERGENCY RUN: MEDI-CAL N:()I/ <2-� �� I 2 -✓ c� - D 3 n til CODE 2/3 OTHER OXYGEN: (PER TANK) rJ P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I r 111 DATES BILLED: ---- — STANDBY: (OVER 15 MIN.) 1 ^rte E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME �flv�.Y.�1�._FiCbtu-cl RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:._....._ .._._ �C1V�IC�...___.__. ._ _._ ORAL AIRWAY: (IF NOT REPLACED) CITY f IPh�C-r�.{_. .. _ __ STATE CA_._ZIP:--e-- C-COLLAR: (IF NOT REPLACED) PHONE: __--- WORK PHONE. L/ DRY RUN: (AUTHORIZED) - EMPLOYER: _ _. OCCUPATIQN: IZlOTHER: ADDRESS: - – CITY: STATE ZIP: COMMENTS: --IY�S±'t TOTAL: i PATIENT RECEIVED BY:X 0000_61 5;c 00 30 Pr.nriJ;-.'de re 6tiitt ,r.' F;•.:: .•�pp 5,r;r. Ye*.' -a;. t EWuhvn CCI'ing (SIGNATURE) pi5-1 AMBULANCE 08 6 r'. Po'CONTHACOSTACOUNry -HOSPITAL CARE FORM I UNIT AUTHORIZATION N ;4 . . CHECK OR FILL IN APPROPRIATE SPACES DATE: /r PATIENT'S NAME 0P_l= . .f -. .3�1�_.�V/hLJ�M ❑ F COMPANY Q r _ ADORE S AGE CITY 1'r{�} -G'— STATE_C)� ZIP___— DOB 2 �D❑ s� ❑ M ❑ T �K W ❑ Th O FI 0 3.� DRIVER'S LICENSE a ___ _. __......_ PHONE _.Cca IQs— NATURE OF DISPATCH 1 TYPE OF TRANSPORT: AMBULANCE OTHER❑ • 1 INCIDENT LOCAL ION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C CQCK) "1 f _ TO SCENE- S.O.—_ CALL RECEIVED .l�L _. P.U. TIME 10-8 2- �p PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 "/7 1 : 'n,,l __� ❑ PSAP TIME 10-49 �i•] —_�'°`` �!A)BL� .p __ MILEAGE. ❑ OTHER/PVT TIME 1D-7 ' - ENDT_3_.� TIME 10-98 1� DOCTOR ._ ]kc>~A_ PM /ER START—.J_l, Y TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER .' WAIT TIME PATIENT ❑ DIRECT ❑ OTHER .� r CALL BACK M: AMBULANCE COMPANY: CA5 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL',ED �l GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ Oa `2q 'D EMT-1A + TECHNICIAN' « Mme 35_5J PARAMEDIC —1 j ( ( Hx: _. ! � Irl -r�7cal DISPATCHER: CHIEF COMPLAINT: �_�LtS_�_��.N — DRY RUN: ❑ YES NO REASON FOR DRY RUN -y AUTHORIZATION FOR DRY RUN(EMS USE UNLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGk: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a--!!r� 5 -7!0 4 ,� PRIVATE INS. CO. ShyC�` W a =�� BASE RATE: KAISER i'f g17 MULTIPLE PTS. BASE RATE BLUE CROSS a .fu yr, TOTAL MILES: J x G•=� G'�PJ nMEDICARE a: f r �� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) -- '✓ / — �Y CCHP/PPRP a: EMERGENCY RUN: MEDT-CAL a: CODE 2/3 1 OTHER OXYGEN: (PER TANK) � v7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ' E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X _- NAME: 7�09, F___L<<? _._ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:_--_.. _.___ _ _ rq .._. ORAL AIRWAY: (IF NOT REPLACED) CITY: _..—....—_ STATE_, ZIP:--. C-COLLAR: (IF NOT REPLACED) PHONE: _-- WORK PHONE- DRY RUN: (AUTHORIZED) EMPLOYER: ____. —. OCCUPATIO(4: — OTIR: 7 ADDRESS: CITY: STATE:--ZIP: j COMMENTS:,_JV l� 1L51A.I tAN —�lollszoS-1N— _ � �a'Ti c'"'S 1 Q•1 TOTAL: Ad' ..:_... ub 0(� PATIENT RECEIVED BY X V ..... _ �v: i.a:. f'. (91liNATUt1E1 {Mt•1 ►'• CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: r PATIENT'S NAME M OF COMPANY N C ADDRESS Z�. �71fG �� I I R� . AGE _ coll 1) CITY.. NFf.�lLILO STATE—C.�y�_ ZIP `(_J. _ 1DOB 2--07 ❑ Sn ❑ M OT OW ❑ Th ❑ F OS DRIVER'S LICENSE It .. ._ PHONE ..l�S.. _.LS3�.__ NATURE OF DISPATCH YYb.h Da� TYPE OF TRANSPORT: AMBULANCE OTHER❑ _._ ..__..__ ......_—._�_ ... INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K) fI `' TO SCENE- 3 9 S.O._ CALL RECEIVED �LC .�� Ad — — -.— ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE-3 O FIRE TIME 10-97 O PSAP TIME 10-49 —"n 1m-c ^lam — MILEAGE: O OTHER/PVT TIME 10-7 1 END__ (a_Ste — TIME 10-98 1-7 : y� DOCTOR .� i.��a S.� PMD, ) START-U TIME 10-22 ..� HOW CHOSEN TOTAL STANDBY TIME I ❑ NEAREST ❑ FAMILY ❑ TRANSFER l WAIT TIME :— ❑ PATIENT ❑ DIRECT O OTHER / CALL BACK N: AMBULANCE COMPANY: C A'S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S Lj RESPONSE ZONE ^) • ❑ YES XNO ❑ 1NF.l':ED GUERNEY O Z_ OTHER — i l PATIENT CONDITION: DRIVERS EMT-tA --j �I TECHNICIAN-t7 SZY� ` U PARAMEDIC Hx: �.Ctc .�C�C-—— _ DISPATCHER: yU 6 CHIEF COMPLAINT: ><C��._+�Lt-�ilW Nr)C DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) / PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: / S.S. 7 -o '7y I _ PRIVATE INS. CO.. BASE RATE: KAISER a: —C1.3CIL- _ MULTIPLE PTS. BASE RATE CROSS TOTAL MILES: X&'no ED AAE N7 O.7 3e!?A E.O.B. ATT. ROUND TRIP: O YES 13 NO O YES ONO NIGHT& CCHP,'PPHP N: EMERGENCY RUN: MEDT-CAL a: ___ CODE 2/3 ' OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO )� DATES BILLED: STANDBY- (OVER 15 MIN.) —7 f, E.K.G.: (PER EPISODE) �•.�S TP NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X nv DRUGS: (PER ADMIN.) X 4yj C^. SC. h _.- RELATIONSHIP:".t— E.O.A.: (IF NOT REPLACED) ADDRESS:--___—_5_c/�_•L}'_—_ _ ORAL AIRWAY: (IF NOT REPLACED) CITY.___-________._.—..----- STATE__—ZIP:__..— C-COLLAR: (IF NOT REPLA PHONE: ._--.___—______ WORK PHONE: —— DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIQN_:_. _._._ OTHEW' n .►�./tAA— (/lI ADDRESS: CITY:--_ ___---- STATE: ZIP: `J COMMENTS:�il> —(.��c 1,�� l a�� le TOTAL., C- - _-- -- - rl n 0000u3_. ....` PATIENT RECEIVED BY:X j� 0 0 — _---� --— (SIGNATURE)FY•ni.?.^r rrtu:� Ai•, ,tet: !' ,: .••T� F,-r.r Yr' . -,, Rf.'vMiIiI'in.7 D1S-1 CON I IIA COSTA COUNTY AMt3ULANCE PRE-HOQDITAL CARE FORM I UNIT AUTHORIZATION 01�_/y4 CHECK OR FILL INNAAP!:- PRRlATE SPACES DATE. `- PATIENT'S NAME/L�vGs 1fT/t� 'i{, OM Ed'FCrlUPANYa v ' � � ,tom . . l� ., � ► c �7 Z, -. ADDRESS 2?;_A&12-� 0_O�0j r,I�j�/�,rU��,, AGE STATE_` • ZIP q/a vI DOB401'z7X16V ❑ Sn ❑ M O T AW 13Th ❑ F OS DRIVER'S LICENSE a - - - -,..- - - --- PHONE ) NATURE OF DISPATCHS7JJD/YAef7 ,Do4i/ts TYPE OF TRANSPORT: AMBULANCEIX OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) I TO SCENE- VS.O. CALL RECEIVED :1 /( P� „�_O�'�f�L� .LL O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10.97 ElPSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 T END .r TIME 10.98 ^� DOCTOR PMD START TIME 10-22 HC'.': C'-'CSEN TOTAL STANDBY TIME ❑ NEAREST C FAMILY ❑ TRANSFER WAIT TIME V PATIENT ❑ DIRECT ❑ OTHER j CALL BACK M: AMBULANCE COMPANY: IC PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE WYES ❑ NO Cl WAL`,ED M:nUERNEY O OTHER J PA IENT CONDITION: DRIVER ARE T EMT-1A kX j TECHNICIAN PARAMEDIC 1 Hx: �dJn_�L�il�. �/�S ----- DISPATCHER* L(N- I 16 CHIEF .COMPLAINT: i/ SLc e7v__ DRY RUN: O YES �M.[JO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) !II PATIENT REFUSED SERVICES- (SIGNATURE) ( MEDICAL COVERAGE INDUSTRIAL ❑ YES &'NO NO. OF PATIENTS: S.S. a �" (o_�C7,e7 81 . PRIVATE INS. CO.:-----.- BASE RATE: KAISER#: —_- MULTIPLE PTS. BASE RATE BLUE CROSS a' _ — TOTAL MILES: X MEDICARE I+: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: �,- MEDI-CAL $I:— -- CODE 2/3 OTHER: _._ OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 1 ` DRUGS: (PER ADMIN.) X NAME `` RELATIONSHIP E O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ' CITY: -_�5. .. ..__...._ _... STATEC!f-f-ZIP:____ C-COLLAR: (IF NOT REPLACED) G OHONE'a�.�. 06/Q WORK PHONE _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: C) -- -------- TOTAL: 1�9 .A0 000'464 �. I _ PATIENT RECEIVED BY:X 0® - - r (SIGNATURE) Provider rrt7:. &.').itr r,; r� s. .n: 1'r"rc ENL" when b=1'ing DIS-1 1 / � CON fnA COSTA COUNTY AMBULANCE - �l PRE—HOSPITAL CARE FORM I UNIT AUTHORIZATION k¢3 gyS� CHECK OR FILL INAPPROPRIATE SPACES DATE: /��3 _I ;� j� t PATIFNT'S NA ,_,X) 1-� `.�S _��. _ '`� OM 1�F COMPANY N �U ,' ' •� ± ADDR[ S, ` `-S AGE'/_� CITY) �'��,. STATE__(_M_ - ZIP DOB1J� . ❑ Sn O M ❑ T aW ❑ Th ❑ F ❑S t DRIVER'S LICENSE tt -C.033 Z -1 L -_ PHONE AQZ! -.-b%Z_I_ NATURE OF DISPATCH /L 7 " ) TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: ESTED BY: TIME- (24 HOUR CLOCK) EOU / r TO SCENE- .O. CALL RECEIVED L 6, .. :' -C �� U - _F' C�11 �.t/c ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 13 FIRE TIME 10-97 I� �n ❑ PSAP TIME 10-49 r1 " MILEAGE: ❑ OTHER/PVT TIME 10-7 END • L TIME 10-98 D Z DOCTOR - _� PMD& START 1 TIME 10-22 ! HOW CHOSE : TOTAL 5 S DBY TIE NEAREST ❑ FAMILY . ❑ TRANSFER AIT TI CCN ❑ PATIENT O DIRECT ❑ OTHER .3 CALL BACK N: AMBULANCE COMPANY: _ GRAS • j PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: c�J RESPONSE ZONE � YES ❑ NO ❑ WAL"ED O GUERNEY O OTHER PATIENT CONDITION. DRIVER �i�� 7 i,� EMT-1A TECHNICIAN_ cOS'7�'r-�� J` PARAMEDIC Hx: _!1G/_rG__.l��___ 1 C v_.._ DISPATCHER: _L!t _c I rc •1 CHIEF COMPLAINT: DRY RUN: P YES a NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__ I MEDICAL COVERAGE INDUSTRIAL ❑ .YES NO NO.OF PATIENTS: ` S.S. It PRIVATE INS. CO.: BASE RATE: 1 KAISER It: MULTIPLE PTS. BASE RATE ` BLUE CROSS#, TOTAL MILES: XG cJ �rV.. MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES �6NO v u O YES ONO NIGHT: (19.00-07:00) CCHP,PPHP N. EMERGENCY RUN. ►=a lMEDT-CAL K: CODE 2 j OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 't NO NEONATAL'_ (INCUBATOR) / DATES BILLED: — _ STANDBY: (OVER 15 MIN.) ire 70• I E.K.G.: (PER EPISODE) I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: WER ADMIN.) X l DRUGS: (PER ADMIN.)_ X NAMELL`c�.t— _.—��)") `$( RELATIONSHIP S _ E.O.A.: (IF NOT REPLACED) ADDRESS .1_D-_J�_.. J1. ��C V..4'�_l�) .L_ ORAL AIRWAY: (If NOT REPLACED) CITY:_ //�1 ` �.�}_r^ �� __ STATE_,ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE. � _ / '�L_ WORK PHONE _ DRY RUN: (AUTHORIZED) (F'T) EMPLOYER: _ __ 1=1 OCCUPATIQ`: OTHER: -- ADDRESS: CITY: STATE: 1 ZIP: C?_ MENTS: LCL_lr��peT� ��ILIT(lf 1 bst TOTAL: -c PATIENT RECEIVED BY:X (SIGNATURE) pts-1 O n F4ovidrr rr'si� :hits rr.d Ii*.. :.epi 51r.r. Ir'Io ";,y t• _N: thrn Fit"iap �y 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I uNlrF-M AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: ( PATIENT'S NAME ._. V�`',r13`� ._ k7 M ❑ F COMPANY N ' / ADDRESS -1---`"._ _R Rc - -��1-- --- --- AGE Z l .CITY.�I `- STATE Lh ZIP-UQly_To Oe��i�(p20 Sn O M O T W O Th O F O S DRIVER'S LICENSE a _ ___._ _ _..._.-_ PHONE_ -`� =� 1 4NATURE OF DISPATCH__ TYPE OF TRANSPORL AMBULANCE OTHER❑ INCIDENT LOCATION: _ RESPONSE CODE: RRE�STED BY: TIME- (24 HOUR CLOCK) •7 � /� TO SCENE- Id S.O. CALL RECEIVED �:T - -L�-`-L—� 1_._� r�-�l ._ - O P.D. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 .71-4 " 2- O PSAP TIME 10-49 �- - MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10-98 : DOCTOR _CA - P /ER START TIME 10-22 HOW CHOSEN: TOTAL _ Z, STANDBY TIME O NEAREST LJ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER 7j CALL BACK N: AMBULANCE OMPANY: P� BULATORY? PATIENT TAKE�O AMBULANCE: Sc� RESPONSE ZONE YES 0 NO ❑ WAL':ED L! GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER+. J�-- _ ►`� � EMT-tA � I Q TECHNICIA �� PARAMEDIC 1 H. C.. �_1N_J,k �._ � —' 1 DISPATCHER: LI �' CHIEF COMPLAINT:'� _.y.t � _ DRY RUN: ❑ YES Gl%,NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL C VERE: INOU TRIAL O YES' RNO NO. OF PATIENTS: ; ,S7eci s.Sa �— � PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS, BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: _ E.O.B. ATT. ROUND TRIP: O YES O NO OYES ONO NIGHT: (19:00-07.00) - ^, CCHP/PPHP EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER. ____ OXYGEN: (PER TANK) f P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) 1 1 / DATES BILLED:- STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:Y. �'`f` ►.`..__ .. n �RELATI HIP1�� E.O.A.:(IF NOT REPLACED) - 7 ADDRESS:-1�T�_ I_...�E�f�(. �. _ ORAL AIRWAY: (IF NOT REPLACED) (�1 10 CITY ._ C!,+A ... STATE______.ZIP:—..__. C-COLLAR: (IF NOT REPLACED) QJ Vt, PHONE: ___ _ WORK PHONE: - DRY RUN: (AUTHORIZED) EMPLOYER: __ _— OCCUPATIOjd: OTHYFR: �� ADDRESS: _ CITY: _ STATE: ZIP:__ COMMENTS:___ _ TOTAL: PATIENT RECEIVED BY:X S 00 hmvidrr• rcta:r 01:i r.r (SIGNATURE) [M<-1 CONTIIIA 17.01STA COUNTY AMnULANCE (� PRE-HOSPITAL CARE FORM I UNII AUTHORIZATION 0 d,3"�U g 7r6 i It .11, E II ! .�-', �� 1 -717 i CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAMt.—GI f3c C' r-0.12-5)1 kn- %J. 19 M '❑G F COMPANY# ADDRESS -2,6.3._2�l�C�L_/7L1.�. --�_�� AGE �- _1 CITY_ [G��'C /1 f /, STATE_1._..13 -ZIP DOB(Z1 O O❑ Sn M T O W � O F 13S--'l DRIVER'S LICENSE# CUL 1 5-Y_0-_...--_ PHONE_NO NATURE OF DISPATCH 6 SC^J TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) ` _ TO SCENE- p3%.O. CALL RECEIVED I I ) a,4U�11�� L-,C�L WCL— p.D. TIME 10-8 . PATIENT DESTINATION: FROM SCENE- � ❑ FIRE TIME 10-97 / ' t s ❑ PSAP TIME 10-49 !,•I �, CC 1 ` — MILEAGE: �( ❑ OTHER/PVT TIME 10.7 : END A ,� TIME 10-98 DOCTOR . Q� PMD/©R START 642 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER T WAIT TIME ❑ PATIENT ❑ DIRECT PLOTHER //� ; �..�. CALL BACK 0: AMBULANCE COMPANY 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE r� YES ❑ NO K WAL':ED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER._ �y�� -� EMT-lA TECHNICIAN PARAMEDIC i n Hx- _ I./C iy- DISPATCHER: ` CHIEF COh1PLAl T: DRY RUN: 13 YES NO REASON FOR DRY RUN '< �}L�__ 110iur(�__�41M.L� ?, lL�� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS: S.S. # PRIVATE INS. CO.:— BASE RATE: `f!.1 1 KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X 6 MEDICARE#: E.O.B.ATT. ROUND TRIP: O YES NO ❑ YES ❑ NO NIGHT: (19:00-07:00) s O• CO + CCHP/PPRP#:_ EMERGENCY RUN: �� V U� MEDI-CAL#: CODE 2/3 I OTHER: OXYGEN: (PER TANK) i� P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) 1 I� (� DATES BILLED: ___ - STANDBY: (OVER 15 MIN) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ff DRUGS: (PER ADMIN.) X NAME' h RELATIONSHIP: ( E.O.A.: (IF NOT REPLACED) .ADDRESS:_ ORAL AIRWAY: (IF NOT REPLACED) CITY: ___._..._ STATE__ZIP: C-COLLAR: (IF NOT REPLACED) �r-- PHONE: ..______..___.__..... WORK PHONE DRY RUN: (AUTHORIZED) EMPLOYER: (�NF_M�(LY .� OCCUPATIOrI: OTHER: »--•-+� ADDRESS: CITY: STATE: ZIP: p COMMENTS: C _ _ v TOTAL: UIJ067 PATIENT RECEIVED BY:X l O4 (SIGNATURE) �I !'nit idt•t• rrLJ"• i tc vr•. ••pp !•::;.rr /'e"..t• ...��. Wil' ►•h�a pi.''inJ OIS-1 / CON IIIA COS IA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M /, '-� 8 7,9.- CHECK 9-CHECK OR FILL IN APPROPRIATE SPACES DATE: -7 { � t nl. -t- AJ _�� I� ❑ F COMPANY PATIENT'S NAME.__.—_____ _. I7 ADDRCSS 1?� `_ S .:L't E C�� / AGE CITY_,& STATE_C�__ ZIP�11 DOB'_�'��= %�.`] Sn ❑ M ❑ T O W �Th O F Cl S `� . __.-__ PHONE�.J� NATURE OF DISPATCH LLQ DRIVER'S LICENSE p _._. _ .__. . TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K) O '_1• eS.O. CALL �/i /�•� �� —VA `^� TO SCENE '?� ❑ P.D. TIME 0.8 RECEIVED 1 PATIENT DESTINATION:I ' FROM SCENE-� O FIRE TIME 10.97 y O PSAP TIME 10.49 L-�. `�—� _ MILEAGE O OTHER/PVT TIME 10-7 1 END y,-7- TIME 10-98 DOCTpR PMD/(3 START�� TIME 10-22 i H W CHOSEN: TOTAL �� STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER ) WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALLBACK N: AMBULANCE COMP Y PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �•� RESPONSE ZONE YES ONOty/l,ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER�_1. ` `7 � /�' EMT-1A TECHNICIAM1 !�L'� 11 Y i�rAA?IAEDIC Hx: _ _ lL� � _ DISPATCHER: (I CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) { I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES�NO NO.OF PATIENTS: I S.S:u _ 1 PRIVATE INS. CO.:_ BASE RATE: KAISER x: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X '1 MEDICARE K: E.O.B. ATT. ROUND TRIP: O YES ❑ NO U r r t ❑ YES ONO NIGHT: (19:00-07:00) V �� CCHP/PPHP a: EMERGENCY RUN: �v MEDI-CAL N: CODE 2/3 OTHER OXYGEN: (PER TANK) - pp J' P.O.E. STICKER O YES O NO NEONATAL: (INCUBATO Gl� 1� DATES BILLED: STANDBY: (OVER 15 MIN.) of ' I E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: 1.V.: (PER ADMIN.). 2L n I� A ,f�� DRUGS: (PER ADMIN.) X NAME (1��i�� -ll)F�.JI_�,A JA REL^ATIONSHIP:_"A � E.O.A.: (IF NOT REPLACED) ADDRESS:;_�7:.�'. _L.___j'_�_aZ�� .t'�_ ORAL AIRWAY: (IF NOT REPLACED) CITY _. /t'L1. 4._ ... STATE__.._.ZIP:--._._ C-COLLAR: '(IF NOT REPLACED) PHONE- '.2!7 "I22 WORK PHONE 1z �12I DRY RUN: (AUTHORIZED) - EMPLOYER: ,.._.___._._—_.. OCCUPATION: OTHER: ADDRESS: — —. CITY: ` STATE: ZIP: COMMENTS:_ _ 1 ��I h(--�'• • -E 7.Z k- `�� S b 1 TOTAL:• 1 (�(1 ___d PATIENT RECEIVED BY: i V VV `� J S G REl �A»nidrr.r�av�• wti.., ..�� Y'' nr ,..►,.. : ^.1 015'1 CONTRA COSTA COUNTY AMBULANCE _72- CHECK PRE-HOSPITAL CARE FORM I UNIT r(�� AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES t C '� DATE: 1�^^ �.,,�� . (� PATIENT'S NAME_+(_1�� _�_' .l�l' ��-If�TSL>T 13M 13F COMPANY# �' / ADDRESS -7_(l AGE�� D�L CITY `%` 1H STATE_- ZIP_ DOB ❑ Sn ❑ M ❑ T OW�Th O F: 13 S_ DRIVER'S LICENSE# _.._.-..._ . .. PHONE _.__-... -_- NATURE OF DISPATCH i TYPE OF TRANSPORT: AMBULANCE OTHER ._.__ ...... .__....__.__-_ .. INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) ' - / �7 TO SCENE- • S.O.-. CALL RECEIVED 't -'. `t..- -I I, C L_ _ _� ❑ P.U. TIME 10-8 l ... , PATIENT DESTINATION FROM SCENE v� ❑ FIRE TIME 10-97 1 O PSAP TIME 10-49 1 MILEAGE: OOTHER/PVT TIME 10-7 r —� r�---- END 919. TIME 10-98 DOCTOR _ -� 1 '_ —�_ PMD/ R� START_ TIME 1022 HOW CHOSEN TOTAL - I STANDBY TIME L i NEAREST ❑ FAMILY O TRANSFER WAIT TIME - O PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE COf�1PANYs PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: - �-? RESPONSE ZONE((,'4--� tq,YES ❑ NO O 1' AL"ED GUERNEY ❑ OTHER ( / PATIENT CONDITION. DRIVER. OF I,N EMT-1A / TECHNICIAW�3- '< < 1 N URAMEDIC Hx: DISPATCHER: (. CHIEF COhZPLAINT: __�' `�` DRY RUN: 11YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YESXNO NO.OF PATIENTS: S.S. K ! . PRIVATE INS. CO.:— BASE RATE: - KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: _ TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ONO - ' 1 ❑ YES ❑ NO NIGHT: (19:00-07.00) 0 > - - 1 CCHP,'PPHP#: EMERGENCY RUN: 3d. 60 f MEDT-CAL#: CODE 2(31 II�II OTHER _ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO — NEONATAL. (INCUBATOR) ///.c'SZ� I DATES BILLED: STANDBY: (OVER 15 MIN.)A �� • E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r ? AA , DRUGS: (PER ADMIN.) X NAME.N,Ir :.t.l�'t�!i`_.V(-_It. _— RELATIONSHIP:��i :'_ E.O.A.: (IF NOT REPLACED) ADDRESS:n� �r-'f..N�_�_��_ _ ORAL AIRWAY: (IF NOT REPLACED) r CITY: IIvL rr T , STATE__ZIP�C:t_� C-COLLAR: (IF NOT REPLACED) PHONE: __hl lz WORK PHONE.!_:�-.,��l L= DRY RUN: (AUTHORIZED) EMPLOYER: -- — OCCUPATIQN: OTHER: ADDRESS:—_..____-_._..__ - CITY' STATE: ZIP: COMMENTS:— r✓ r`I-.'`-y��'j —{-�, =t I-/-� � 1 ( �1_I(�V_��C1�'1•'�tVC TOTAL-' � �+ .._. 2L CA,'A ` ALJ--- (�9 PATIENT RECEIVED BY:X 0 h / r-_/„A•yv:pry rrry••Y.lif '•t ., 7i.�-7t,nyA\1 ,", Yr•' . -1 !y.^ 0- 1il'ina ( IGNA URE) DIS-1 L;(. CONTRA COSTA COUNTY ' AMBULANCE p3 Q gCj 1 .!; PRE-HOSPITAL CARE FORM I I 1 UNIT AUTHORIZATION 0. G ! J ,`tri:1• , d3 q CHECK OR FILL IN APPROPRGTE SPACES .t .' DATE: PATIENTS NAME >gLM ❑ F COMPANY N ADDRES�SSAGE CITY CITY STATEC;P(Q�ZIP Ml_ DOB 274 ❑ Sn OM ❑T O W XTh OF OS- DRIVER'S S'DRIVER'S LICENSE N_ PHONE_13__S�vNATURE OF DISPATCH C`y SC TYPE OF TRANSPORT: AMBULANCE Er OTHER❑ INCIDENT LOCATION: ; � RESPONSE CODE: REOUES D BY: TIME— (24 HOUR L CK) a TO SCENE- — CALL RECEIVED P :�- +:,: ❑ P.U. TIME 10.8 ' PATIENT DESTINATIO FROM SCEN D FIRE TIME 10-97 r -I - D PSAP TIME 10-49 �0" 1� MILEAGE: p�/ n ❑ OTHER/PVT TIME 10-7 : END 0 7L / TIME 10-98 1 DOCTOR PM /ER START TIME 10-22 HOW C EN: TOTAL — — STANDBY TIME Ti'I� NEAREST= '❑ FAMILY ❑ TRANSFER WAIT TIME j O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBUI,.4W FOMPANY: So I PT. ULATORY7 PATIENT TAKEN T�MBULANCE: RESPONSE ZONE YES ❑ NO ! D WALKED 2 GUERNEY ❑ OTHER { �•9 y 1 41PATIENT CONDITION: DRIVER EMT-1A O n TECHNICIAN Wit^ PARAMEDIC a s Hx: DISPATCHER: - • '.,CHIEF COMPLAINT:' ` DRY RUN: ❑ YES REASON FOR'DAY RUN T AUTHORIZATION FOR DRY RUN(INS USE ONLY) s PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: IND4TRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N � .._ . PRIVATE INS.CO.: BASE RATE: .�..��„. KAISER M: 1 MULTIPLE PTS.BASE RATEv BLUE CROSS q: TOTAL MILES: MEDT ARE M E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YE O NO NIGHT:(19:00-07:00) O / EMERGENCY RUN: DI-C a. _ CODE 2/3 OTHER: j OXYGEN: (PER TANK) ��/• P.O.E. STICKER O YES ❑ NO NEONATAL:.(INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) a�,w DRUGS: (PER ADMIN.) �NAME: (2RELATIONSHIP .O.A.:(IF NOT REPLACED) ADDRE S: ORAL AIRWAY: (IF NOT REPLACED) —�CITY: _� STATE4 J4 ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHON�EO, _. DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OT ER; �� OCT ' :. ADDRESS: \JLCCD 9is�iirtiGt.�6� _ 1'4 qR O.00� CITY: STATE' ZIP:— CAmtm ., Bu ANrX COMMENTS ' 4 TOTAL: ROO ' ®` _ PATIENT RECEIVED BY:X Pmuidor main k to .xd tick cops hotum Y.'i.w ,v+py t • III.- when LU'llla (SIGNATURE) tM6.1 _.....• .. .... ... ..w• �wY wr1 w.l..w rJ... •r.. 1•�Ir` • M:/tY�/• r .. ... .,.. :'�' w.itry I Mr ,.1..•r: III I.1/ -1 tM•_I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL.CARE FORM 1 UNIT AUTHORIZATION N_._ ll . � D ^� CNECK OR FILL IN APPROPRIATE SP CES DATE: --1__ _ L a � PATIENT'S N,4L _C'1� y _ QS___ ❑ M COMPANY"M l ^i T ADDVS _ `- AGE ` ( ,( .1/I. CITY 1�f+ v STATE��^ ZIP-17.LLv. _ DOB ._� �I ❑,5n ❑ M ❑ T ❑ W Th ❑ F ❑ S DRIVER'S LICENSE p __._.__-.___.._.. ... _ -... PHONE 3S._ _ .. .DNATURE OF DISPATCH.- TYPE OF TRANSPORT: AMBULAN OTHER❑ INCIDENT LOCATION: f RESPONSE CODE: REQt ESTED BY: TIME- (24 HOUR•CLOCK) _ TO SCENE- ❑ 6.0. ______ CALL RECEIVEDan / --c-- T ---_�-- ❑ PD. ___T_ TIME 10-.8 PATIENT DESTINATION: FROM SCENE, O FIRE TIME 10-97 _ v ❑ PSAP TIME 10-49 EAGE: MIL ^^ ❑ OTHER/PVT TIME 10-7 END ��-�_ __ TIME 10.98 DOCTOR _ PMD/ R) START-' �� — TIME-10-22 HOW CHOSEN �.L, a'.`� TOTAL --L• _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER -__ -_- WAIT TIME _ ATIENT ❑ DIRECT ❑ OTHER � ) CALL BACK#: AMBULANCE COMPANY:/ C PT MBULATORY? PATIENT TAKEN 30 AMBULANCE: RESPONSE ZONE kle�ES ❑ NO ❑ WALKED UERNEY ❑ OTHER '(PATIENT CONDITION: DRIVER-0-1- __ EMT-tA / TECHNICIAN- i PARAMEDIC�LG J Hu. /Lf�,l/L L-_[,cam DISPATCHER: it.l«1 CHIEF COMPLAINT: _ CIYZ�:) DRY RUN: ❑ YES �CYNO REASON FOR DRY RUN — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT EFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: _ ATEINS. _ CTS._` ��=�"1 "`nL 4 BASE IjATE KAISER x: i / ___ MULTIPLE PTS.BASE RATE BLUE CROSS k' - - ' / 'I" ` '� TOTAL MILES: — X MEDICARE R: �' �� -� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES .0 NO NIGHT: (19:00-07:00) �- 1 CCHP/PPRP p: EMERGENCY RUN: L. .� MEDT-CAL K: — CODE 2/3 OTHER: OXYGEN: (PER TANK) �',f / P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED. STANDBY: (OVER 15 MIN.) s �' i E.K.G.: (PER EPISODE) -To lij <<� EAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) _ X C92, \J tl DRUGS: (PER ADMIN.) X NAME: -le-1-1 OGS RELATIONSHIP:h'e-J E.O.A.: (IF NOT REPLACED) ADDRESS: 5��j ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:QLS'_� 4 OCCUPATION: OTHER: ADDRESS:_ _ [ ' _ _ O, CITY: STATE: ZIP:_- COMMENTS:i C LL c , -- ' -- _.._ TOTAL: V. -- 7y• Z _.. - 0 0 - _- PATIENT NE:CEIVF.f>l!Y X 00007 ` CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION r 93—109 CHECK OR FILL IN APPROPRIATE SPACES DATE: + —5%—3 ' PATIENT'S NAME AJ-44--t- �1 _t, 1 SJL� x m ❑ F COMPANYU ) L ZJJ Q--t--- L� 'J t ADDRESS c� �Q� l�swe Er YC 5Q*G" LIGE � 3 ` CITY� ff _ STATE `� ZIP_ DOB�jLL� ❑ Sn ❑ M ❑T ❑W o Th V FrC! 171 DRIVER'S LICENSE a ___._..___.__. PHONE_J_1(0..P#y6 [ NATURE OF DISPATCH �E7ZIA,QG-S / TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)' \ w p TO SCENE- ❑ S.O. CALL RECEIVED 'L.I••+ ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 2, ❑ PSAP TIME 10-49 MILEAGE: i-OTHER/PVT TIME 10.7 END- 06• bI 1_0I1L_. TIME 10.98 . DOCTOR _ t5 � PMD/ER STARTTIME 10-22 a HOW CHOSEN: TOTAL �r� STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY:^c-71 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: / RESPONSE ZONE II YES ❑ NO ❑ WAL':ED T GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER. , b''��pp_ EMT-1A AArtrt�S� TECHNICIAN�� PARAMEDIC Hx: _ T��._rn' DISPATCHER: no / •�J 1 'I CHIEF COMPLAINT: 4� S£lZ DRY RUN: ❑ YESNO REASON FOR DRY RUN AUTHORIZATION OR DRY RUN(EMS USE ONLY) -� �jl ( PATIENT REFUSED SERVICES: (SIGNATURE)X- tll MEDICAL COVERAGE: Q INDUSTRIAL Q YES ❑ NO NO.OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: �j z r.c KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO C^"j ❑ YES ❑ NO NIGHT: (19:00-07:00) {'�� /) s CCHP/PPRP '� EMERGENCY UN: t:2`�O- E AL Y{ 0150 .5�'YL,5 CODE 2�3) IOTHE OXYGEN: (PER TANK) .rs.�t.�a ' ' d• i P.O.E. STICKER ❑ YES ❑ NO �t✓rt DATES BILLED: STANDBY: (OVER 15 MIN.) BILLED CO. E.K.G.: (PER EPISODE) PARTY: q g I.V.: (PER ADMIN.) X - - SEP �2j 6 �q83 DRUGS: (PER ADMIN.) X { — RELATIONSHIP' E.O.A.:(IF NOT REPLACED) -- - I I�I� ORAL AIRWAY: (IF NOT REPLACED) - (I STATE- _ZIP-• C-COLLAR: (IF NOT REPLACED)._ •••.-.• -- )RK PHONE.' DRY RUN: (AUTHORIZED) OCCUPATION: OTHER: BILLED CO. ` STATE: ZIP: COMMENTS: Ira(� _jl�d�t±'�$ UULMIZ IQ-enk TOTAL: U� yr._al-�1.� ___/!I-'_r>�_.UAKCAN�. . ��_.�Y��- PATIENT RECEIVED BY:X IcIGNAtUQEI Dec-. VIA CONTRA COSTA COUNTY ! AMBULANCE r� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N J4 CHECK OR flll IN APPAOPRlA7E SPACES DATE: �] -• •- PATIENTS NAME,' .0 �'�J�C"�- O F COMPANY N ADDRESS F I.( ( i rG �� J j C� � AGE Q 111 In - i CITY fr�4 ) CZ• STATE ZIP s� DOB z- r J 'o Sn O M O T OWE(O�Th O F O S DRIVER'S LICENSE N-�- 7 (� C�_ PHONE- - t • NATURE OF DISPATCH_.� ' TYPE OF TRANSPORT: AMBULANCE OTHER O 1 (% NCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: 'TIME-(24 HOUR CLOCK) j 1��1.� TO SCENE- �A S.O. CALL RECEIVED _L,2;; 2 � \� O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-: 13FIRE TIME 10`97 +•.... - Z ❑ PSAP TIME 10-49 %7 : 2 �' 00A 1 �1�5 MILEAGE: O OTHER/PVT TIME 10-7 y -7 L.EN TIME 0 TIME 10-98 !� DOCTOR-� C` O l PMDlo START TIME 10-22 - HOW CHOSEN: TOTAI STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME .._ 'PATIENT ❑ DIRECT O OTHER '� CALL BACK C AMBULANCE COMPANY.n� PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: Q/j� RESPONSE ZONE- (�r� .- YES ONO O WALKED JQGUERNEY O OTHER PATIENT CONDITION: DRIVERQ�Ati EMT-1A TECHNICIAN PARAMEDIC ' •,',( Wx: �� s DISPATCHER: � .� .t _��•� •1... 1 (-)�1 Z., .. .. CHIEF COMPLAINT: s-�C93 DRY RUN: ❑ YES �c NO (-REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r: PATIENT REFUSED SERVICES:(SIGNATURE)X ' MEDICAL COVERAGE: / IND STRIAL O YES NO NO.OF PATIENTS: S.S. N 1 NATE INS.CO.: V14 BASE RATE: �0•(1D; 5.1 l�':�t ( � f -1tps2�A: MULTIPLE PTS.BASE RATE `s9tHESS N:S-'�� I (l (�� ( TOTAL MILES: X 1C ,� MEDICARE N: E.O.B.ATT. ROUND TRIP: O YES O NO ❑ YES ONO NIGHT:(19:00-07:00) CCHP/PPRP N: EMERGENCY RUN- MEDT-CAL N: CODE 2/f'3" OTHER: OXYGEN: (PER-UNK) 6Z)0 7 P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I' E.K.G.: (PER EPISODE) SO�C/�. NEAREST RELATIVE/RESP NSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X - NAME:��/�1 L ll)M,ljn l f RELATIONSHIPO?i�Tlp E.O.A.:(IF NOT REPLACED) '- ADDRESS:a '� I l" C ORAL AIRWAY: (IF NOT REPLACED) CITY: 017 STATE_ZIP C-COLLAR: (IF NOT REPLACED) PHONE: - �� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: `, CITY: STATE' ZIP• COMMENTS: In n •3 TOTAL: T - � a PATIENT RECEIVED BY:X Provider retain Aite clad Pink copy ReturnYellow COPY to DIS&Am billing IG UR -1 00 49 k' CONTRA (.OSIA COUNTY 1(• AM(1ULANCE PRE-HOSPITAL.CARE FORM I �\ ` UNIT AUTHORIZATION S3 CHECK OR FILL INAPPROPRIATE SPACES DATE: 9. � rZ PATIENT'S NAME—i�'L' 1� ❑ M COMPANY M ADDRESS t STIG c—j?oz�c_ /�� AGE �� CITY_ Si_ STATE C •r+ ZIP_C�! '�T2_ DOB-4-13—d0_1 ❑ SI, ❑ M ❑ T ❑ W ❑Th AFI O g•• DRIVER'S LICENSE It __._..._.. . .. PHONE. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE ZI OTHER❑ Cj INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME— (24 HOUR CLOCK) I V/ / I TO SCENE- O. CALL RECEIVED �U . C,U �-1C LIiMA � ) P.D. TIME 10-4 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 3 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ENO 14.3 -tom TIME 10-98 DOCTOR .- —_. PMD(1�R START—--Ll-,-I _ TIME 10-22 HOW CHOSEN: `./ TOTAL — `J'— STANDBY TIME - j4EAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ' /UJ'PATIENT ❑ DIRECT ❑ OTHER �� CALL BACK#: AMBULANCE-COMPANY: ..) PT AMBULATORY? PATIENT T EN TO AMBULANCE: RESPONSE ZONE S YES ❑ NO ❑ WAL'CEDUERNEY ❑ OTHER j PATIENT CONDITION: DRIVER TECHNICIAN wI u(I Y _3�,SARAMEOIC Hv _ ��TB — DISPATCHER: P"(-(_ 1-1 D CHIEF COMPLAINT: DRY RUN: ❑ VES O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X.— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: (� S.S. PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATEsp BLUE CROSS k— TOTAL MILES: X � ME I- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO £I ;,g y' ('1 y ❑ YES ❑ NO NIGHT: (19:00-07:00) -D• [z) c•~ �a CCHP,'PPHP a: A et t3 c oy• EMERGENCY RUN: ��•L�O)E �\ MEDT-CAL a: t53 n---) -Lo..I L-1'Y3 12 CODE 2( 3 �f l_ OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES . ❑ NO NEONATAL: (INCUBATOR) 1 yMDATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) 1 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ _ STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: . WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: L/ i•�' l�.1� f/ CITY: STATE: ZIP: COMMENTS: — TOTAL:a- �D —�.. 0 0 PATIENT RECEIVED BY:X Y. •i.frr ry r (SIGNATURE) yl,i• •=ri L�I:.r+ f... �, ,,,. ^C^ utiw t i 1•ino OIS•1 CON IM COSTA COUNTY � AmnULANCE. / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M�` , CHECK OR FILL IN APPROPRIATE SPACES DATE; -71 Z gr ? LL -) 5 i PATIENT'S NAM j,)_t` 1 .��-��• �� AL1•(1 !�M ❑ F COMPA Y / ADDRESS, t- �J�(1^ AGE� ' CITYL- t�• STATE_CA^ - ZIP_- DOB_6LLdff_J ❑ Sn ❑ M ❑ T ❑ W ❑ Th �F ❑S DRIVER'S LICENSE q PHONE 1� -��_�L� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R_E9UESTED BY: TIME- (24 HOUR CL CK) e- TO SCENE- S.O. CALL RECEIVED O P.U. TIME 10-8 , Y PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 . .I L kA (Le /y O PSAP TIME 10-49�/Cl / MILEAGE: ,�� 13OTHER/PVT TIME 10-7 END 1 TIME 10-98 C( ) DOCTOR __.� - PMD/ER START j"1 n TIME 10.22 t HOW CHOSEN TOTAL T® STANDBY TIME -� O NEAREST O FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT W.OTHER ) CALL BACK N: AMBULANCE COMPApW: ( 'A PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE if YES ❑ NO ❑ WAL':ED '4GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER_ DEMT-11A i TECHNICIAN -S PARAMEDIC Hx:AJC�(� f:�_ 1LJL:C DISPATCHER: CHIEF COMPLAINT: _ t_ Zt� _ DRY RUN: ❑ YES )4 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES J.%NO NO. OF PATIENTS: S.S. K PRIVATE INS. CO.:— BASE RATE: KAISER a: MULTIPLE PTS.BASE RATE BLUE CROSS$V TOTAL MILES: �� X 7;75 J9 MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ten— CCHP/PPRP q: EMERGENCY-RUN: 'aLD C� MEDI-CAL#: COD 2/3 I OTHER: OXYGEN: ( R TANK) -, i P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ( DATES BILLED: STANDBY! (OVER 15 MIN.) i r1 E.K.G.: (PER EPISODE) �I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 1 ADDRESS: ____..._ ' - ORAL AIRWAY: (IF NOT REPLACED) CITY -__-__._ .._.. STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _..._ OCCUPATkQN: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: vtj f: TOTAL 1' 1 0 0 _ PATIENT RECEIVED BY:X <1 Avuidrr rru:c Vhit.r ..r.: Pic% PP �rtr7► Yt•.ir�� •o;p DV when tii"inp (SIGNATURE) OIS-1 I CON IIIA c.6STA COUNlY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N f 3 ' /[G Z-7 CHECK OR FILL INAPPROPRIATE SPACES DATE: 7' -77 'f PATIENT'S NAME_��1^?.l..�n.l__. l_� [« : _ -OM 7 ❑ F COMPANY N ADDRESS :2 AGE 3 CITY__�L_-_.-- STATE—G.zo-- ZIP_5 .BGG DOB_L)4'4G ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F: ig S DRIVER'S LICENSE a _ ._ PHONE — � _ NATURE OF DISPATCH 7 q TYPE OF TRANSPORT: AMBULANCEA OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL(?C}C '� ) / TO SCENE- S.O. CALL RECEIVED �� (( O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 / StL ,20 I Z ❑ PSAP TIME 10-49 Z— :LL MILEAGE: ❑ OTHER/PVT TIME 10-7 0 : Q END 3 TIME 10-98 --FF -9}--IJ�3/ DOCTOR _ �_��r� r PMIrE START__' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME -AEF NEAREST ❑ FAMILY ❑ TRANSFER �, WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE CQMPANY: I 1 l J ... PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Q-�ES ❑ NO ❑ WAL' ED7*�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER cl, -`1EMT-1A TECHNICIAN 'KC ^4PARAMEDIC T� J� Hx: ---��C.✓I ------ --- DISPATCHER: havoQ a � CHIEF COMPLAINT: _. Gc;�_/�L—L1�5 DRY RUN: ❑ YES-.-;YNO REASON FOR DRY RUN' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES A NO NO. OF PATIENTS: 5 �� s.s. n .. �`�- PRIVATE INS. CO.:____ BASE RATE: KAISER a: MULTIPLE PTS.BASE RATEC. BLUE CROSS a:— _ _ TOTAL MILES: X MEDICARE : E.O.B. ATT. ROUND TRIP: ❑ YES 1N ❑ YES ❑ NO NIGHT: (19:00-07:00) Esc �✓ CCHP,'PPHP a:I _^_--- _ EMERGENCY RUIN: i`. -d '° •_% ;' A MEDT-CAL a: CODE 2�3j 3_ °.�� .OTHER:-- - OXYGEN: (PETANK)c-- ^'`- ' - 1 P.O.E. STICKER ❑ VES ❑ NO NEONATAL: (INCUBATOR) _ DATES BILLED: STANDBY: (OVER 15 M1141 3°S`�'rU E.K.G.: (PER EPISODE) /�07 �3 ' _•_ NEAREST RELATIVE,RESPONSIB LE PARTY: I.V.: (PER ADMIN.) —7t- DRUGS: (PER ADMIN.) X _.�... NAME:_14>14 r'e RELATIONSHIP: -4c-4A E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-.__ZIP:___. C-COLLAR: (IF NOT REPLACED) PHONE: _. ---__.... WORK PHONE -_ DRY RUN:- (AUTHORIZED) EMPLOYER: .<'v«�"�r �� _�!t OU�IIPATIO1�t� Jlil�'` / OTHER: ADDRESS--__.--4_�� CITY: r rIt le-t/ STATE: ZIP: COMMENTS: -- -- ---- � -v /77, 25 _ TOTAL .SL Pa71:r4T rAECEPrED BY X (SIGNATURE► CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT [/�` AUTHORIZATION• M ( L CHECK OR FILL INAPPROPRIATE DATE: / '••ice PATIENT'S NAME_//l "1 }��M D F COMPANY a ��ADDRESS/� AGE V CITY_��L __ STATE-- ZIP _— DOB (LY❑ Sn D M D T D W D Th D F DRIVER'S LICENSE a _._..__._..__.._.. ...__.___...__ PHONENATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LO ATION: /� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,/ -� TO SCENE- n S.O. CALL RECEIVED __0_J :1 ! t 7 qoj, P.U. I TIME 10 8 O 1 :1fg PATIENT D STINATION: FROM SCENE D FIRE TIME 10-97 D PSAP TIME 10.49 ' MILEAGE: ❑ OTHER/PVT TIME 10.7 C--)1 % END TIME 10-98 ' o ( 3 DOCTOR _ -� PMD R START--1 TIME 10-22 _.. 7 HOW CHOSEN: TOTAL — _ STANDBY TIME - ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME — r•tl�`PATIENT D DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMP!►NY: T AMBULATORY? PATIENT TAKEN TO AMBULANCE: ��11� RESPONSE ZONE YES ❑ NO VAL"ED O GUERNEY ❑ OTHER ' PATIENT CONDITION. DRIVER_ __— EMT-1A t� TECHNICIA PARAMEDIC } �,r- �---'- - DISPATCHER: (•/y Lf .. CHIEF COMPLAINT: __ L_G«'L �._ZV�fLSDRY RUN: ❑ YES�_,�'N0 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -�) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YE NO NO. OF PATIENTS: �V _� ._... PRIVATE INS. CO.: _ BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: D YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) /S0 UO l CCHP%PPRP a EMERGENCY RUN: od ex) - MEDT-CAL a:_ � CODE 2/�3 I ? .dJ OTHER _ ''1` OXYGEN: (PER"TANK P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) / � r DATES BILLED: STANDBY: (OVER 15 MIN may•✓ E.K.G.: (PER EPISODE) f NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) ^ X / DRUGS: (PER ADMIN.) X NAME:— __ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _— ORAL AIRWAY: (IF NOT REPLACED) CITY: __—_:z..._.. ..._... . .... ._ . STATE___ZIP:_.___ C•COLLAR: (IF NOT REPLACED) PHONE �� _ /WORK PHON DRY RUN: (AUTHORIZED) _ EMPLOYERS=_►��rf' � OTHER: ADDRESS:_ CITY: ISTATE: .ZIP: _ COMMENTS:— _ _— TOTAL:-- � J '! ___ PATIENT RECEIVED BY:X '�"L O Providr rr i i t^.,i I i •n t (SIGNATURE) t• :�:� ten. S'o' �;^ u>,� ti7"ivp DIS-1 I1 CON IRA COSTA COUNTY AMBULANCE / r PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N 3 ' CHECK OR FILL IN APPROPRIATE SPACES DATE:. w �� `f 3 PATIFNT'S NAME( C. 0 U(��.0(C�!__,rl M ❑ F COMPANY N 7 l s '. ADDRESS _J -�_ 7 eLtC.6l-- - � AGE L]Cl 0116 7 1 � C i CIT fLYL dJ� STATE Ck• ZIP 11 DOBct7nt?f�__Dl ❑ Sn ❑ M O T O W O�Th 11 F ,0 S DRIVER'S LICENSE a __._._.__._.^ ...._-_... PHONE _- .. � 3..` NATURE OF DISPATCH�A y'`Ty ;L TYPE OF TRANSPORT: AMBULANC THER❑ INCIDENT LOCATION: RESPONSECODE: EQUESTED BY: TIME- (24 HOUR C SOC N 17 ) I� I ll 6A t? C d TO SCENE- l S.O.- CALL RECEIVED � 3/") ❑ P.D. TIME 10-8 / 7 1 PATIENT DESTINATION: FROM SCENE OS ❑ FIRE TIME 10-97 / a77 ❑ PSAP TIME 10 49 a 4Q_ o c SPS - MILEAG ❑.OTHER/PVT TIME 10-7 �7 n I �� END TIME 10-98 DOCTOR _�[L L PMD/ R� STAR TIME 10-22 HOW CHOSEN: € TOTAL �" (' STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER ( _l WAIT TIME ATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMB�(LANCE CpMPANY: L J i PT AMB TORY? PATIENT TATGUERNEY TO AMBULANCE: �=��1 RESPONSE ZONE O YESNO ❑ Wtil`:ED ❑ OTHER PATIENT CONDITION: DRIVER f'_LJ��_7�N�M C�L 1 ( '` EM�T_lA� ' 1 � Q TECHNICIAN S2 UN L C 1/1/►! p�A AI„1Fpl� Hz: ..._Ll L L_.--pp_-..-------- J� DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X-- MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO. NO. OF PATIENTS: _ PRIVATE INS. CO:: BASE RATE: /\ KAISER#: MULTIPLE PTS. BASE RATE `BLUE gj OSS#.,A-- �1�` TOTAL MILES: � X DI�44 #: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO d`, ❑ YES ❑ NO NIGHT: (19:00-07:00) dl- I CCHP/PPRP N: EMERGENCY RUN: , MEDI-CAL N: CODE 2/3 _._. a 1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER Cl YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: _ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: �1 I.V.: (PER ADMIN.) X I 1 DRUGS: (PER ADMIN.) X NAME _ n_1.j1 L_-. Wj{�I_ RELATIONSHIF E.O.A.:(IF NOT REPLACED) ADDRESS:.__. - -_ ORAL AIRWAY: (IF NOT REPLACED) CITY =� _(�._. ..-__-_ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: -"y� WORK PHONE: DRY RUN. (AUTHORIZED) EMPLOYER:�e SC OCCUPA71pN: OTHER: -- ADDRESS: CITY: STATE: ZIP: COMMENTS: p TOTAL: �'� _\ H 0 PATIENT RECEIVED BY: X �J Provider rrta:c ws;i'n rx4 Pin: ,•.�rp Lrtur+. le',!w npp !*G' when bil:inp ISI ATURE) sms 1 CONTRA COSTA COUNTY AMBULANCE j� �� PRE-HOSPITAL CARE FORM 1 UNIT O AUTHORIZATION ,//j CHECK OR FILL IN APPROPRIAT SPACES DATE: ` Q (f 7 PATIENT'S NA E HO lam ' f T �� / _ __ �M ❑.F COMPANY N ADDRE 5 _ AGf CQ — _ CITY _ _ STATEC a ZIP_ OSnOM OT OW OTh O "1 O S , DRIVER'S ICE SE # _. _.. . PHONE ;jD .... URE OF pISPATCH -( TYPE OF TRANSPORT. AMBULANCLLEN_OTHER❑ _- INCIDENT LOCATION: /�-f�L J RESPONSE CODE: REE ESTED BY: TIME— (24 HOUR CLOCK) i 1 �� TO SCENE- J� S.O. CALL RECEIVED ( J� ._�_� �+�� -/L, O P.U. TIME 108 ; PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10`97 . ; O PSAP TIME 10.49 MILEAGE: 3 0 OTHER/PVT TIME 10-7 I ,.t� � END ` TIME 10- ' ! DOCTOR PM 1 /ER START TIME 10-22 I I HOW CHOSEN: TOTAL STANDBY TIME li KNEAREST ❑ FAMILY ❑ TRANSFER \ WAIT TIME I f ❑ PATIENT ❑ DIRECT ❑ OTHER i CALL BACK N: AMBULANCE COMPA Y-yis 1 PT AMBULATORY? ATIENT TAKEN TO AMBULANCE: c��;� RESPONSE ZONE 0.YES ❑ NO WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER_— U `J Q EMT-tA TECHNICIAN �� •�-7( 'PARAMEDIC ( I H< DISPATCHER: (� CHIEF COMPLAINT: cj�-X�_ DRY RUN: ❑ YES kNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r. PATIENT REFUSED SERVICES: (SIGNATURE) X, ICAL COVERAGE: INDUSTRIAL O YES NO NO.OF PATIENTS: '� � S.S I RIVATE INS CO' BASE RATE: •• KAISER+t: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X �sx_. +�• MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ONO i 0 YES ONO NIGHT: (19:00-07:00) • , CCHP%PPHP#: EMERGENCY RUN: • MEDT-CAL q: —_ CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES Q NO NEONATAL: (INCUBATOR) f � DATES BILLED: _ STANDBY: (OVER 15 MIN.) '11 +� E.K.G.: (PER EPISODE) j NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X f jj n a , DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHI .__ E.O.A.: (IF NOT REPLACED) i ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:__._ _ _.. _____ STATE—_ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: _ _ _ W K PHONE._. DRY RUN: (AUTHORIZED) EMPLOYERCUPATIO(J OTHER: ADDRESS: �{ CITY: -l�L�_ STATE: ZIP: 1 f COMMENTS:` lledX ' ' - '79 TOTAL: PATIENT RECEIVED BY:X 0 0-5- Previdcr reta.r r.i r::•:= (SIGNATIUREI CON IRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT S AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME 1-1r1(]..k -ti.?.�_L�� .M 0 COMPANY0 ' ADDRESS 1'�1 ��_f�'.L:�.__.._5�;, AGE (C-A Co D 6 /.g` . ' CITY4,r,��-� — STATE'f ZIP �.� (c, DOBa- LAA 15 Sn ❑ M O T O W ❑ Th O F. O S 'I DRIVER'S LICENSE q i7�_XD_-_-. -.:•. -'.. t.._.___.. PHONE ____ NATURE OF DISPATCH��n TYPE OF TRANSPORT: AMBULANCE'X OTHER❑ INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY: TIME- (24 HOUR CLOCK) ` - TO SCENE- .� KS.O. CALL RECEIVED 2�`fJ t W �t1t._L - \ ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ,r ' _ : • END ll!� TIME 10-98 DOCTOR�ti11`LL _d - PMDICR)` START __L__R _ TIME 10-22 HOW CHOSEN: TOTAL_ STANDBY TIME ❑ NEAREST- ❑ FAMILY ❑ TRANSFER WAIT TIME lW PATIENT ❑ DIRECT ❑ OTHER �'�` CALL BACK N: AMBULANCE COMPANY: CQ s i PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: f RESPONSE ZONE -) YES 11 NO 13WAL`:ED 7d.GUERNEY ❑ OTHER v �. n PATIENT CONDITION: DRIVER N LJ- 2 r> MT-1 TECHNICIAN �� - PA DIC 'lII� Hx: (r:> Z( ?--- �:------- ' DISPATCHER: ( l(� i �•� I C /_�C r CHIEF COMPL,,A�lIINT: 1.1L_�.�.I�(.`�_�3i�;L.x►_�_ DRY RUN: ❑ YES t NO REASON FOR DRY RUN `1'� _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE' INDUSTRIAL ❑ YES NO NO. OF PATIENTS: -1, .- r^' 1 PRIVATE INS. CO.:_ BASE RATE: •••► KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS p _— TOTAL MILES: X �-`� �• MEDICARE,#:._U _ Y- c) E.O.B. ATT. ROUND TRIP: D YES ❑ NO -i P- I 1 �{ • 1'I' -1 Lam' ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:_ Cy' EMERGENCY RUN: a MEDT-CAL a: CODE 2/3 I If OTHER - OXYGEN: (PER TANK) c)/ \� - P.O.E. STICKER ❑ YES ❑ NO NEONATAL' (INCUBATOR) i DATES BILLED: _ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X n(1 1 -- DRUGS: (PER ADMIN.)_ X _�I NAME. . RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:._ __. _____._ _...._ ORAL AIRWAY: (IF NOT REPLACED) CITY .__ __._._-______._.__ STATE_.-ZIP:-_.- C-COLLAR: (IF NOT REPLACED) PHONE: _.___.__ WORK PHONE..__. DRY RUN. (AUTHORIZED) EMPLOYER: __- OCCUPATION: OTHEy: l/ `D) 7 ADDRESS: CITY. STATE: ZIP: =+- COMMENTS:' r .j TOTAL: 0055 _ PATIENT RECEIVED BY:X Provider• relay- 4z{'. .,.? r .: .•>rL c.•,+• .� (SIGNATURE) CONTRA COSTA COUNTY t) \ AMRULANCE PRE-HOSPITAL CARE FORM 1 ` UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES - DATE: -7_//, k3 PATIENT'S NAME—� _ tLG w: IZ r. 4�v rL 4 fgM O F COMPANY 7t yT �� Apt- ADDRESS prADDRESS 7 c) 1 ) ncI�u•:. c:r� + lZ<< r AGE—I� CITY_ STATE_ i•_ ZIP vis; Kr'0LLl DOB_gz..z j_/4 •O Sn k M O T O W O Th:O F• OS DRIVER'S LICE-NSE# _ .L—i'�l! r-CLI-Jt;.•.__. _ PHONE ZYA—g7'02_NATURE OF DISPATCH O r+ir t tJw�>�a1 TYPE OF TRANSPORT: AMBULANCE .OTHER❑ ! INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) !� TO SCENE- 41S .O.—. CALL RECEIVED iP.D. TIME 10-8 V PATIENT DESTINATION: L om F. FROM SCENE ❑ FIRE TIME 10-97 PSAP TIME 10-49 MILEAGE O OTHER/PVT TIME 10-7 > > _ END �Py TIME 10.98 DOCTOR _ �l�s PMD& START _j± TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT 13 DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: _j N�.S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES O NO ❑ WALED O GUERNEY O OTHER { , PATIENT CONDITION: DRIVER //O TECHNICIANlely�z .�f t PARAMEDIC Hx: �� c DISPATCHER: `= ' CHIEF COMPLAINT: _�L.111: ❑ YES DKN0 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— (. MEDICAL COVERAGE: INDUSTRIAL O YES D NO NO. OF PATIENTS: PRIVATE INS. CO.:— BASE RATE: po'�•-' K, SERx��_ MULTIPLE PTS. BASE RATE BLUE CR SO S M TOTAL MILES: �U X 1"50 li S.!!D EDICARE 4: E.O.B. ATT. ROUND TRIP: O YES O NO O YES ONO NIGHT: (19:00•07:00) i CCHP/PPRP#:_ EMERGENCY RUN. I \ MEDI-CAL M: _ CODE 2/3 (j OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) ' �rI DATES BILLED: _ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X j DRUGS: (PER ADMIN.) X NAME: )A c LA 171 LL,11 0- RELATIONSHIP:rc�.x d E.O.A.: (IF NOT REPLACED) Ij ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:.,Tti_y ne wjL.. DRY RUN: (AUTHORIZED) t7}.EMPLOYER: Ciir�_ltt_1i.:.t, OCCUPATION: Pt Ip o<t ri�X POTHER: ADDRESS: _.—_ CC1h. +��/�:: /2_ I S.1J7) F i1 CITY: Crr >! STATE: c tl ZIP- COMMENTS:-24- A rct,. q U 1 cl 47 d7i ` TOTAL: &-v PATIENT RECEIVED BY:X �96"100 O"1�� 00 -� 1 IGNATURE) a5-1 �j Provider rctr.'� L�itr v•i Pic; r_,pL Sotur. Ye",v MAY }I ohrn ti1'ing CONTRA COSTA COUNTY AMBULANCEp�� //AF PREHOSPITAL CARE FORM i AUNIT �J� AUTHORIZATION N[1 •T q pit d L CHECK OR FILL INAPPROPRIATE SPACES` DATE:' : PATIENT'S \ 'YkM ❑ F COMPANY K ADDRESS LIGE CITY _ STAT ZIP___ DOB _____ 0 SnOQ ❑ T 0 W 0 Th O F ❑S DRIVER'S LICENSE N 1— PHONE NATURE Of DISPATCH & TYPE OF TRANSPORT: AMBULANCE 0 OTHERO_ INCIDENT LOCATION: y RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) G _y TO SCENE- O. CALL RECEIVED .L nE ,;2 OB t V_ QY P.D. TIME 10-8 C! :PATIENT DESTINATION: ! : FROM SCENE"- ❑ FIRE TIME 10.97 :�L _�� ❑ PSAP TIME 10-49 +� ford 'T+ .Z�•� �l Co—s/lJPlof;Z;7jILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR ^ xa } PMplER START TIME 10-22' _.!_2-:_J,5 HOW CHOSEN: - TOTAL STANDBY TIME - 0 NEAREST. ❑ FAMILY O TRANSFER. WAIT TIME " ❑ PATIENT I ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE-,,-f- 0 ONE0 YES ❑ NO 0 WALKED ❑ GUERNEY 0 OTHER PATIENT CONDITION: DRIVER" TECHNICIAN _ A�R M DIC f ' /- Hx: DISPATCHER: ' 7 CHIEF COMPLAINT: DRY RUN: =L ES 13-NO REASON FOR DRY RUN .t om AUTHORIZATION FOR DRY RUN(EMS USE ONLY} �•- ,PATIENT REFUSED SERVICES:(SIGNATURE) X 7 � AA,II U6, �z I MEDCAL COVERAGE: INDUSTRIAL ❑ YES O NO NO.OF PATIENTS: S.S. >s . PRIVATE INS.CO.: ' ` ' ' BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE - SLUE CROSS Ie: TOTAL MILES: X MEDICARE 0: E.O.B.ATT. ROUND TRIP: 0 YES O NO - - O YES 0 NO NIGHT: (19:00-07:00) ` CCHP/PPRP EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: , , -i OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES 0�NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —NEAREST RELATIVE/RESPONSIBLE PARTY: LV.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ._.._NAME. RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) STATE-�.,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: ` ADDRESS: � ? ,•;. CITY, STATE• ZIP. ._. COMMENTS: .,.e,' TOTAL: -- CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# ✓ % CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME_v__ 0 1� ► �' M WF COMPANY N ADDRESS �Y 3 /✓• MAC.0 e, (�Q AGES` CITY nrGkh-o—n STATE CALr ZIP%��$�f DOB 5''_S8 ❑ Sn A M ❑ T OW OTA ❑ F ❑S DRIVER'S LICENSE# it r PHONE _ .+{ NATURE OF DISPATCH r' S GQ►L21A5 e TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME—(24 HOUR CLOCK) ` LL11G? wM C d"'.4/cl TO SCENE- Drs.0. CALL RECEIVED❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 - 2 O PSAP TIME 10-49 MILEAGE; . ❑ OTHER/PVT TIME 10-7 �~t< 2 END S TIME 10-98 (l DOCTOR i 1 l PM ER START— .9 • TIME 10-22 HOW CHOSEN: TOTAL 3/2 STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER /-• WAIT TIME ( ❑ PATIENT ❑ DIRECT ❑ OTHER �� ) CALL BACK a: AMBULANCE COMPANY: a GAS # PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑.YES .NO ❑ WALKED 1�GUERNEY O OTHER •- n, PATIENT CONDITION: DRIVER V 1 G v I S `/v EMT-tA TECHNICIANy� T 3 PARAMEDIC Hz: IITCP.art�aSt QCr�'Ect F—e�t� DISPATCHER: I.?u�_•�:*ti4., 3q A►�OM/N 4� Pte►• /� CHIEF COMPLAINT: DRY RUN: OYES �NO REA`SON.FOR DRY RUN C� _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ll �� PATIENT REFUSED SERVICES: (SIGNATURE) X AL COVERAGE: INDUSTRIAL ❑ YES (!�'N0 NO.OF PATIENTS: PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: 7 X �! MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ` -- CCHP/PPRP EMERGENCY RUN: Q(:% MEDT-�L# O oA Sb—O CODE 2/3THERO OXYGEN: (PER TANK) I J r V P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ej NEAREST RELATIVE/RESPONSIBLE PARTY: ` I.V.: (PER ADMIN.) X -6G DRUGS: (PER ADMIN.) X t ,�jQ �{l,a I/f,r-aFP NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED)• - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 3 -D �� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYE~ ADDRESS: OCCUPATION: OTHER: c 00 O Q -CITY: STATE: ZIP: COMMENTS: pT 300 6L HL L. ) _ TOTAL:.L-2�r'U.. . ._ ,.. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# • CHECK OR FILL IN APPROPRIATE SPACES DATE: �.r ')'PATIENTS NAME ❑ M O F COMPANY# .ADDRESS_ _ I AGE c r51zlxzo;7,'� I CITY _ STATE_ ZIP DOB '❑ Sn ❑ M O T OW O Th OF O S DRIVER'S LICENSE#' PHONE ' NATURE OF,DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER INCIDENT LOCATION: {.±7 RESPONSE CODE: % REQUESTED BY: TIME- (24 HOUR CLOCK) �• TO SCENE- . 0'S.O. CALL RECEIVED x � j t13 P.D. TIME 10-8 :L_ yPATIENT'DESTINATION:.._ .' FROM SCENE- 13 FIRE TIME 10-97 ❑ PSAP TIME 10-49 f1�.. �,i11�� `•'T T' 'Iii; � ,•^ MILEAGE: ❑ OTHER/PVT TIME 10-7 ; END TIME 10.98 -- DOCTOR 1 T ; i PMD/ER START ( TIME 10-22 HOW CHOSEN: _ TOTAL STANDBY TIME +:r ❑ NEAREST 3 ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J �,� RESPONSE ZONE ❑ YES ONO_ O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER -' ` `�' L I �� _f-MT-11A ; w' fig is ► I.... i 1 TECHNICIAN 'G' ' / /'PARAMEDIC Hx: DISPATCHER: i �� CHIEF COMPLAINT: I DRY RUN: 0 YES 13 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ' Si F, 0-,':!PATIENT REFUSED SERVICES:(SIGNATURE) X q5 MEDICAL COVERAGE: INDUSTRIAL O YES 13 NO NO. OF PATIENTS: 'S � d- S.S.# PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE i BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#1 EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER:- OXYGEN: (PER TANK) ' P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ` -`NEAREST RELATIVE/RESPONSIBLE PARTY:' I.V.: ?PER ADMIN.) X DRUGS: (PER ADMIN.) X ti"-NAME'"' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: STATE- ZIP: C-COLLAR:. (IF NOT REPLACED) PHONE: WORK PHONE:_;, DRY.RUN: (AUTHORIZED) 2 P� EMPLOYER: OCCUPATION: OTHER: ADDRESS: e ' CITY: STATE: ZIP- Lei Li L) C� —COMMENTS:' _. TOTAL:- 00 OTAL OO cam" PATIENT RECEIVED BY: X. ,...,; �.. . .. rclnNArurirl •. . (� CON IRA COSTA COUNTY / AMBULANCE ) r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# j CHECK OR FILL IN APPROPRIATE SPACES DATE: - PATIENT'S NAME ] ❑ F COMPANY N ADDRESS �4,d{_ / I5= 1— AGE L 1 CITY_'S ` ' STATE ZIP DOB ❑ Sti ❑ MT OW O Th 13F,-OS ' : • DRIVER'S LICENSE# __.___. PHONE NATURE OF DISPATCH—//— -79 TYPE ISPATCH //— TYPE OF TRANSPORT: AMBULANCE❑ OTHER O INCI ENT LOCATION: /E,CTSCy(� RESPONSE CODE: E STED BY: TIME— (24 HOUR CLOCK) TOS - O S.O. CALL RECEIVED � r (j( D. TIME 10-8 ^ ! ATIENT DEST ATION: FROM SCENE O FIRE TIME 10-97 ' O PSAP TIME 10.49 _i5T 1`� ' ► / G`^'t S MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _ PMD/ER START TIME 10.22 -. HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY ❑ TRANSFER WAIT TIME v O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULA CE NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE ES ❑ NO O WAL'CED ❑ GUERNEY O OTHER. PATIENT CONDITION: DRIVER EMT AA -� TECHNICIAN • PARAMEDIC J "I �%{ Hx:riv��r'7v7C DISPATCH : �{ CHI F COMPLAI CCL�/ZiSi �N( S -fl DRV RUN: YES ONO REASON FOR ORY RUN ` l AU HORI FOR Y RUN(EMS USE ONLY) �1 ! __E&jLENLBEEUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES O NO OF PATIENTS: .75 i, i S.S. # PRIVATE INS. CO.: BASE RATE: �i KAISER#: MULTIPLE PTS. BASE RATE +� BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO i l O VES ONO NIGHT: (19:00-07:00) I CCHP/PPHP#: EMERGENCY RUN: ' MEDI-CAL#: CODE 2/3 (• -••-- OTHER: OXYGEN: (PER TANK) _ P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _ ____ ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: __ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP• COMMENTS:_ Cr--"C-" G O(hQ r S CVCtiTC11C r-rOI" t', 0's L,C c_vN C_ geTOTAL:—. 00 PATIENT RECEIVED BY:X (SIGNATURE) Provider retG:n. ;Rite v'd Pir, rope beturn le:luu cwp:, t+ IMS Yhm biking DIS-! I 1111 i CONIIIA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZA ION N ( d 1 CHECK OR FILL IN APPROPRIATF.SPACES DATE: PATIENT'S NAME__ P�P�.�.y 5 _ �riV�f� �M OF COMPANY r J ADDRESS V1�C) ��- _ ma A -' AGE41 1 CITY_.- rn� 1"�N�_2-• STATE._.__ ZIP—__—___� DOB IQ23 � O Sn Om OW O Th OF O S PHONE .U.-.7.04�d NATURE OF DISPATCH DRIVER'S LICENSE# _ _ ..._.. .. _ - TYPE OF TRANSPORT: AMBULANCE O OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR r( CLOCK)TO SCENE- O.-_ CALL RECEIVED ' y f -- -v --- - -- —J ❑ P.U. TIME 10-8 L1 :. 7T, .I PATIENT DESTINATION: FROM SCENE ` ❑ FIRE TIME 10-97 � �_' :_.2,2L O PSAP TIME 10-49 �I �' :_32 CCS _ MILEAGE: O OTHER/PVT TIME 10-7 L : � END. '�' TIME 10-98 DOCTOR _- _ _ PMD/ER START J� TIME 10-22 HOW CHOSEN: TOTAL —_ STANDBY TIME O_NEAREST O FAMILY O TRANSFER _ WAIT TIME PATIENT O DIRECT O OTHER CALL BACK N: 9MpU� CE COMPANY: �o P MBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE l YS ❑ NO O W;.l';ED UERNEY O OTHERAj _ PATIENT CONDITION. DRIVER_Lr EMT-1A I i TECHNICIAN W1 Lc- ? L PARAMEDIC Hx"-tI-^ i` � DISPATCHER: CHIEF COMPLAINT: ..-.3--�p._�_�-__\�]^'G DRY RUN: O YES O REASON FOR DRY RUN • _-�__—.__.____ �"�L_ _ AUTHORIZATION FOR DRY RUN(EMS USE UNLYJ PATIENT REFUSED.SERVICES: (SIGNATURE) 1 MEDICAL COVERAGE: INDUSTRIAL O YES.O NO NO. OF PATIENTS: S.S. ft. - PRIVATE INS. CO.:— BASE RATE: A KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: —._ TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO 1 /l/ O YES O NO NIGHT: (19:00-07:00) J CCHP/PPRP#: EMERGENCY RUN: o/ �S ! ( MEDT-CAL#: CODE 2/3 i; OTHER I/ 'VA OXYGEN: (PER TANK) !� / P.O.E. STICKER ❑ YES O NO NEONATAL' (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X X DRUGS: (PER ADMIN.) NAME: L.�:D Er Pf_� RELATI NS IP::l,2 1 uL E.O.A.: (IF NOT REPLACED) " — ADDRES :! 1"QL.__Jogo� - ORAL AIRWAY: (IF NOT REPLACED) 1I CITY _.�._.-...._.__ -.ZI.-____ STATE---ZIP:---- C-COLLAR: (IF NOT REPLACED) PHONE: 2 d-S��iL;l� WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: - OCCUPATIQN ___ OTHER:. ADDRESS: CITY: _ STATE: ZIP: �l \ COMMENTS: TOTAL: I PATIENT RECEIVED BY:X Prorddr•• rrrJi! wh7 •,�� .n. }.r•• .� �, (SIGNATURE) � I CONTRA COSTA COUNTY AMBULANCE y. PRE-HOSPITAL CARE FORM I UNIT T� .; AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES r DATE: PATIENTS NAME � �= �' �T / — "`:°�� O M ❑ F COMPANY N =� .ADDRESS AGE ox reO �l CITY _ STATE ZIP DOB ❑ Sn O M O T ❑W D Th OF O g DRIVER'S LICENSE•l. j PHONE---- NATURE OF DISPATCH—(?— TYPE ISPATCH (?—TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ ..! RESPONSE CODE: REOUESTED BY: TIME 24 HOUR CLOCK INCIDENT.LOCATION: ( ) sTO SCENE- ❑ S.O. CALL RECEIVED 1 'A t11 P.D. TIME 10-8 PATIENT1G-97 -L��— � DESTINATION:. _! FROM SCENE- ❑ FIRE TIME 10 97 •,QQ - • S' ❑ PSAP TIME 10-49 _T �..�_•(J MILEAGE: ❑ OTHER/PVT TIME 10-7 END . TIME 10-98 3t;DOCTOR! r� w� PMD/ER START TIME 10-22 '-'' �,) HOW CHOSEN: _ _ TOTAL. STANDBY TIME M .,❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK A AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 RESPONSE ZONE ❑ YES ❑ NO O WAL KED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EL r, Z)" EMT-IA '4 T U TECHNICIAN PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: M'YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X / 7 / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: TS 4// Cjl, r1 S.S.M I r ��//t*� PRIVATE INS.CO.: BASE RATE: 1 KAISER 0: 1 MULTIPLE PTS.BASE RATE BLUE CROSS q:} TOTAL MILES: .X ! MEDICARE C ' E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑•YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M EMERGENCY RUN: MEDI-CAL N: CODE 2/3 i OTHER: ' , OXYGEN: (PER TANK) P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) l E.K.G.: (PER EPISODE) i _NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X !NAME.``" """" RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED] CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) Y" 'EMPLOYER: OCCUPATION: OTHER: ADDRESS: —.CITY:-- STATE: ZIP: COMMENTS: ` TOTAL: r�C' PATIENT RECEIVED BY' (SIONAT,IRE) ►qc_ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION NA-3'jj2 �1C1 CHECK OR FILL INAPPROPRIATE SPACES j DATE; - V\ PATIENT'S NAME_ / � 2 _ '(�� .1*m ❑ F COMPANY#��^� / i�5 AGE a- ADDRESS �/ _�_�QGs. . �� CITY ,/C__ STATE�—_�� ZIP 9yS5� DOB J `1' ❑ Sn ❑ M 1 ❑ W 13 Th ❑ F'0 S 1 DRIVER'S LICENSE# ..C.Oyi OW_o...._____-. PHONE .-�I�D- p_�� NATURE OF DISPATCH _ j TYPE OF TRANSPORT: AMBULANCE❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C CK I TO SCENE- S.O. CALL RECEIVED - - D P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 : :- D PSAP ' TIME 10-49 j �� MILEAGE: ❑ OTHER/PVT TIME 10.7 -J END -��r TIME 10-98 �1 DOCTOR : _. PMD/ER START--4-7,Z TIME 10-22 HOW CHOSEN: TOTAL 7 STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY' PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL':ED ❑ GUERNEY d OTHER .J PATIENT CONDITION, DRIVER` (}S EMT-1A TECHNICIAN " WRAMEDIC ' Hx __._ I-L�. DISPATCHER- CHIEF ISPATCHE 1 h T / CHIEF COMPLAINT: DRY DRY RUN: ES ❑ N REASON FOR DRY UN f ZATION FO Ry U E LY)� 1 PATIENT REFUSED SERVICES: (SIGNA ' MEDICAL COVERAGE- INDUSTRIAL ❑ YE$w NO NO. OF PATIENTS: VATE INS. Qr�?L••+ o�af�� / BASE RATE: a: MULTIPLE PTS. BASE RATE T BLUE CROSS K: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) - CCHP/PPHP a: EMERGENCY RUN: MEDI-CAL a: CODE 2/3 _I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) l I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X NAME:.. 1/J0� IT �'___ RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: , �.-3 .._ ylvU^. �._�- _—.— ORAL AIRWAY: (IF NOT REPLACED) CITY._L✓Lt7lr1�. ._. C-.r_CCk. STA�E 4-Z±ZIP:S C-COLLAR: (IF NOT REPLACED) PHONE: >Q--)al�-_ WORK PHONE: _ DRY RUN: (AUTHORIZED) [ EMPLOYER: -___ OCCUPATION:— OTHER: ADDRESS: CITY: I— STATIE- ZIP: COMMENTS:— 62 P rh�p P 000088 c 0 _ PATIENT RECEIVED X (SIGNATURE) A•nuidrr rrta:-. N;itr .x.i �i.:: r.•r� hrturr Y�'..a• ��. t !TI: uhra tit ina CIS-1 CON I IIA COS TA COUNTY AMBULANCE 3 I '1 C PRE-HOSPITAL CARE FORM I UNIT. 1� AUTHORIZ TION v 1 3 •] CHECK OR NU IN APPROPRIATE SPACES DATE: 2 I PATIENT'S NAME_— ^_. IS G �_ c [>___. 111-?3j O F COMPANY# ^_ Y -' ADDRESS N_.� — -- - _ G 33 j C O I CITY _ STATE_ ZIP----.-- DOB�� kf ❑ Sn ❑ M Trr❑W ❑Th ❑ F ❑S DRIVER'S LICENSE# ._..� _.3Cl�� _..__. PHONE _._.__.... _. _..—..__ NATURE OF DIS TCH TCF'� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: ES TED BY: TIME— (24 HOUR CLOCK) V J� (� TO SCENE- S. CALL RECEIVED ..(. :_� ��—_- 1 ❑ .D. TIME 10 8 7 7 3 PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 f l 2 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 EmrD V TIME 10-98 i DOCTOR .__�_ .__ PMD/ER START- TIME 10-22 { HOW CHOSEN: TOTAL —�_ �_ —_ STANDBY TIME 1 O NEAREST O FAMILY Cl TRANSFER WAIT TIME 1 ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMLPS COMPANY: I PT AMBULATORY? PATIENT TAKE TO AMBULANCE. RESPONSE ZONE ES ❑ NO ❑ WAL':ED UERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER_ / � 2 EMT-tA TECHNICIAN— `--iti t l i l PARAMEDIC Hx: __ _ __ _ _— DISPATCHER: j CHIEF COMPLAINT:L._ _� -_-(J— f CDRY RUN:aU AUTHORIZATION FOR DRY RUN EYES ON MS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 . PRIVATE INS. CO.:._.—. _ BASE RATE: �✓0"^� f KAISER a: MULTIPLE PTS. BASE RATE I) BLUE CROSS#: ___� TOTAL MILES: '�� X !Qi?1L =ei1/ i MEDICARE #:_____�,�_L_�. E.O.B. ATT. ROUND TRIP: ❑ YES ONO �O YES ❑ NO NIGHT: (19:00-07:00) CCHP,'PPHP#: EMERGENCY RUN: crd MEDT-CAL#: —____ --_ CODE 2/3 OTHER: _ OXYGEN: (PER TANK) _.. \ P.O.E. STICKER Cl YES ❑ NO NEONATAL: (INCUBATOR) II 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: el RELATIONSHIP:_ E.O.A.: (IF NOT REPLACED) ADDRESS:— —_ __ ORAL AIRWAY: (IF NOT REPLACED) CITY __.y_.--._._ _.._ STATE___.—ZIP:.—. C-COLLAR: (IF NOT REPLACED) PHONE: _x:____ _.—_-._ _..- WORK PHONE:_ _. DRY RUN: (AUTHORIZED) EMPLOYER: _.._-____,________ OCCUPATIQN: _..__ OTHER: ADDRESS:, ---- --- �f3S A4•-V CITY: __.--- STATE:--ZIP:_ COMMENTSf it -------- —— - __ TOTAL: �— 000089 7 Q(��%� • _ _._ ._ _.— (SIGNATURE) . PATIENT RECEIVED BY:X '00 -- Pr- ?;r rrr_,,3:� Vki! •rI Pi r,: r,pp .I.r� Jr'::c y !NC _hrti !i2'in� 015-1 CONTRA COSTA COUNTY AMBULANCE F PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: 7- 1-1 i ' f PATIENT'S NAME_rI!?LL r.7__-`'-<<�:/�el ,____—_ O M 16 F COMPANY M ADDRESS -��----�.� -cLLr' AGE 13— -- q Sn MT O W C O FSTATE _ ZIP / �7O DOB-Z---- S' DRIVER'S LICENSE q PHONE _/L/c+.Y+_ _.._____ NATURE OF DISPATCH Fes, II TYPE OF TRANSPORT: AMBULANC OTHER❑ I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK)`� ( 2 4/ T TO SCENE- S.O. CALL RECEIVED _6)o/—L�L ---_3 ❑ P.U. TIME 10-8 5�. C PATIENT DESTINATION: ( ,1 (� FROM SCENE - l 13 FIRE TIME 10-97 ; ❑ PSAP TIME 10-49 L=_. MILEAGE: ❑ OTHER/PVT TIME 10-7 ��-ti_,\ END 313- TIME 10-98 �Sil___ �_ DOCTOR IS�i_f_L_r+�_-. PMD/o START__$ TIME 10-22 HOW CHOSEN TOTAL ___3'7_ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER , WAIT TIME _Z PATIENT ❑ DIRECT ❑ OTHER i�/ CALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: G RESPONSE ZONE ES ❑ NO ❑ WA(',ED $I GUERNEY ❑.OTHER PATIENT CONDITION: DRIVER._&-,! 1 `�\ EMT-1A TECHNICIAN__L^r I I►'n �= (• PARAMEDIC - 1 L•'• Hx: .__.__-___ __. = DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ANO. REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES NO NO. OF PATIENTS: S.S. p_—suis 2-3 y4z7_ PRIVATE INS. CO.'—. BASE RATE: KAISER a: MULTIPLE PTS.BASE RATE BLUE CROSS Il: TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES O NO r O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: �GloF �G MZEDT27CE*L:101�: -� _ ^sp�,'Q CODE 2/3 OXYGEN: (PER TANK) t P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) i DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X p r[ DRUGS: (PER ADMIN.) X NAMERELATIONSHIP:1,_46441k E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY _'_ ,_c.k. _ STATE-<2'_tZIP:-___ C-COLLAR: (IF NOT REPLACED) '. / PHONE �..__._. WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _______—._ OCCUPATIQN: -_ OTHER: ADDRESS: CITY: - STATE: ZIP: COMMENTS: --- TOTAL -- ------------ - --= - 0 0 0 0 9 0 SL 00 PATIENT RECEIVED BY:X — V -- — /1•,,rri.... rrr.r Lv, (SIGNATURE) rp ,. .. , �L•• ..tom, I•rl'r,a as-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M t)) J CHECK OR FILL INAPPROPRIATE SPACES DATE: rl PATIENTS NAME IDA, - N I (Z 1\y�� (� M COMPANY N 1 n ADDRESS AGE - .� ro q 4 y s - CITY (1�Al2"f l�+t`Z STATE ZIP S 3_ ooB, o s� ❑ MI ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M ____._._ ___._-__--_ PHONE _�_� � NATURE OF DISPATCH— TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ ,.— INCIDENT LOCATION: RESPONSE CODE: REESTED BY: TIME— (24 HOUR CLPCK) n- ?� n TO SCENE-� .O. CALL-RECEIVED L:� ' ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 :l=5 •/ MILEAGE: ❑ OTHER/PVT TIME 10-7 . n! ENDO S TIME 10-98 DOCTOR PMD START—i.u11 TIME 10-22 KK HOW CHOSEN: TOTAL — 1 STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— /hQtATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBIANCE COMPANY: S E�zBULATORY? PATIENT TAK N O AMBULANCE: RESPONSE ZONE 13 NO ❑ WAL':ED ERNEY ❑ OTHER PATIENT CONDITION. DRIVER.LY " EMT-1A TECHNICIAN W lL�Y I PARAMEDIC _ Hz: T DISPATCHER: U r7 CHIEF COMPLAINT: DRY RUN: ❑ YES � REASON FOR DRY RUN AIN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) tlCf PATIENT REFUSED SERVICES: (SIGNATURE) X +� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE ROSS TOTAL MILES: / X #: E.O.B. ATT.. ROUND TRIP: ❑ YES ❑ NO ' " . pJ �_ ❑ YES ❑ NO NIGHT: (19:00-07:00) 'AD CCHP/PPRP M: EMERGENCY RUN: j MEDT-CAL#: CODE 2/3 ( OTHER: OXYGEN: (PER TANK) i P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) U O U r E.K.G.: (PER EPISODE) =4 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �J DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ' ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: ADDRESS: ' C1�,�.-r.;<+,!'�— /0. CITY: STAT11E: ZIP: COMMENTS: S r C C `` ``-tied I ' ------ - TOTAL U00091, 00 —— j - -- ---- -- - -- - - PATIENT RECEIVED BY X - Tmuidar Patau, Vliih ,.r:f r .;: ff, h,run. i. ��I .,�,.•. I:1 ,, — (SIGNATIME) 1.n 1 J, CONTRA COSTA COUNTY AMBULANCE i PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M / 9 ( L' CHECK OR FILL IN APPROPRIATE SPACES t DATE: ��•' �� X PATIENTS NAMES ,�.J ❑ M OF COMPANY 0 4 �p ' ADDRESS — , AGE � A -1 ' I CITY _ ISTATE ZIP DOB - ❑ Sn ❑ M AIT' '❑W ❑�-Th OF OS DRIVER'S LICENSE M ( PHONE NATURE OF DISPATCH—A pf < < ACK TYPE OF TRANSPORT: AMBULANCE OTHER 0 _ INCIDENT LOCATION:'' i;1 I RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) ' TO SCENE- S.O. CALL RECEIVED �91/A v/'z�'f rt►�`� �l(,,r ❑ P.D. TIME 10 8 :E'L := I 'PATIENT DESTINATION: J FROM SCENE ❑ FIRE TIME 10-97 ❑ TIME 10-49 OTHER/PVT _ MILEAGE: ❑ OTHER/PVT TIME 10-7 � I _ END TIME 10-98 yr ,DOCTOR I PMD/ER START TIME 10-22 -1 HOW CHOSEN: I " ' TOTAL STANDBY TIME ❑ NEAREST• ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT c� ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j l RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:.._ DRIVER_rV�11_�>uC A� I/' 1-•!EM - TECHNICIAN . 11Lll.I�kl�� ARAMEDI Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: >4 + {' • PRIVATE INS.CO.: BASE RATE: KAISER W. MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: X r.... MEDICARE 8: E.O.H. ATT. ROUND TRIP: OYES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) u q CCHP/PPHP Ar EMERGENCY RUN: 'T- MEDI-CAL M: ' I CODE 2/3 ' OTHER: OXYGEN: (PER TANK) A P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) ._ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 7A` NEAREST RELATIVE/RESPONSIBLE PARTY:_ I.V.: (PER ADMIN.) X I• DRUGS: (PER ADMIN.) X ...._NAME: RELATIONSHIP* E.O.A.:(IF NOT REPLACED) . ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) :,.CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: �a, DRY RUN: (AUTHORIZED) ;,,i.!r:.EMPLOYER: OCCUPATION' OTHER: i:;•`y ADDRESS: CITY: STATE- ZIP. COMMENTS: ID'Z`LfN C/?"%= QY J , TOTAL: •' 2 n� _ PATIENT RECEIVEn SY X CONTRA COSTA COUNTY AMBULANCE �7 I PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL INAPPROPRIATE SPACES DATE: �'l� " y�,, ��JJ nn r- • PATIENT'S NAM E.Wf)ZNMIRL&4i�J r �,�5_ ;y�"� �M O F COMPANY K ADDRESS --+ ST �r1.� _ AGE AJ_ CITY STATEClA ZIP q`1 /._ DOB DRIVER'S ,1f6 13SI, ❑ M T O W O Th 13F ❑ S Its DRIVER'S LICENSE w PHONE _._ .. ___._ NATURE OF DISPATCH._ - TYPE OF TRANSPORT: AMBULANCEN OTHER❑ .. _. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) TO SCENE -kS.O. CALL RECEIVED �� 1 S ` 5� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCEN - ❑ FIRE -- TIME 10-97 ❑ PSAP TIME 10-49 -� MILEAGE: ❑ OTHER/PVT TIME 10-7 END�5_n_ TIME 10-98 DOCTOR PMq/E�R START_ — TIME 10-22 HOW CHOSEN: ��/ TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE CO�IAPANY: CA., PT AMBULATORY? PATIENT TAE TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAUIED VGUERNEY ❑ OTHER PATIENT CONDITION:513�8L--!�' DRIVEREMT-1A TECHNICIAN__ PARAMEDIC Hz: _._ DISPATCHER. 1 CHIEF COMPLAINT DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: IN USTRIAL ❑ YES NO NO. OF PATIENTS: - S-S. a 'S PRIVATE INS. CO.: BASE RATE: LrGS�i� KAISER R MULTIPLE PTS. BASE RATE I i BLUE CROSS#: TOTAL MILES: 7 X 6'T ` MEDICARE rr: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO .S OYES ❑ NO NIGHT: (19:00-07:00) 30.Iry CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 EA: Li � �� raj► OXYGEN: (PER TANK)/ e7 ( P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 7 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X •/ �� DRUGS: (PER ADMIN.)_ X ( 1� NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ` ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ ST-ATE___ZIP:_—.— C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: /7 ADDRESS: _ <<�-r.?-��jt CJ i .J CITY: _ STATE:__ZIP:_...___ COMMENTS: _._--_____. -- ---- - -- - TnTAL _-_ _ PAIIFNT RFCa ivm IAY X .f .ark's•.. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 6 �r CHECK OR FILL IN APPROPRIATE/SPACES DATE: !7_& MOR -^ PATIENT'S NAPM 4. k 52 C601�f,' j a(M OF COMPANY I". ArDDRESS _IaL_`! � AY �� -��,1 AGE _ CPt E- 3i /O F- I 62 SrA��' STATE__ ZIP-"_:_i�-- DOB12��` O Sn O M O T O W ❑ Th O F; O$ j1 • DRIVERS LICENSE q _! _. ✓ PHONE _ _._.—..__.�_ NATURE OF DISPATCH 51'10 TYPE OF TRANSPORT: AMBULANCE OTHER O INCIDENT LOCATION: RESPONSE CODE: REPOISTED BY: TIME— (24 HOUR CLOCK) ' e TO SCENE- S.O.— CALL RECEIVED j � : x V ----- [ o 6 j LRI: O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 11FIRE TIME 10-97 / / 2— O PSAP TIME 10-49 �.G' .'. Po'sMILEAGE: ❑ OTHER/PVT TIME 10-7 : V ENDTIME 10-98 /E RT DOCTOR i`� PM STAf t -�.+ - TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ RANSFER WAIT TIME _. i ❑ PATIENT ❑ DIRECT OTHER ��'> CALL BACK N: AMBULANCE,COMPANY: PT AMBULATORY? PATIENT TAKENTO AMBULANCE: �� RESPONSE ZONE ~� ❑ YES *No ❑ WALKED YUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVEREMT-tA TECHNICIAN O ARAMED , Hx: _ �L7_._'_ �['1_ DISPATCHER: CHIEF COMPLAINT: �S1ry- � DRY RUN: O YES AGO REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL C VERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. $1_ 0 Q PRIVATE INS. CO.: BASE RATE: _ KAISER a: MULTIPLE PTS.BASE RATE BLUE CROSS It: TOTAL MILES: �'' X �J MEDICARE u: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO , NIGHT: (19:00-07:00) CCHP;PPHP q: EMERGENCY RUN: DI-CAL CODE 2/3 I OTHER: OXYGEN: (PER TANK) P.O.E STICKER ❑ YES Q'NO NEONATAL: (INCUBATOR) i DATES BILLED: STANDBY: (OVER 15 MIN.) .0 E.K'G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X If 1 J DRUGS: (PER ADMIN.) X NAME:. RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:—_________________ __ ORAL AIRWAY: (IF NOT REPLACED) i CITY: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) EMPLOYER: ,Q QN: - OTHER: ADDRESS-.�.(_n/t 1• .L4 T r CITY: ( STATE — ZIP: - ad / COMMENTS:�.�� 04'- 4 ' / TOTAL: ",,,� ( �'� /_r.ljc•t L PATIENT RECEIVED BY:X C ti — (SI ATUR 0 ( Prouidrr�rCr�i�,l+Ai(� V41Y'4, -AT-4 .•SrturmYr'i,w -opr, EmrLApnbft:ting r CONTRA COSTA COUNTY �'� AMBULANCE I 1 PRE-HOSPITAL CARE FORM 1 �� UNIT AUTHORIZATION N�, 1 1 , ` I ' CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NA MQr `..`�`_ _ � �M ❑ COMPANY p �" ADDRESS "—�cc— `- �� AGE(t2�__. r CITY I AA E-1.t ZIP-1.. . DOB .� �It�sajl0 ❑ S. O M O T W O Th OF 0 & �,,`` DRIVER'S LICENSE M _ PHON -[31�._— NATURE OF DISPATC Vm TYPE OF TRANSPORT: AMBULANCE OTHER❑ ___.__...._..- ....___ ._. INCIDENT LOCATION: RESPONSE CODE: REOPE6fED BY: TIME— (24 HOUR CLOCK) �^A. TO SCENE: I� 4c S.O. — CALL RECEIVED ❑ P-U. — TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 -^A ❑ PSAP TIME 10-49 - �, MILEAGE: ❑ OTHER/PVT TIME 10-7 G� END TIME 10-98 DOCTOF� Z� P /ER START If C) TIME 10-22 I ' HOFATIENT EN: TOTAL STANDBY TIME EST O FAMILY O TRANSFER WAIT TIME❑ DIRECT 11 OTHER \ (� CALL BACK N: A CE COMPANY: PT /AMBULATORY? PATIENT TAKEN AMBULANCE: ��r(�� RESPONSE ZONE�'!S-- RYES ❑ NO O WALKED OGUERNEY ❑ OTHER —_ 1 PATIENT CONDITION: DRIVE EMT 1A ` TECHNICIAN P7I�--�trll L PARAMEDIC HK: —Sd1.zt� DISPATCHER: �1�►� 1' CHIEF COMPLAINT: DRY RUN: ❑ YES O REASON FOR DRY RUN_ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL�1Q,VER;� INDUSTRIAL 13 YES NO NO. OF PATIENTS: I 1 S S.S.>t l � I PRIVATE INS. CO.; BASE RATE: KAISER p: MULTIPLE PTS. BASE RATE TOTAL MILES: X emu' / DICA �- �" 1 `�� 7' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 111_00 CCHP/PPRP p: EMERGENCY RUN: MEDI-CAL M: CODE 23 OTHER: OXYGEN: (PEk TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) T NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X '�� — " • i DRUGS: (PER ADMIN.) r X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) i ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) [ CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: (1f ! / CITY: STATE: - ZIP: Iy' L COMMENTS: Q i TOTAI —/ 7S. OG 09.5 PATIENT RECEIVED BY:X 0 6 Provider retain, Aite xd Mr., rup� hetur" Ye'in+.' • py n/.' when 6i1.iry (SIGNATURE) EMS-1 '1 ( CONIIIA ( ()•:IA ('.011!17Y AMBULANCE PIIS-IIO SPI TAA CAIIIE FORM I 1�1 UNIT �) AUTHORIZATION N CrrfCr(OR flll IN•rrnorAu ff SPA DATE: F'ATIFNT'S NAME. ��r:�L��'s`� fJ. -A�•L . _. ---_ �M F -� ❑ F COMPANY k �: 3 , ADD RES s (��►t,Uc /ST A VIE _ _. -- - ----- -- AGE ) j CITY_-0r� �n.._.-_._._ STATE.-K, ZIP (7L.__ DOB 7-'l3�`s ❑ Sn O M O T ❑W O ThO F O S DRIVER'S LICENSE a PHONE OGS ) _ __ NATURE OF DISPATCH TYPE OF TRANSPOR T: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ,7 CALL RECEIVED d 3 C/✓%C ytTrTrrJ .�/26' ! ! - � O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- D FIRE TIME 10-97 11- 0 PSAP TIME 10-49 • ' N44 . j l� ` �� MILEAGE: ❑ OTHER/PVT TIME 10-7 �-�'- •�3 y'! ' END 3 4 • TIME 10-98 DOCTOR /e��L'-' PMD/ER START a a` ' TIME 10-22 - HOW CHOSEN: TOTAL - STANDBY TIME ❑ NEAREST (Q FAMILY Cf TRANSFER WAIT TIME _.. ❑ PATIENT IRECT ❑ OTHER 3 CALL BACK N: AMBULANCE COMPANY: - - i 1 f PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5/0 RESPONSE ZONE _ YES ❑ NOLY yVAL':ED 13GUERNEY ❑ OTHER _ + PATIENT CONDITION: DRIVER �/ �j / EMT- TECHNICIAN )10 RAMEDIC -_ Hx: DISPATCHER: NU"ILl S Qo(p r c� CHIEF COMPLAINT. `'{/C'�6�g1 DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ` AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X �)•� MEDICAL COVERAGE INDUSTRIAL ❑ YESeNO NO. OF PATIENTS: S.S. a — --- - +� PRIVATE INS. CO.:. BASE RATE: KAISER n: -- _._ MULTIPLE PTS.BASE RATE BLUE CROSS k:_ _ TOTAL MILES: �= X 1- �J --• MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) T— - CCHP/PPHP a: _____-_ EMERGENCY RUN: 03 MEDT-_CAL a: COD 2k ' OTH L,( v OXYGEN: PER TANK) -� P.O.E. STICKER ❑ YES ❑ NO NEONATAL' (INCUBATOR) J f DATES BILLED:-_ __.-__.___.. __ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) r NEAREST RELATIVE/RF.SPONSIRLE PARTY: I.V.: (PER ADMIN.) X ✓1 DRUGS: (PER ADMIN.) X ✓ NAME _ ___.-.___�. ._ RELATIONSHIP: -- E.O.A.: (IF NOT REPLACED) ADDRESS:____ ORAL AIRWAY: (IF NOT REPLACED) CITY: _._.__ ___ .__ .. STATE.- -_ZIP:-_-___ C-COLLAR: (IF NOT REPLACED) PHONE: _ WORK PHONE: DRY RUN. (AUTHORIZED) EMPLOYER: -_ OCCUPATION: OTHER: - ADDRESS: THER:ADDRESS: _ CITY: STATE: - ZIP: COMMENTS: 96 TOTAL. •�J PATIENT RECEIVE Prnuidrr rrtci� vhi!r vrd Pi-4. cop? Re[urr Yr;lpp. , , Ew- ( NATURE) .00 f r. r� .rhe., t1 trw ✓� CONTRA COSTA COUNTY AMBULANCE I v" PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M Ell- U 35 6 � ISN Fe CHECK OR FILL IN APPROPRIATE SPACES` DATE: 3 PATIENTS NAME C0.i^c-I ^-I 3:' l f O $M ❑ F COMPANY#-. ADDRESS NC-5 1 C--tAGE t �t CITY Nom,rG u L u STATE c14ZIP __-. DOB 5_�J!SJX�' ❑ Sn ❑ M ❑ T ,kW O Th O F ❑ S DRIVER'S LICENSE M PHONE NATURE OF DISPATCH ,L-1 TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ .___ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) l TO SCENE- S O.—_____ CALL RECEIVED - -�� O P.U. TIME 10-9 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 141 2_ O PSAP TIME 10-49 MILEAGE: ❑ OTHERIPVT TIME 10-7 END TIME 10-98 DOCTOR �� +/ PMC14® START-__ZJ•� TIME 10-22 HOW CHOSEN: TOTAL !- STANDBY TIME A@ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER �- CALL BACK#: AMBULANCE COMPANY: G!4 s PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE ZONE �l1U 21'YES ❑ NO ❑ WAL'(ED'$ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER T-C,11 — 50�) _ EMT-lA TECHNICIAN PARAMEDIC 11 Hz: DISPATCHER: 5r)kA:-L- t. CHIEF COMPLAINT: u-'s/re4�-R km c-t-_ DRY RUN: ❑ YES O NO REASON FOR DRY RUN r C� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES RI NO NO. OF PATIENTS: S.S. # _ 1 PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE ,I BLUE CROSS#: TOTAL MILES: X ) w MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07.00) _ CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL.R: CODE 2/l3 THER: vG►1 - OXYGEN: (PER TANK) P. E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEA EST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: _ E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ` WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYE14- OCCUPATION:\ OTHER: ADDRESS: C / CITY: STATE: ZIP: COMMENTS: , f- w PATIENT RECEIVED BY X LI., (SIG ATONE) Ltn� _ f'n,Uid✓r rOtutr Mhih- �.n.l I'ir,: rrl�l. 5.•I,.r». )��" ..�: �p C 00 7� ,,... I,; :, rrs CONTRA COSTA COUNTY l AMBULANCE ;t PRE-HOSPITAL CARE FORM I ` UNIT ® AUTHORIZATION M_ CHECK OR FICC IN APPROPRIATE SPACES DATE: _7._ 101— j 2 PATIENT'S NAME- }- Jc�tr_,_. 4�� lY M 11F COMPANY ADDRESS "2J1r?!.5� AGE �� 119)44 STATE--CA ZIP_ DOB. I� y9❑ Sn O M O T eW O Th O F-0 S DRIVER'S LICENSE k .__ ._ ._. _....... ...___.. PHONE 1JI�LY�O�S NATURE OF DISPATCH VtMCA Of:RIGA Ur TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REPUESTED BY: TIME- (24 HOUR CLOCK) 1 Q( C TO SCEN rg S.O.— CALL RECEIVED /G' ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 Zy 00 C � MILEAG 13OTHERIPVT TIME 10-7 L,_ ;�/Sy'- ' ENDTIME 10.98 DOCTOR . PMD/ER START-65-10- TIME 10.22 HOWWeHOSEN: TOTAL 3� STANDBY TIME C�-NEAREST ❑ FAMILY . ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE�C,(O�PANY: PT AMBUL TORY? PATIENT TAKE TO AMBULANCE: IO' RESPONSE(ZONE ' ❑ YES XNO ❑ WAL':ED)GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER_(__.lC4 QQU0CAL9 LAO EMT-1A TECHNICIAN �_\aJN 2.3 21 RAMEDI HxC�S�� i'�V_L� DISPATCHER: �_A L- (� CHIEF COMPLAINT: __CCY-_ t V,�IQ� �. �_ DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (��I PATIENT REFUSED SERVICES:(SIGNATURE) X.___--- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: 50' KAISER W MULTIPLE PTS. BASE RATE BLUE CROSS#:r - TOTAL MILES: X� MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP p:O7 3O O� OCs? (p Q� EMERGENCY RUN: EDI-CAL q: NU L - NQT' AVAIL CODE 2/,.3 ` O OXYGEN: (PER-TANK) (Z � j P.O.E. STICKER ❑ YES ANO NEONATAL: (INCUBATOR) JI DATES BILLED: STANDBY: (OVER 15 MIN.) v E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: __ _ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: -.__ ORAL AIRWAY: (IF NOT REPLACED) CITY: �_ STATE- ZIP: C-COLLAR: (IF NOT REPLACED) /.5•Ue PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _-_ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: r �� 5' (• /9^O COMMENTS: (] TOTAL: I! (2 o J S O 0 _ PATIENT RECEIVED BY:X � -----^ (SIGMA E) Prruider rrra-r Whi1r y.j ,in:, r.,p} Srrurn YP:Irr• -n,:, _rw v+v, til inp 015-I CONTRA COSTA COUNTY AMBULANCE y3-jl 3 7v PRE-HOSPITAL CARE FORM 1 UNIT [;M AUTHORIZATION K CHECK OR nLL IN APPROPMATE SPACES DATE: �' 3 "PATIENT'S NAME n 1 ''-�y�� OM ❑ F COMPANY N ADDRESS % llyi'4LI / _ I L AA)l# ^ ZIP TCITY O W O ThO F O S DRIVER'S LICENSE M�( I I PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT:1 AMBULANCE THER❑ _... INCIDENT.LOCATION: CODE: R OUESTED BY: TIME— (24 HOUR CLLOCK) CR ' TO SCENE-3 S.O. CALL RECEIVED 74 y ❑ P.D. TIME 10-8 �f L• �7-� c ; PATIENT DESTINATION: FROM SCENE- 13 FIRE TIME 10-97 Q�/ �� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 ' : rUd6f0R•( 1-7112 1 PMD/ER START TIME 10-22 .LZ C C, HOW CHOSEN: TOTAL — STANDBY TIME ' r* O NEARESTn, (FAMILY ❑ TRANSFER I WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE C PANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: '510 RESPONSE ZONE ❑ YES L13 NO..�; O WALKED ❑ GUERNEY O OTHER' PATIENT CONDITION: '" DRIVER- , ?b:g J I u',: r. a ,.�:; �, - l TECHNICIAN_-Z-421f—T 10 PARAMEDIC Hx: r " DISPATCHER: 50 CHIEF COMPLAINT: �2& DRY RUNA ES 0 NO REASON FOR DRY RUNvOQE QiOAf`'d� 00 ; AUTHORIZATION FOR DRY RUN(EMS USE ONLY) "Ad U•:PATIENT REFUSED SERVICES:(SIGNATURE)X r � tt.gq MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: 1 ��jj S.S.« ` t - ._ ! � �� -,�•I 9" PRIVATE INS.CO.: BASE RATE: KAISER K: I MULTIPLE PTS. BASE RATE I BLUE CROSS N: / TOTAL MILES: X MEDICARE M: _ E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP qt^ ~r EMERGENCY RUN: j MEDI-CAL M: CODE 2/3 i /1 OTHER: ;_I OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES 811-LED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X +� __ ..... ......-___ DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PH(jNE' DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:_ OTHER: ADDRESS: CITY: STATE-, ZIP: COMMENTS: 9 . TOTAL:, PATIENT RECEIVED BY, X. _... ... - .._.____�... Provider Feta{r. Acte ,.nd Nn4 v ketum Yr' (SIGNATUiiE) ,. PY 1••c .•,.1'Y ' ' fir" when bi! i'i�r U15-1 ' WCONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN PPR OPRIATE SPACE DATE: V i y PATIENTS NAME De ($ M '❑ FF COMPANY# , 7 q ADDRE SS .?�6 L!L/ //S� � T p AGES Z t CITY I` G A 22 n,.-n STATE�Lp- ZIP 1uDOBlf__s:�_ -/ ❑ Sn O M AT ❑ W ❑ Th 13F ❑ S DRIVER'S LICENSE# PHONE iL�ZZD3 NATURE OF DISPATCH � ' TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: i,.:' RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) TO SCENE- lg'S.O. CALL RECEIVED J ❑ P.U. TIME 10-8 ' f' i$ } PATIENT DESTINATION: . •! FROM SCENE- ❑ FIRE TIME 10.97 �j ❑ PSAP TIME 10-49 a�3...-..•I�S /�� MILEAGE:.-� 13OTHER/PVT TIME 10.7 I I END 375-_ i TIME 10-98 ;DOCTOR PMD/ER START-3-;?.S TIME 10-22 HOW CHOSEN: TOTAL -, STANDBY TIME -. ❑ NEAREST ❑ FAMILY ❑ TRANSFER z. WAIT TIME ❑ PATIENT ❑ DIRECT ®OTHER �a J CALL BACK a: AMBULANCE C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE JVYES ❑ NO ❑ WALKED WGUERNEY ❑ OTHER . y PATIENT CONDITION: DRIVER Zt-r TECHNICIAN J -PARAMEDIC Hz: 281mm DISPATCHER: Cir, b-2., ✓5 2 CHIEF COMPLAINT: pQISrur-eS = D•' -�P�i c DRY RUN: ❑ YES �NO REASON FOR DRY RUN J _o 1j 6.0 ��L+ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ?rNO NO. OF PATIENTS: d� S.S. a 'fcr / /a PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS.BASE RATE i BLUE CROSS#: TOTAL MILES: - X to ilJ �j• ' MEDICARE#: E.O.B. ATT. ROUND TRIP: OYES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �o.u' CCHP/PPHP q: EMERGENCY RUN: s.�_.1 d, MEDI-CAL#: CODE 2/-3 bOTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "-'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -"' NAME:�oS t/ � � C OC ��ELATIONSHIP; E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) - CITY: STATE-_ZIP: C-COLLAR: (1F NOT REPLACED) PHONE: 9 3 7 ?L ORK,PHONE: DRY RUN: (AUTHORIZED) `- EMPLOYER: PATION: OTHER: ADDRESS: An A 0 n CITY. STATE: ZIP:— �J Lu4-�:'dd� serer-, � yzy c�Le-)14A aNz' sr TOTAL: J oE. y1/ _•! w PATIENT RECEIVED BY: X.__.~ _ iSl16Nnll:FE) 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT fQ� AUTHORIZATION N I CHECK OR FILL INAPPROPRIATE SPACES DATE: / 10 _" PATIENT'S NAME ,Y �!!(_,(�-(/ �_L 1 �l 1y�� ❑ MFF COMPANY N / ADDRESS __s_ .71./_�. __,r7%_.G �[DIrG Al � AGE dS/. CITY Z STATE le_ - ZIP_ (ff_3 DOOBB_ ❑ Sn O M OTA W O Th ❑ FI O-S DRIVER'S LICENSE a __ .__...__� PHONE2-- NATURE OF DISPATCH' erSCn pp�,M� - TYPE OF TRANSPORT: AMBULANCE Qr3THERO INCIDENT LOCATION: RESPONSE CODE: EOUESTED BY: TIME- (24 HOUR CLOCK) ! I RC / �/ TO SCENE S.O. CALL RECEIVED _S_7v 1 a47d r(t G� I'-� O P U. TIME 10-8 :�L PATIENT DESTINATION:' v+/' Z� FROM SCENE ❑ FIRE TIME 10-97PSA �� ( -_ d ��/�5� ❑ TIME 10-49 ' MILEAGE: O OTH OTHER/PVT TIME 10-7 � '• f END TIME 10-98 DOCTOR _ _._ - - PMD/ER START--��LTIME 10.22 HOW CHOSEN: TOTAL - STANDBY TIME ` ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULA E OMPANY: I PT�MBULATORY? PATIENT TAKEN TO AMBULANCE: ��O RESPONSE ZONE YES ❑ NO O WAL'tED ❑ GUERNEY ❑ OTHER _. PATIENT CONDITION: DRIVER 600 6OO EMT-1A j TECHNICIAN J - 6 •• LIP- . ,tSO�^ IDJOpARAMEDIC . _ Hx: .!_ Of'1 e - -- DISPATC S I tDo CHIEF COMPLAINT: I ZZ �Gr S`1rk"" )EDRY RU YES ❑ NO REASON FOR DRY RUN AUTHORI FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE I s ' MEDICAL COVERAGE: INDUSTRIAL S.S. N vu, (✓ PRIVATE INS.CO.:- BASE RATE: KAISER x: MULTIPLE PTS. BASE RATE - �' BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO I ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPHP N: EMERGENCY RUN: III MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) ( P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'I NEAREST RELATIVE/RESPONSIBLE PARTY: LV.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X 'i NAME LL%Ao1l)-5LCZZ-tA)/ -RELATIONSHIP- _ E.O.A.: (IF NOT REPLACED) I ADDRESS:-_ j-7 Z�.. `tl.!t�►+�_.L� ORAL AIRWAY: (IF NOT REPLACED) CITY" ___: M rr77� - STATE --ZIP:----- C-COLLAR: (IF NOT REPLACED) PHONE: _ L�70-7_vORK PHONE...__ ___ DRY RUN: (AUTHORIZED) EMPLOYER:'-------.---. OCCUPATtQN: -._ OTHER: !!! ADDRESS:- CITY: STATE: ZIP: I 1 COMMENTS: _ -- -- i'I l I v OO - - --.- - PATIENT RECEIVED BY X 1 (SIGNATURE) Pr r: r rrrc VI r _ . . rrfP r• 7r:ze�w •n;p 'M.' when tiVi y D1l-1 CONTRA COSTA COUNTY , AMBULANCE PRE-HOSPITAL CARE FORM 1 1 UNIT AUTHORIZATION / CHECK OR FILL IN APPROPRIATE SPACES DATE: 19'3 , Ift M / PATIENT'S NAME �%LLY?!�_ (lL�S1L�L� O MT F COMPANY J� � j.. ..._ ADDRESC �rZ��:L�f•`L' �1�I— � AGE ; / CITY,//))fiN �'�LJ7�.1�._..__ STATE.t/ ZIP1313`� DOB'5 _ ❑ Sn M ❑ T*w D Th F. 0 S I � DRIVER'S LICENSE M _..... _._.._.. -____lHONE NATURE OF DISPATCHJ� O� TYPE OF TRANSPORT: AMBULANCE ' OTHER❑ _ _ _ ( v' ; R CC cc INCIDENT LOCATION: _ RESPONSE CODE: RE VESTED BY: TIME- (24 HOUR CLOCK) I _ hh �• � �' � � TO SCENE- S.O.— CALL RECEIVED � • ='�7 ❑ P.U. TIME 10-8 PA f NT DC ESTINATION: ' FROM SCENE ❑ FIRE TIME 10-97 �� ,�•• ❑ PSAP TIME 10-49 Jti MILEAGE: 912 - IAR D OTHER/PVT TIME 10.7EDTIME 10.98 �DOCTOR `� _ PMD ER STT_ � TIME 10-22 HOW CHOSEN: TOTAL _ .rL STANDBY TIME } NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME I ❑ PATIENT O DIRECT ❑ OTHER n CALL BACK M: AMBULANCE COMP -` PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: `��- RESPONSE ZONE ❑ YES 4 NO ❑ WAL"EDeGUERNEY OTHER, C �� PATIENT CONDITION. DRIVER -�� . 150 EMT-1A 0 TECHNICIAN - ,,G 7' fZlifZ ?--Q PARAMEDIC I I Hx ._._ T�1t! 11jf�_!u ✓Lt� U DISPATCHER: ULKI fSF .� CHIE�'COMPLAINT: � 11 J i l21 DRY RUN: ❑ YES IrNO REASON FOR DRY RUN �11z — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I • PATIENT REFUSED SERVICES: (SIGNATURE) X_- (�5 EDICAL COVER :. -1 I DUS RIAL YES NO NO.OF PATIENTS: C S. (._v �O� ) RIVATE INS. CO.:— BASE RATE: - KAISER n: MULTIPLE PTS. BASE RATE BLUE CROSS M TOTAL MILES: X MEDICARE it: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ,30,La O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP q: — EMERGENCY RUN: I MEDI-CAL#: CODE 2�311 OTHER: -- OXYGEN: (PER TANK) 5 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) C t, DATES BILLED: STANDBY: (OVER 15 MIN.) ^ / E.K.G.: (PER EPISODE) NEAREPT RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X LItithd DRUGS: (PER ADMIN.) X NAME:,i:1 _IPAL-�'rL�_ RELATIONSHIP -E.O.A.: (IF NOT REPLACED) ADDRESS: -..___ ORAL AIRWAY: (IF NOT REPLACED) s� CITY: __ j" __ STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE:2 '-� /y r �— WORK PHONE DAY RUN: (AUTHORIZED) EMPLOYER:.=' _ OCCUPATION: -__ OTHER: ADDRESS: _- _./ ./ /. i_t�''�'� i S•L2'�/. CITY: STATE: ZIP:— � �21�-' . 7, 40 y5 lU•ey 17 COMMENTS --+d TOTAL C7�' SO LLL ••, , G �'ya.Lt/�',C't! Li ✓��YJr!`� ___ PATIENT RECEIVED BY:X OSIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT FM AUTHORIZATIOINN�3 ( _j CH ,ECK OR FIL4 IN APPROPRIATE SPACES DATE: ( _ - 3 PATIENTS NAMES S! e _ O M C F COMPANY# - ADDRESS ' �� R n L AGE 15 1111:1.q CITY��h ( �' STATE -YA(- ZIP_q_(_-4_rr!!d_Q DOB.!Z�o$ ❑ Sn O'M ❑ T O W �Th OF O S' DRIVER'S LICENSE M - _ __ PHONEl1Zq.^ S�ATURE OF DISPATCH Sr 3 I TYPE OF TRANSPORT: AMBULANCE OTHER❑ 1 INCIDENT LOCATION: 1 RESPONSE CODE NQUESTED BY: TIME - (24 HOUR CLOCK) Ll ' TO SCENE- 3 S.0. - CALL RECEIVED ✓ �' _ O P.U. TIME 10-8 PATIEZESTINATilOT FROM SCENE- ❑ FIRE TIME10-97 1013PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 c END SuS'S TIME 10-98 r DOCTOR _ � y S PMD/ R START TIME TIME 10-22 HOW CHOSEN: TOTAL �� STANDBY TIME. ❑ NEAREST J%AMILY O TRANSFER WAIT TIME ❑ PATIENT .❑ DIRECT ❑ OTHER 1'` .✓l) CALL BACK p: AMBULANCE COMPANY- Pg. Cr P AMBULATORY? PATIENT TAKEN TO AMBULANCE: s;r RESPONSE ZONE DYES ❑ NO ❑ WAL':ED XGUERNEY ❑ OTHER J — PATIENT CONDITION. DRIVER �^G`"�G t�CL�--. u 4} EMT-1A ' TECHNICIAN IV1 C 1 (Or "1 i PARAMEDIC v Hx: 46T ` DISPATCHER: Li CHIEF COMPLAINT: DRY RUN: ❑ YES XNO REASON FOR DRY RUN C� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ] PATIENT REFUSED SERVICES:(SIGNATURE) X 1 MEDICAL COV/ERAGE: _ NDUSTRIAL ❑ YES 11NO NO. OF PATIENTS: PRIVATE INS.CO.SCH to,- _S¢Cvrr tLlj f; - = BASE RATE: I KAISER R: F MULTIPLE PTS. BASE RATE BLUFF CROSS#:c- Z _ c-� TOTAL MILES: X DICAA a 7 J �NIE.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ( I ❑ YES ❑ NO NIGHT: (19:00-07:00) I I \CCHP/PPRP#: EMERGENCY RUN: EDI-C K: CODE 2/3 OTHER: OXYGEN: (PER TANK) ! P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) - E.K.G.: (PER EPISODE) NEAREST,RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:C.-_US el O S G RELATIONSHIP V br E.O.A.: (IF NOT REPLACED) ADDRESS: S a'P ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE- ZIP: C-COLLAR:, (IF NOT REPLACED) PHONE: WORK PHONE: - DRY RUN. (AUTHORIZED) EMPLOYER' 4;t I, O OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ��lrtin V HAS J%j O CAS/f _ TOTAL:. : `�-- PATIENT RECEIVED BY. X�� ` c L Ir �� t (SIGNAlUHl) ' . .f'tVUi�OY tYtJIR 1.911 Ir' .J7,1 1'lr;:. ••.•(•p rlpr+. i. b' r :V. i.•),,•. f:! it EM'• 1 CONTRA COSTA COUNTY `� AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT n I AUTHORIZATION LI � CHECK OR FILL IN APPROPRIATE SPACES DATE: - PATIENT'S NAME-A r1.1.1�_�== �.-.---_-. -�/�Y� A'M ❑ F COMPANY M / "��% �' �• ADDRESS - � ` r /' t�CL /r AGES. �`� L.• «-- CITY><l STATE�_�I.�.�!i_ ZIP DOB-yL11—i TO Sn ❑ M ❑ T 13W Th' 13F ❑SI^'�- DRIVER'S LICENSE W __ _:. :�'...%.�.� PHONE ►` / 0 NATURE OF DISPATCH19 TYPE OF TRANSPORT: AMBULANCE/U�l OTHER❑ INCIDENT LOCATI(QN: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR-CLOCK)`/� TO SCENE• S.O. CALL RECEIVED Ito ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE• ❑ FIRE TIME 10-97 • LL. :f�� 1 ( ❑ PSAP TIME 10-49 5lt11 _ `� i.L1 �i\, 1-{ MILEAGE: I', ❑ OTHER/PVT TIME 10-7 ' �' r•F END TIME 10-98 DOCTOR r M /ER START_SL� TIME 10-22 HOW CHOSEN: C TOTAL ____L_7- STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME LN PATIENT ❑ DIRECT ❑ OTHERC!i CALL BACK N: AMBULANCE COMPANY: .._. [CAULATORY? PATIENT TAKE TO AMBULANCE: 0RFSPANSF 70NF b NO ❑ WAL;CED UERNEY ❑ OTHER .:.. .. , PATIENT CONDITION: DRIVE Zo5EMT-1A_ 45k/,J TECHNICIAN I7 cu ��e r O PARAMEDIC f Hx: _ � � �7 `1 ' DISPATCHER: MOrr&id5 Lo� •��' CHIEF COMPLAINT: .__ f 4i"'' "� DRY RUN: ■ YES XNO REASON FOR DRY RUN , AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X l I ME-f Cl AL COVERAGE- INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. CO.:— BASE RATE: - ~ KAISER n: _ MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: X �3 MEDICARE 4: E.O.B. ATT. ROUND TRIP: ❑ YES (XNO ' ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: �J 1 MEDI-CAL u: CODE 3 , OTHER:__ OXYGEN: (PER TANK) r (( >! P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) / 1 DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �t DRUGS: (PER ADMIN.) X NAME:. (�-! �r: I��'_ R L IONSHIP:1 1-� EE.O.A.: (IF NOT REPLACED) 1. - � �{ ADDRESS_:! �_ C ----- ORAL AIRWAY: (IF NOT REPLACED) CITY: ��}'ti✓1 ' ' STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE- WORK PHONE: V `�'Z� DRY RUN: (AUTHORIZED) EMPLOYER: r7 �7J,(AS OCCUPATION: �� r£i� OTHER: ., ADDRESS: i �r CITY: // STATE: ZIP: _ C M ENTS: �� O TOTAL: PATIENT RECEIVED B _ Fmvidtr rr[ai� ►�i'r 7 Ii..- r.?T} Frr�rc ��• -,;•. FV.- when �:� (SIGNATURE) 01b-1 CONTRA COSTA COUNTY Ir ` AMBULANCE �� Lt l PRE-HOSM AL CARE FORM I/ , UNIT AUTHORIZATION# CHECK OR F!C[!H APPROPWATE SPACES DATE:/ zff c 1 -7 PATIENT'S NAME VR`'�? '_---::__ � C� _�\ �'M ❑ F COMPANY N ADDRESS =5� -� /AGEnZZ- `•./ C CITY.£C Ctpu I- jy__— STATE__CA__ ZIP 9�_� 3 UL D013 O Sn O M O T El W C111 O F O$ Yi.CSSw6C YJ DRIVER'S LICENSE# ___.._.__....._._. .__ PHONE NATURE OF DISPATCH M C_ TYPE OF TRANSPORT: AMBULANCE ,-0 THER❑ INCIDENT LOCATION: / RESPONSE CODE: R OUESTED BY: TIME- (24 HOUR CLOICK) - r �`�'`� —�� •�� [ L� �,� TO SCENE- � �S.O. CALL RECEIVED — 'J .:2-0- -� t C ❑ P.D. TIME 10 8 PATIENT DESTINATION: FROM SCENE- L_ O FIRE TIME 10-97 / �] ❑ PSAP TIME 10-49 % — _._ _ MILEAGE: //�� TIME 10-7 a12 V l I END o,U T TIME 10-98 DOCTOR 3 _ PMD/E� START--,-!,6-1_ TIME 10-22 HOW CHOSEN: TOTAL - STANDBY TIME O NEAREST O FAMILY O TRANSFER _. WAIT TIME PATIENT ❑ DIRECT ❑ OTHER I_I CALL BACK#: AMBULANCE COMPANY: c - r-.4-T. 1 PT AMBULATORY? I PATIENT TAKEN TO AMBULANCE- PVT RESPONSE ZONE YES ONO ❑ WAL-ED UERNEY O OTHER _ T PATIENT CONDITION: DRIVER. M6 �X EMT-1A c� n TECHNICIAN PARAMEDIC Hx: _.D_��V�� DISPATCHER: 1 C )to o CHIEF COMPLAINT: ___��- •_. DRY RUN: OYES O REASON FOR DRY RUN AUTHORIZATION*OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X. MEDICAL COVERAGE; INDUSTRIAL ❑ YESNO NO. OF PATIENTS: f S.S. # - -- PRIVATE INS. CO.:� _!li ►�► BASE RATE: 1°� ' KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS$V TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ONO 1 O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: —_ CODE 2/3 OTHER OXYGEN: .(PER TANK) d 7 P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) V DATES BILLED: STANDBY: (OVER 15 MIN.) d/ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X AD•��')-'jj'11 r DRUGS: (PER ADMIN.) X NAME:/�VujG^Quit �� ELATIONSHIP (w✓ E.O.A.: (IF NOT REPLACED) ...�.�++ ADDRESS:f�t�L �"` _ ORAL AIRWAY: (IF NOT REPLACED) ' CITY ..t CP i 1U STATE_�—ZIP:_ C-COLLAR: (IF NOT REPLACED) -- PHONE_131 Y_ .)jJ_7..) , WORK PHONE _ - DRY RUN: (AUTHORIZED) EMPLOYER: _UAItA lE'L �� OCCUPATJON: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: AJ PATIENT RECEIVED BY:X 5 7j j lT++t+i,i�r tft:, ih.i!c P`'.: (SIGNATURE) 00 a� rrd + •-rp �• urn Y. .•,t,• .•,,+,: t!4.'' vhrn !�i 2�i•w b15-1 F { CONTRA COSTA COUNTY AMBULANCE 1 ►' PRE-HOSPITAL CARE FORM 1 , UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE' 7_ • ■_V� PATIENTS NAME C40DA4, 'AA — O M ,�FF COMPANY N_ f ADDRESS 7Sl 2 Y�.FsIR'AC��—� { U� �_ I r i •I --._-- -_-�- AGE_ CITY E- STATE ZIP__ DOB J1 jO Sn O M O T,yO/W Th O F O S DRIVER'S LICENSE# _ _-__ PHONE_PLY- y _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. __ CALL RECEIVED r �"�• +- _ V P.U. TIME 10-8 �t PATIENT DESTINATION: FROM SCENE- O FIRE _ TIME 10-97 2 'O.PSAP TIME 10-49 "51 MILEAGE: O OTHER/PVT TIME 10-7 END +15 TIME 10-98 DOCTOR��"DW 114 PMD/CR START__3_q_ TIME 10-22 HOW CHOSEN: TOTAL — 5• STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER ��, CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: CJ`7) RESPONSE ZONE ❑ YES NO O WALKED VUERNEY ❑ OTHER PATIENT CONDITION: DRIVER -3-p&" � (l EMT-1A 1 TECHNICIAN 4A' ?A5 L&_V ?JS PARAMEDIC — Hx: �gp �IRtl S _ DISPATCHER: UIK.IL:�__ 14 jI CHIEF COMPLAINT: �� S��(1x�C DRY RUN: ❑ YES 7NO REASON FOR DRY RUN .1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i j PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: s . KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: / X 1 ME ICAR 1 A E.O.B. ATT. ROUND TRIP: OYES ONO \Ij O YES ❑ NO NIGHT: (19:00-07.00) sCCHP/PPHP#: EMERGENCY RUN:M I-CA N: D ' 0`1 CODE 2/3 OXYGEN: (PER TANK)P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR)DATES BILLED: STANDBY: (OVER15 MIN.) UE.K.G.: (PER EPISODE) ' NEAREST RELATIVE/RESPONSIBLE PARTY: IN.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X AME: ✓ ` A_l-'--bp-, RELATIONSHIP:— E.O.A.: (IF NOT REPLACED) DDRESS: L e ORAL AIRWAY: (IF NOT REPLACED) CITY: Wti' -.4 STATE (2ZIPi�� C-COLLAR: (IF.NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) I EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:— ZIP: -_ COMMENTS: TOTAL' 73- 00 PATIENT RECEIVED BY: X_ Provider retainWhite erd Pin.:: ropy heturn 7c'i::. •.:,: 6�L: when t-.'V:j (SIGNATUqO1 0®5-1 CONTRA COSTA COUNTY AMBULANCE • PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# CHECK OR FILL IH APPROPRIATE SP ES DATE: U • H iPATIENTS NAME, " O M O F COMPANY# />` / / � ADDRESS, ► AGE1_ { CITY 1 STATE ZIP DOB O Sn O M O T ❑W ❑Th it. O g DRIVER'S LICENSE Nt.r j PHONE -- NATURE OF DISPATCH---poss. TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: 1 c�?'t RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED L!L U P.D. TIME 10-8- 7 K ( , ' FPATIENT DESTINATION: 1 FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 - MILEAGE: ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 �i DOCTOR y l PMD/ER START_' TIME 10-22 1 - HOW CHOSEN: TOTAL STANDBY TIME J1 ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME '❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: 1 PT. AMBULATORY? ' PATIENT TAKEN TO AMBULANCE: % L RESPONSE ZONE ! ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER f A3Z.- PATIENT CONDITION: . DRIVER «= 2 % EMT-1A ♦ '' TECHNICIAN � �T 7� �-1 PARAMEDIC . ! Jr11�tJ.s �.J. . .i_ Hx: DISPATCHER- J _ CHIEF COMPLAINT: DRY RUN: #YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X �j�j n a}•MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ; O YES O NO NIGHT: (19:00-07:00) CCHP/PPHP N: ' EMERGENCY RUN: MEDI-CAL#: CODE 213 OTHER: ' OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X �.NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) it ADDRESS: " ORAL AIRWAY: (IF NOT REPLACED) _CITY: - 'STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:1 DRY RUN: (AUTHORIZED) OU �. EMPLOYER. OCCUPATION: OTHER: 000107 ADDRESS: .._CITY:. STATE_ZIP4 _ _._COMMENTS: TOTAL: `SCS V _ ( � PATIENT RECEIVED BY: X -. �...,.t I .. �....... 0,i r. (SIf;NAT1IPE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M 983 �11570$ IMA U; CHECK OR FILL IN APPROPRIATE SPACES DATE: 'jam p ^l };i PATIENTS NAME_ 1/`` ILA ❑ M O F COMPANY N ?C ADDRESS ( AGE j CITY _ -M)STATE ZIP DOB '❑ Sn ❑ M O T O W O Th 96 F OS i DRIVER'S LICENSE N�, ( PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER 0 — , INCIDENT LOCATION. "'ii ?; RESPONSE CODE: QUESTED BY: TIME—(24 HOUR CLQ K) (' ,� /1 t TO SCENE- S.O. CALL RECEIVED ��: 1';.� �1�11�C-� = l Wv►�UJD `4"��C• Q'[INI ( P.U. TIME 10-8 ` t a,PATIENT:DESTINATION: FROM SCENE--, ❑ FIRE TIME 10-97 ` ( ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 , END TIME 10-98 � DOCTOR I PMD/ER START TIME 10 22 :T HOW CHOSEN: ` " TOTAL-" STANDBY TIME O NEAREST, ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT l ❑ DIRECT ❑ OTHER �� CALL BACK N: AMBULANCE COMPANY: c AS • PT.AMBULATORY? _ PATIENT TAKEN TO AMBULANCE: ✓c' RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:. .... DRIVERS �', EMT-1A i' L \ TECHNICIAN � PARAMEDIC_ ' Hx: DISPATCHER: ' CHIEF COMPLAINT:` DRY RUN: ❑ YES NO REASON FOR RY UN AU RIZA DRY RU MS U 0 LY) PATIENT REFUSED SEbVICES: (SIGNATURE)X — 9Qq. , MEDICAL COVERAGE: INDUSTRIA O YES ❑ NO NO. OF PATIENTS:— 1i / 9�5 PRIVATE INS. CO.: BASE RATE: /r\T II KAISER R: I MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: ' X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP NST__, EMERGENCY RUN: MEDI-CAL N: ' CODE 2/3 I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t _ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (.PER ADMIN.) X DRUGS: (PER ADMIN.) X .,..,,_NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ..CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) j PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) aL"� :,EMPLOYERS OCCUPATION: OTHER: V O O 1 ®8 r.. ADDRESS: -.. CITY., STATEZIP• COMMENTS: —� -,. TOTAL: s cz 11 o PATIENT RECEIVED BY: X. M-rl(•r -�• ,r. (RMNA tUnE) -�" CONTRA COSTA COUNTY AMBULANCE n i PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N CHECK OR FILL IN APPq OPpIA TE SPACES DATE: 7 6/s— vE � /= PATIENTS NAM JU��. /�!�NY ❑ M c�(F� COMPANY p n -2 7 �- ;' " HADD _ ?,7q n ��t;Qn AGE \J 1101 CITY 4 STATE�L.ZIP �j DOOB'6� 11 '❑ Sn ❑ M ❑ T ❑ /W 13Th ❑ F ❑ S i DRIVER'S LICENSE N I ! i PHONE Zs1Z=��L��_ NATURE OF DISPATCH--L/-72 TYPE OF TRANSPORT: AMBULANC OTHER❑ —y INCIDENT LOCATION, RESPONSE CODE: 1 REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- NifS.O. CALL RECEIVED j ❑ P.D. TIME 10-8 PATIENT DESTINATION:.. .. : FROM SCENE 13 FIRE TIME 10-97 >' �` 13PSAP TIME 10-49 �.1 L /� 0� MILEAGE: 11OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR a�Xcw 1 TZ PMD ER START TIME 10-22 HOW CHOSEN: i TOTAL �•r ) STANDBY TIME �., $NEAREST:_ 13 FAMILY 13 TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �� CALL BACK N: AMBULAbiS ?MPANY. " PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: o RESPONSE ZONE _7 YES ❑ NO. . ❑ WALKED Z�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER O %J EMT-1A TECHNICIAN �/ '' PARAMEDIC Hx:.. DISPATCHER CHIEF COMPLAINT- / ,DRY RUN: (DYES XNO REASON FOR DRY RUN — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i:' PATIENT REFUSED SE VICES: (SIGNATURE) X MEDICAL COVE AGE:I �I STRIAL ❑ YE ANO NO. OF PATIENTS: 5_N PRIVATE INS.Ca:"�` BASE RATE: LZ�J✓' KATSER N: J l -� 91V MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ' ❑ YES ❑ NO NIGHT: (19:00-07:00) /l CCHP/PPHP N: EMERGENCY R MEDI-CAL N: CODE /3 OTHER: I OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'r NEAREST RELATIVE/RESP NSIBLE PARTY: I.V.:"(PER ADMIN.) X DRUGS: (PER ADMIN.) X —NAM ^�'�`) � u RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:<I' IOCT- OCCUPATION: OTHER: ADDRESS: _ CITY: .. STATE: ZIP:— COMMENTS: IP:COMMENTS: /G_ .G �C. Ste. , � / n /2L.,�_�' 7r`c�`i L�_4' cry TOTAL, r, jJ S—2 _ PATIENT RECEIVED BY: X r+•,,,:,,,� r.'t.,ic tq; ", (SIGNAT.IRE) � I CONTRA COSTA COUNTY 1 AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: 7 11,51PS1 PATIENTS NAME ,]re-pollC/ Ll � 2! t e Om O F COMPANY M r � ADDRESS (� f V /Of i dL1 //''�� AGE CITY f>r(,C' 1Y.CJ_L�(� STATE C1_ ZIP qj DOBE / O Sn O M O T ❑ W Cl Th n F O S DRIVER'S LICENSE a _ PHONP�a_-S_Lcl .— NATURE QF DISPATCH IU0H— Brea er _ i TYPE OF TRANSPORT: AMBULANCE OTHER O __ --._. STATION-I(A)_2(8)_3(C)_41D)_5(E)_ INCIDENT LOCATION:' RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) - QNh TO SCENE- 3 A S.O. CALL RECEIVED S ❑ P.D. TIME 10-8 �q PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 r MILEAGE: ❑ OTHER/PVT TIME 10-7 —r END 2••r? TIME 10-98 DOCTOR L aM��t� PMD< RD S START y4 TIME 10-22 ! HOW CHOSEN: �� TOTAL 2- STANDBY TIME `"' ❑ NEAREST FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ANO ❑ WALKED GUERNEY O OTHER PATIENT CONDITION: DRIVER ) OhsoYJ EMT-tA TECHNICIAN PARAMEDIC Hx: DISPATCHER: - ' (•: J CHIEF COMPLAINT: r DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN )G 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: L PRIVATE INS.CO.: BASE RATE: IO,C) KAISER M; MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X �: DCA C - �6 - E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO r IN O YES ❑ NO NIGHT: (19:00-07:00) CC1F PIPPHP M: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �-�- DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �!f EST RELAT PONSIBLE PARTY: I.V.: (PER ADMIN.) X ff-- nn DRUGS: (PER ADMIN.) X ~NAME: SUr'�tit RELATIONSHIP: UH E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) - -CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: If ADDRESS: -CITY: STATE' ZIP:— COMMENTS: IP:COMMENTS: TOTAL: PATIENT RECEIVED BY' X�-r - oNAiiIAE) ` l OProvider retain Vhito � rd Pink ropy hoturn Yr:1.-1.- 'opy t LN:;arhen bit:I-IV LMS-1 0 CONTRA COSTA COUNTY AMBULANCE F3 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATI N M \.` CHECK ON FILL IN APPA OPRIA7E SPACES GATE: PATIENT'S NAME (rl_ Q"! M D F COMPANY M ADD [ S �/_.--- .1 �'-rte!/ AGE_ CITXv ,4 STATE_ .��✓ ZI4��IJ _ DOB _ ❑ Sn ❑ M ❑ T ❑ W ❑Tb �' ❑S DRIVER'S LICENSE p _... ._.__ _ : PHONE _ NATURE OF DISPATCH �. TYPE OF TRANSPORT: AMBULANCE OTHER O _.__-_-_____.--•_�__._ ti:► ',: INCIDENT i_ CATION: RESPONSE COD E�ESTER BY: TIME— (24 HOUR CLOCK) `,7Yllqg�o TO SCENE- �qS.O. CALL RECEIVED .f�- ❑ P.U. TIME 10.8 I PENT DESTINATION: C FROM SCENE ❑ FIRE TIME 10.97 � l ./ ❑ PSAP TIME 10-49 tt i I; f ci MILEAGE: ❑ OTHER/PVT TIME 10.7 / END TIME 10-9 8 =1 DOCTOR __ PM •ER START_ TIME 10.22 HOW CHOSEN: TOTAL _ STANDBY TIME O AREST ❑ FAMILY O—TRANSF R E .� WAIT TIME PATIENT ❑ DIRECT ❑ OTHER C� CALL BACK N: AMBULANCE COMPA - I TAMBULATORY? PATIENT TA EN O AMBULA E: RESPONSE ZONE -ArYES ❑ NO ❑ W/L':ED kiJ GUERNEY LOTH _— PATIENT CONDITION. DRIVER �./ 1 �� EMT-tA "- a TECHNICIAN '<,/ PARAMEDIC /;• Hx: _ DISPATCHER: "0 I CH F h1P IN C. _. __ _— DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) / I PATIENT REFUSED SERVICES: (SIGNATURE)'X____. S TICAL C ERA — INDDU$TR�AL DYES �NO NO. OF PATIENTS: RIVATE INS. CO:. BASE RATE: KAISER a: _— MULTIPLE PTS. BASE RATE UE CR � TOTAL MILES: X / . , �_' SO ILEol CARE a:: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r I kYES ❑ NO NIGHT: (19:00-07:00) CCHP;PPHP k: EMERGENCY RUN: '- 1 MEDI-CAL#- _ CODE 2/"1 ��E(R OXYGEN: (PER�TANK)R ❑ YES ❑ NO NEONATAL: (INCUBATOR) �J 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X l DRUGS: (PER ADMIN.) X NAME �_ "�1._. ,�S ._._`/•RELATI NSHI 1/,C1 E.O.A.: (IF NOT REPLACED) ADDRE S' �_ .__ �!+`Py ORAL AIRWAY: (IF NOT REPLACED) CITY: ti' _ -Y � __. STATE . ��_//'//��.ZIP - C-COLLAR: (IF NOT REPLACED) .S PHONE: _. __.. WORK PHONE._7_Y' — DRY RUN: (AUTHORIZED) EMPLOYER I— l�)_ l-Cr�%"�OCCUPATIOIy _ __P- OTHER: ADDRESS:_/h I— _ CITY:"xl�A. _ ST��_ZIP:_._ COMMENTS:— TOTAL:Izg PATIENT RECEIVED BY:X Pr I,idrr mtT`- :n:i.� � •. n c,. ,. ., ISI TURF) � --- I CONTRA COSTA COUNTY �I ` AMBULANCE 2 ' ;\ PRE-HOSPITAL CARE FORM) \ ` UNIT AUTHORIZATION J CHECK OA FILL IN APPROPRIAT SPACES / DATE: PATIENTS NAME �. ._. �. _ C ❑ til F COMPANY k ADDSS _ AGE CITYHC. STATE _ ZIP 1-.7�6-15-7 DOB"- I ❑ Sn ❑ M ❑ T ❑ W. ❑ Th OF ❑ S DRIVER'S LICENSE M ______... ._______-_-.. PHONE L/ O` AE OF DISPATCH- S TYPE OF TRANSPORT: AMBULANC,kC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: .TIME— (24 HOUR CLOCK) �7 � -- - i TO SCENE-�- S-0. —_. CALL RECEIVED /l ❑ P.U.__ TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �j _ ❑ PSAP TIME 10-49 MILEAGE:. OTHER/PVT TIME 10.7 END�� TIME 10-98 I :�- DOCTOR PMSTARV6 TIME 10.22 HOW CHOSEN: TOTAL —__; _.:__.__ __ STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER --_ WAIT TIME PATIENT ❑ D(RECT ❑ OTHER �_ CALL BACK p: AMBULANCE COMPANY: - PT. A LATORY? PATIENT TAKENTO AMBULANCE: RESPONSE ZONET ES ❑ NO ❑ WAL,ED,1z GUERNEY ❑ OTHER / PATIENT CONDITION. DRIVER LfY-1EMT-1A TECHNICIAN - PARAMEDIC Hx: _— �__ DISPATCHER: 7 CHTF COI.PLDRY RUN: ❑ YES .❑ NO REASON FOR DRY RUN r L C 6LnclT a- AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. n PRIVATE INS. CO.: BASE RATE: /5D• + KAISER rr: MULTIPLE PTS.BASE RATE I i •� ,,3!iEY UE.CRO � TOTAL MILES: X Sh;eL E ARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: EMERGENCY RUN'. MEDI-CAL#: CODE 2(3 OTHER: __ OXYGEN: (PER TANK) SWI P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) i C E.K.G.: (PER EPISODE) ✓�' �� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ll Qp,�,,,, ��,, II l DRUGS: (PER ADMIN.)_ X NAME�SGLLII.S� RELATIONSHIPtY� E.O.A.: (IF NOT REPLACED) ADDRESS: , 12410 0 ORAL AIRWAY: (IF NOT REPLACED) CITY: _ _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _ OCCUPATION:— CCUPATION: OTHER: I/ ADDRESS: CITY: __. STATE:--ZIP:-_-- _ ___-_-- COMMENTS: ------ ----- - - --- - IO1AI /v cz, 000112 0/7 1 PA 111 Il I IIJ I I IVI I I I,Y X (J :j 1 .+I.rl� ln+l l 4. ft 0, (: CONTRA t.051A COUNT AMBULANCE Q -� /��I4 PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION MI/--S IN / CHECK OR FILI IN APPROPR/ATF SPACES DATE: / I Cr L PATIENT'S NAME L/A,.(.C.-E?C-_, M IN F ,\ COMPANY N ' ADDRESS i� -'nl__.- ----.__ AGE I GITY.___Vc__ _ ._ _STATE� 2_1P�Y�.` DOB -1L' 7 1 D Sn D M OT Ow O TADF'DS DRIVER'S LICENSE p PHONE.-,?,J7_-k-5171NATURE OF DISPATCH -'Iu 11ff-drQ TYPE OF TRANSPORT: AMBULANCE IR OTHER❑ -.__..__ ...__..-__.... __.. ... INCIDENT LOCATION: RESPONSE CODE: REOUESTEO BY: TIME- (24 HOUR CLIO/CK) L �f TO SCENE- VS.0. CALL RECEIVED —Q - ❑ P.U. TIME 10-8 :a PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 j PSAP TIME 10-49 .,._ MILEAGE: D OTHER/PVT TIME 10-7 —1 END_ TIME 10-98 DOCTOR _ _ _____..PM9fE4 START i TIME 10-22 HOW CHOSEN: TOTAL — _ STANDBY TIME ' I ❑ NEAREST ❑ FAMILY ❑'TRANSFER WAIT TIME _ . ' ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. / RESPONSE ZON,E.,,. n r ❑ YES ❑ NO ❑ WAL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION DRIVER,__.��ZP. ._�� -�L� TECHNICIAN _r / PARAMEDIC Hx: DISPATCHER: �•.;, -- CHIEF COMPLAINT:—_ �.ic,7t;0 . _ DRY UN;BCYES '❑ NO REASON FOR DRY RUN PT FtLtocQ• I _ A IZA^TI`ON, FOR DRY RUN U/ E'VNLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES §r NO NO. OF PATIENTS: ' < 51VATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE TOTAL MILES: X J MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES D NO - �')( D YES ❑ NO NIGHT: (19:00-07:00) CCHP,PPHP It: EMERGENCY RUN: MEDI-CAL k:-- CODE 2/3 OTHER: OXYGEN: (PER TANK) P O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:— STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME��_ �•. C_iSr— RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:S f . ST- _ __ - ORAL AIRWAY: (IF NOT REPLACED) CITY: I C _._ _ _ STATE&!\,_ZIP:___.__ C-COLLAR: (IF NOT REPLACED) PHONE: 2.3_Z_,F3'.'__7C/WORK PHONE.__ZL& RY RUN: (AUTHORIZED) o V EMPLOYER: OCCUPATION: 64'ef'S OTHER: ADDRESS. CITY: S�-�Er�r,,t_' STATE: ZIP:— COMMENTS: TOTAL' PATIENT RECEIVED BY:X i (SIGNATURE) 00 8' +r.r� r rrt, N t. .r: r:. ,r:n. 'r:" �•^ :.hen tir"i.l� 015-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M 93si� CHECK OR FILL IN APPROPRIATE SPACES DATE: v �- 1� ❑ M 'F COMPANY S I ', , PATIENTS NAME G ��r PIF ADDRESS E� ` AGE A01 qqo r-.... _., CITY ^� 1'� ' STATE �� 21PqDOB fi O Sn OM O T. O W O Th .O F CIS-- DRIVER'S LICENSE M __.__�-_-- — PHONE =3!2L49NATURE OF DISPATCH 6- ►�� ^'J TYPE OF TRANSPORT: AMBULAN OTHER O _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ ._ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME-(24 HOUR CLOCK) r 1 �j TO SCENE- �O. CALL RECEIVED I( O �I . �L� ll. /' ❑ P.D. TIME 10-8 ' —1'7 : PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 2 ❑ PSAP TIME 10-49 _L7: d/ MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR -! �3•t_ PMD/6 START CZ TIME 10-22 HOW CHOSEN: TOTAL _' _ STANDBY TIME . NEAREST ❑ FAMILY ❑ TRANSFER _ WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKENO AMBULANCE: RESPONSE ZON • ❑ YES P<O ❑ WA-..-- L'r GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER ` _EMT-1A r TECHNICIAN PARAMEDIC Hx: DISPATCHER: CHVF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ' ^ -\� I�i� e — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT R SED SERVICES: (SIGNATURE) X_ MEDICAL COVERA E: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE M; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) \ CCHP/PPHP M: EMERGENCY RUIk: MEDT-CALM: CODE 2 -=- t ' OTHER: OXYGEN: (PER TANK) j P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1� .?v.�� ❑ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r DRUGS: (PER ADMIN.) X NAME.f HL2<S b �ui`RELATIONSHI .O.A.:(IF NOT REPLACED) ADDRESS: "26&3X ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:' OCCUPATIpN: OTHER: ADDRESS: CITY: STATE! ZIP.— COMMENTS: IP.COMMENTS: -- TOTAL: 1�)c7 3. QV' AAA - PATIENT RECEIVED BY:X `. 0 C� (SIGNATURE) Q �.: Provider rrta:r, Vhitr ....i P.,K riI`Y wtbrr vf• ..•:'' . . N� ..4r. ►!r•:.� DIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# i) CHECK OR FILL INAPPROPRIATE SPACES DATE: /" - -— f� •i x'PATIENT'S NAME ❑ M OF COMPANY# 'f�- .ADDRESS. i AGE }_ CITY STATE_ ZIP DOB.` ❑ Sn ❑ M ❑ T O W O Th ❑ F ❑ S •. t DRIVER'S LICENSE# PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER — INCIDENT LOCATION: _y 1 '.�:?. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 1 TO SCENE- �,{ I g S.O. CALL RECEIVED 12- •. O P.D. TIME 10.8 PATIENT ESTINATION:. . } FROM SCENE- ❑ FIRE TIME 10-97 —T ❑'PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 $- END TIME 10-98 y� f 'DOCTOR.' ( 3 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL ( STANDBY TIME MI I, ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: , ,I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: >l_► [RESPONSE ZONE ❑`YES ❑.NO ❑ WALKED ❑ GUERNEY ❑ OTHER I ' PATIENT CONDITION: DRIVER r off -JG'�� 'l (-) EMT-1A .IllIaUi t -- TECHNICIAN',t,,tSL PARAMEDIC Hx: DISPATCHER: yuu CHIEF COMPLAINT: . DRY RUN: 12YES ❑ NO REASON FOR DRY RU /tl 1 l / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) .?(} E,.�I.; PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: I INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 7 S.S.# 't PRIVATE INS.CO.: BASE RATE: ' KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO -{ O YES ❑ NO NIGHT: (19:00-07:00) 1 CCHP/PPRP C ' EMERGENCY RUN: MEDT-CAL C CODE 2/3 1 OTHER: a OXYGEN: (PER TANK) .� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �! ---NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:" '" RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) • , PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) cgi —EMPLOYER: OCCUPATIOIJ' OTHER: ADDRESS: - -CITY: STATE: ZIP: • `COMMENTS: • TOTAL:—_ �'��'• r • 0 0•' ` % r PATIENT RECEIVED BY- X .._.._ 000115 /y.•nl,br rvti/r, Vbi I.. ..r,l I•;.. ,...p�, �.v,,,... r. •'.,�, ..i.,, i.. . I:i! .� (SIGNATURE) LJIb-1 CONIFIA COSTA COUNTY 1 AMBULANCE �j7 // V e PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 0 -� CHECK OR FILL IN APPROPRIATE SPACES I DATE: vvPATIENT'S NAME <' =Lflr-�Y� I I_ O M ;KF COMPANY p ADDRESS a�4v iC/7�1:,�%•�.TfiT - elt/ AGE��z CITY _7 � `_/ '^'$TATE`j` _. ZIP L ySG3 .D08. � Cl Sn O M O T O W O Th F O g-- pRIVER'S LICE-NSE p _ PHONE 3-J Cr..-e3 LL- NATURE OF DISPATCH l-K F m e A t TYPE OF TRANSPORT: AMBULANCE OTHER 0 INCIDENT LOCATION: RESPONSE CODE: �RErQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE-2 W�`S.O.— CALL RECEIVED Vi�U� -- _v ❑ P.D. TIME 10-8 PATIENT DESTINATION: • FROM SCENE-. ❑ FIRE TIME 10-97 �y J ❑ PSAP TIME 10-49 I ( �� _ /'/rte /J�1� 1-✓ I' -1 I� MILEAGEL 13OTHER/PVT TIME 10-7 END '/3 � TIME ID-98 DOCTOR _ d �� PMDCF� START�'� TIME 10-22 NOW CHOSEN: TOTAL '7 L' STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME I 'PATIENT ❑ DIRECT 11 OTHER �) . CALL BACK 0: AMBULANCE COMPANx: C t i PT AMBULATORY'? PATIENT TAKEN TO AMBULANCE v RESPONSE ZONE S- YES ❑ NO t6 WAL"ED O GUERNEY O OTHER PATIENT CONDITION: DRIVER; (� FF A� A T_1 > 1 TECHNICIAN ,glX'vim► ) " PARAMEDIC 1 Hx .o_ft. c� BIS k frkuCk ,DISPATCHER: / , •/ 1 CHIEF COMPLAINT: DRY RUN: ❑ YES XO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) c.t PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES 43ZNO NO. OF PATIENTS: l �� S.S. a j PRIVATE INS.CO.: BASE RATE: /41 KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X SO MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) O j, CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL a: COD 2/3 OXYGEN:y, ER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) SII' OATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X � f DRUGS: (PER ADMIN.) X NAME: AAW A) RELATIONSHIP: �u E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 1 STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK.PHONE: DRY RUN. (AUTHORIZED) EMPLOYER: ___ OCCUPATIOtsl: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X O! ,1'I 1T wrd�r mfi:'n Whit, r 4 . . � (SIGNA REI l: J ••P� ;:•.r Yr.l.c nL' r4:•• !iin� DIS-1 1 CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM 1 �`f 111 UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATESPACES DATE: PATIENTS NAME Pa L- '� Cl M >(F COMPANY N 7 — ADDRESSY�/'��/�� 6 n'1f�L[]L(,� AGE l ! CITY wLQ�Q STATE ZIP 77 /D�OB 1+?I '` / D Sn O M O T O W ❑Th O S . . DRIVER'S LICENSE N _ PHONE-SL1Z - liL&ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER O STATION 1(A)_2(8I._3(C)_4(D),5(E)_ INCIDENT LOCATION: RESPONSE CODFajA,rMOUESTED BY: TIME-(24 HOUR CLOCK) E�f� `,^ /1 (�( i In / TO SCENE- - 7� S.O. CALL RECEIVED `• %~ � F I1OL1le T11LLUP 3� O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-/7 13 FIRE TIME 10.97 r -I :o z' i L O PSAP TIME 10.49 s' •' :1_ J v�T'• - 1 MILEAG63 (,-.�j ❑ OTHER/PVT TIME 10-7 END——�1� TIME 10.98 DOCTOR ( �n WET 27 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL,--- - STANDBY TIME NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMP,AIIIY: PT. AMBU TORY? PATIENT TAKEN TO AMBULA CE: ��//,�,, - RESPONSE ZONE�- O YES. NO O WALKED�GUERNEY70THE4<1 PATIENT CONDITION: DRIVER Cy /J -EMT-tA TECHNICIAII:�l D(Ml ,6612ia� PARAMEDIC L� Hx: '� DISPATCHER: / (/)� CHIEF COMPLAINT: '� DRY RUN: ❑ YES O NO REASON FOR DRY RUN r7 J, AUTHORIZATION?OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X \' MEDICAL COVERAGE: INDUSTRIAL O YES RNO NO.OF PATIENTS/ S.S.N PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE if: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES •❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL N: CODE 2/3 e- OTHER: OXYGEN: (PER TANK)' P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEIRESPONSIBLE PARTY: LV.: (PER ADMIN.) X �,y J DRUGS: (PER ADMIN.) X `�J✓ NAME! RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) n CITY; STATE_ ZIP• C-COLLAR: (IF NOT REPLACED) / PHONE: WORK PHONE: DRY RUN: •(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: / el(�- ADDRESS: -' CITY: STATE' ZIP: c t(,1 t�k EQ PATIENT RECEIVED BY:X.-__ O0 11 Prouider retain Whim ,.n,f ,•1.:: ..;.;.. ,ol ,-, 1•. ;r �1• .1 (SIfiNATIJIol l rM. I CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES .� � DATE: PATIENT'S NAME�� R �l,� nn 1� L.S(j[ i( M )b F COMPANY# ADDRESS AGE CITYRN –_ - TZIP `IyoI081v5 '61O Sn O M O T O W j O Th O F O S DRIVER'S LICENSE r _ PHONE Lt� NATURE OF DISPATCH TYPE OF TRANSPORT;. ULANC THER❑ — TA A)�'1(B)_3(G)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: R ESTED.BY: TIME– (24 HOUR CI OCK) .-. -T A � TO SCENE- S.O CALL RECEIVED - ' �OC1 Iy�Ur P.D. -TIME 10-8 (: PATIENT DESTINATION: FROM SCENE, ❑ FIRE TIME 10-97 �C O PSAP TIME 10-49 MILEAGE ❑ OTHER/PVT TIME 10-7 ENO d'� TIME 10-98 DOCTOR � rT�+ PMDSTART �_77 TIME 10.22 HOW TOTAL STANDBY TIME EA 0 FAMILY ❑ TRANSFER _ WAIT TIME PATIENT O DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: ��S Eo . AMB RY? PATIENT TAKE LANCE: RESPONSE ZONE YES O WALKED GUERN O OTHER I .ice. PATIENT CONDITION: DRIVER MT 1A 1 TECHNICIAN '�1��-/ r PARAMEDIC 53 Hx: ZGrL4tYTCS4ILV/2F S - 'GRAIN C,00GURYISPATCHER: ' Vo ,/ CHIEF COMPLAINT: _ __ DRY RUN: ❑ YE REASON FOR DRY RUN `I S 1 T 7-U R'ci S AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X ICAL COVERAGE: INDUSTRIAL OYES NO NO.OF PATIENTS: PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS K: TOTAL MILES: X i MEDICARE x: E.O.B. ATT. ROUND TRIP: O YES ,C) NO O YES .O NO NIGHT: (19:00-07:00) ��. CCHP/PPRP C EMERGENCY RUN: MEDT-CAL C CODE 2(3 i OTHER: OXYGEN: (PEA TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) n NEAREST RELATIVE/RESPONSIBLE PARTY; I.V.: (PER ADMIN.) X (U'1 ' DRUGS: (PER ADMIN.) X NAME: >10 Pif2��=t RELATIONSHIP: YLt o E.O.A.: (IF NOT REPLACED) ADDRESS: 5 ORAL AIRWAY: (IF NOT REPLACED) CITY: - STATE– ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: - DRY RUN: (AUTHORIZED) �EEMPLOYER: OCCUPATION: OTHER: DDRESS: CITY' STATE: ZIP: COMMEN $: L.4 a o Y (RA N Ic C I N k) L L_ . 110 Da p)�' V T N TOTAL:J JOU �,1 S 00 _ PATIENT RECEIVED BY' Iti •,(Jir .v r., :n:, (SIr;NAII ld 1 - CONTRA COSTA COUNTY AMBULANCE ( f 1 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION-0 "T CHECK OR FILL IN APPROPRIATE SPACES DATE: -•I / :%a— PATIENTS NAME Uw OM ❑ F COMPANY M fa X18 /3 ADDRESS AGE CITY _ STATE ZIP _ DOB— O Sn OM OT' O W 0 Th O F ;dS DRIVER'S LICENSE M — PHONE —_ NATURE OF DISPATCHell n6/ 1_ TYPE OF TRANSPORT: AMBULANCE/V OTHER O _ — STATION 1(A)_2(B)-3(C)-4(D)-5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) `7 TO SCENE-` 91S.O. CALL RECEIVED .i ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE/--++ 13 FIRE TIME 10-97 w) ❑ PSAP TIME 10.49 MILEAGE: ; ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE COMPANZ- N_.S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: , , . RESPONSE ZONE O YES ❑ NO Q WALKED O GUERNEY O OTHER PATIENT CONDITION: DRIVERAz- E T-lA1 TECHNICIAN MEDIC Hz: — DISPATCHER: CHIEF COMPLAINT: ` DRY RUN: k YES ❑ NO REASON FOR DRY RUN L� rl ------- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) U,;l� PATIENT REFUSED SERVICES:(SIGNATURE)X a 1 q` MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: S.S.« PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 8: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00'-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: = ORAL AIRWAY: (IF'NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) S PHONE: WORK PHONE' DRY RUN: (AUTHORIZED) �G•_cei EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE ZIP: COMMENTS: TOTAL: -�'C�. �� 119 911 PATIENT RECEIVED BY. X . ISIr.N�,� llfl Ac OSTA COUNTY AMBULANCE PREAL CARE FORM I UNIT ( l AUTHORIZATION N P CHECK OR nLL INAPPROPRIATE SPACES DATE: PATIENTS NAME IZ �.t � ❑ F COMPANY N ADDRESS - ��G t +� 5 AGE ^ � / ( CITY +` cSTATE T4 ZIP Cl %o k �D,O�B!L_� ❑ Sn O M OT OW O Th O FQ DRIVER'S LICENSE N {� � 35 PHONE_13-5 1-a NATURE OF ATCH TYPE OFTRANSPOR LA HER O - STAT10 2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:• RESPONSE CODE: 4REQUESTED BY: TIME- 124 HOUR CLOCK) TO SCENE CALL RECEIVED!7 '7�� 1 Ts ST gar fP.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97L 11I. �. � � ^ n O PSAP TIME 10-49 a3 IT 7 " MILEAGE: ❑ OTHER/PVT TIME 10-7 � END 6 s. ( TIME 10-98 -• Z S.,D - `' OCTOR PMD START 3- Irl TIME 10-22 HO HOSE / TOTAL t T STANDBY TIME <�O�U�XtEaV O FAMILY O TRANSFER — WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANC COMPANY: —r'- c .I BULATORY? PATIENT TAKEN�AMB NCE: _� l l RESPONSE ZONE t.. ❑ NO O WALKEDJ9,-SUERN OTHER PATIENT CONDITION: DRIVER k1b r9� ' kAT.� 1A 1 TECHNICIAN I/)�LTt- 1,41 OIC 55 H.: _/'Ln n&f-2 tA x DISPATCHER: CHIEF COMPLAINT: DRY RUN: Cl YES REASON FOR DhY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 5 VIL, PATIENT REFUSED SERVICES:(SIGNATURE)X N=CAL COVERAGE: INDUSTRIAL ❑ YES '% NO.OF PATIENTS: PRIVATE INS.CO.: BASE RATE: �rl� KAISER C MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: % X - -� /1 MEDICARE C E.O.B. ATT. ROUND TRIP: O YES •P NO. ,IGI r I� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:' EMERGENCY RUN: MEDI-CAL N' CODE 2/3 1 OTHER: OXYGEN: (PER TANK) J G P.O.E. STICKER ❑ YES NEONATAL: (INCUBATOR) j DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME10015p r LrL RELATIONSHIP: n 7 E.O.A.: (IF NOT REPLACED) ADDRESS' �/� ORAL AIRWAY: (IF NOT REPLACED) ' ' CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE' DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ' •S -- MG C 4-1 ' •- _ TOTAL: c.� 0 �I PATIFNT NF('FtVFn tIV X • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACE$ DATE: PATIENTS NAMEt��-��N(Ltd J ❑ M COMPANY N ADDRESS 14 AGE Ct%�� L/J AGE - J CITY_I�lrL(��' STATE ZIP _- DOB ^_.,S_ I' fl Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N — PHONE'2 '� _.�Z�_'a, NATURE OF DISPATCH_ TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUES TED BY: TIME– (24 HOUR CLOCK) TO SCENE- S S.O. _ CALL RECEIVED L' ► I c��'`- —-- ❑ P.D. TIME 10-8 PATIENT DESTINATION(: r\ FROM SCENE ❑ FIRE _-- TIME 10-97 r� �- 1 I •� ❑ PSAP TIME 10-49 2. MILEAGE -� ❑ OTHER/PVT TIME 10 7 I rte( END TIME 10-98 DOCTOR V '�V L�-( PMD/6START 2Z ' TIME 10-22., HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST eFAMILY 11TRANSFER WAIT TIME _ ❑ PATIENT 11 DIRECT ❑ OTHER CALL BACK N: AMBULANCE COAQNY: 2PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ]'RESPONSE ZONE A YES ❑ NO ❑ WAL'CED X GUERNEY ❑ OTHER _ - PATIENT CONDITION: DRIVER�7C �' _ EMT-1A � �r�(/ uG. tJ(�'f '� � tel. llI•lL.d 'PARAMEDIC _ Hx:� U �+�uL�m LmECHNICIA b. I-II c.�I: t I./. DISPATCHER: ,��, CHIEF COMPLAINT: �� ' �� 1 DRY RUN: ❑ YES' &'NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE/ 7NDL RIAL ❑ YES C/NO NO. OF PATIENTS; -- .1 S.S. N 1; N Le_ _ PRIVATE INS. CO.: BASE RATE: KAJ$ER rim, _ MULTIPLE PTS. BASE RATE EBLUE CROSS N: N C.�"�� - %�� "f-r�.� 7 TOTAL MILES: X ( j.\�M6& f AAE C �- E.O.B. ATT. ROUND TRIP: YES ❑ NO !' . i 3 I � t�/ ❑ YES ❑ NO NIGHT: (19:00- 7:00) OCHP/PPHP N: �L ='L' �,I EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: ` OXYGEN: (PER TANK) d7 / P.O.E. STICKER,.;©'YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: 1 012 1) �I RELATIONSHIP: l /• E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) •CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) HONE: WORK PHONE: DRY RUN: (AUTHORIZED) a�J'EMPLOYER: Y S-' 77 OCCUPATION:, s� `=C, OTHER: `` ADDRESS: CITY: STATE: ZIP: COMMENTS: ~ v- --7 YITOTAL. `� 7TH t -----•-----p 0 0 x,.21 PATIENT IlI:( EIVF(T 13v X l CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION III I C? 7 1 CHECK OR flLl IN APPROPRIATE SPACES DATE: _ /6 1 T / r s PATIENT'S NAME—�. l.�1-�1�.'.)�?_� --,-��- �' /� ❑ M ��- COMPANY M ADDRESS S �� 1 S T AGE 2� ' CITY V`S.L 1*4 STATE ZIP D013 O Sn O M O T O W O Th ,O F 4$—'f i DRIVER'S LICENSE q _____ —_--- PHONE a �_1 NATURE OF DISPATCH 154-r- TYPE OF TRANSPOR AMBULANCE El OTHER❑ 11AN-2 1_31C1_4(D)_5(E)j INCIDENT LOCATION: j P/l 13�XUjFr h RESPONSE CODE: H ED BY: TIME—(2/HOUR C 0 K) �,�j TO SCENE- CALL RECEIVED / l so-11 t S�rI,IV - CR( aAe � O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 O PSAP TIME 10.19 ' MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START - TIME 10-22 1� ' HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE 3MPANY: �••----� EPY BULATORY? PATIENT TAKEN TO AMBULANCE: ; J U RESPONSE ZONE ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER Z PATIENT CONDITION: DRIVER a 7 ` EMT to X' J------------- TECHNICIAN ►71�)+�+4 P 1 PARAMEDIC - ISPAT - CHIEF COMPLAINT: OA- Y RUN: 9 YE ❑ NO REASON FOR DRY RUN Pr Rf I;:usAi_ ' A t1QRI��ON FOR DRY RUN(EM�j►1SE OT — ,.T PATIENT REFUSED SERVICES: (SIGNATURE) X (/-f/�- MEDICAL COVERAGE: INDUSTRIAL ❑ YE NO.OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: - KAISER N: MULTIPLE PTS.BASE RATE - BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES 91 NO O YES ❑ NO NIGHT: (19:00-07:00) - ��` CCHP/PPRP N: EMERGENCY RUN: �_ . -• MEOI-CAL N: CODE 2/3 (- --1 �I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ---� DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X . faE DRUGS: (PER ADMIN.) X i NAME: Z U I?l m 7E LO - RELATIONSHIP: D• E.O.A.:(IF NOT REPLACED) ADDRESS' S ORAL AIRWAY: (IF NOT REPLACED) CITY: ___ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WOOK PHONE: DRY RUN: (AUTHORIZED) .SO• EMPLOYER:_ OCCUPATIION: OTHER: ADDRESS: ' L STATE: ZIP• COMM S: PI STATES 5H� (,JS�.L� �V(1 TOTAryjT— V PATIENT RECEIVED BY:X O O H (SIGNATURE) Provider retoir• White r-rd Pin; •ray 5vtu." Ye' P ;' v -^Tv t• SNp hp. !i'ing ) r� , c. 1 ir•� CONTRA COSTA COUNTY �3 # AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 461 � ��a CHECK OR FILL IN APPROPRIATE SPACES DATE' IC-e St��v �3 PATIENT'S NAME '(�- ( q��c 0(-t y I/.4- ��" O M �F COMPANY N I � � +! ADDRESS AGE _ Cv / V r • . ..� CITY ` STATE �-�` ` ZIP DOB /0- 0 O Sn O M D,T O W O Th• O F f(S DRIVER'S LICENSE» PHONENATURE OF DISPATCH .S L TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ -_-_ STATION 1(A)_2(8)_3(C)_4(D)_S(E)-:,—.. INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) y ��r\ TO SCENE- ^ S.O. CALL RECEIVED V LAY L ❑ P.D. TIME 10 8 ,C ~1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-971 ❑ PSAP .TIME 10-49 MILEAGE: c ❑ OTHER/PVTTIME 10-7 END S TIME 10.98. DOCTORkl, — PM EES START ' TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME --+-t ❑ NEAREST O FAMILY .❑ TRANSFER WAIT TIME �. PATIENT ❑ DIRECT ❑ OTHER CALL BACK»: AMBULANCE COMPANY: ...�_� PJ. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I-' RESPONSE ZONE _ YES ❑ NO ❑ WALKED groGUERNEY .❑ OTHER t �T _. PATIENT CONDITION: DRIVER LJAUCE 2 MT-tA + TECHNICIAN ( �� ' AMEDIC �)t Hx: DISPATCHER: { r' CHIEF COM LAINT:`3 IJ •DRY RUN: O YES ❑ NO REASON FOR DRY RUN P F.( �I� 214 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) rf, T PATIENT REFUSED SERVICES: (SIGNATURE)X / MEDICAL COVERAGE: IN S, IAL ❑ YES ❑ NO NO.OF PATIENTS: �• 3o I � - , S.S. » a _ n PRIVATE INS.CO.: BASE RATE: --� v KAISER»: MULTIPLE PTS. BASE RATE B U CROSS»: TOTAL MILES: X -_J 7EDICA�: Q.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) - -- CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL»: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) U DATES BILLED: STANDBY: (OVER 15 MIN.) 9 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X S .� NAME 0►'► -2 Q'! ��-� RELATIONSHIP: E.O.A.: IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: C Qyl Ord STATIC ' ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE:U0 "l uq 3( WORK PHONE:(01(.9_l Sly DRY RUN: (AUTHORIZED) EMPLOYER:.;" OCCUPATION: OTHER: - -^ ADDRESS: CITY: STATE' ZIP-, COMMENTS: 1 ( COOT - TOTAL: �..a,�//�. ( PATIENT RECEIVED BY:Xhphll ( V 6 L} IGNATURE) 04-1� Provider ntn,r, Whit, ,-rd Pir.R ropy Rety,. r�:lot• r+py t• W whin Pii"inp CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I UNIT Z' AUTHORIZATION N y� I 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: 7 - /.c Y ti+ 1 }} PATIENT'S NAME ../2 U,�_ .. C_tkcA; ❑ M WF COMPANY N /• � L__..... /I / ADDRESS _�!_rii:Ti f_f7_ AGE ' CITY i L'c' _ STATE C a' ZIP `Z DOB�y/��Sn ❑ M O T O W O Th O F!._�S DRIVER'S LICENSE a _.�.I i (�rc•../'_._......_ _—.. PHONE__� .5__-.Z,�E?� NATURE OF DISPATCH A4,a TYPE OF TRANSPORT A MBULANCE/K OTHER❑ i INCIDENT LOCATION: !� RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 7 i A TO SCENE- ViQ;0 CALL RECEIVED LZ '1 F`y ', 1368 `'Jn_u,lfl� X •�e � __ 13P.U. TIME 10-8 1 7 h PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 /� : oz ❑ PSAP TIME 10.49 MILEAGE: O OTHER/PVT TIME 10.7 END_q3 TIME 10.98 : DOCTORy� p PWCQR,,l START yL`3 TIME 10.22 , HOW CHOSEN: TOTAL STANDBY TIME :T_ NEAREST ❑ FAMILY . ❑ TRANSFER a WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER 3 CALLBACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1- RESPONSE ZONE 1 ❑ YES P NO ❑ WAL';ED WGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT•1A� iii A TECHNICIAN P91_he�� f_5 IC � PATCHER: ( CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION OR ORY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. INDUSTRIAL ❑ YES KNO NO.OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: L D�. KAISER a: MULTIPLE PTS.BASE RATE I CME _ OSLA _ TOTAL MILES: XCARE 8' .I lie c,,i E.O.B. ATT. ROUND TRIP: O YES O NO 4 ,fit �— 3 O YES ❑ NO NIGHT: (19:00-07:00) OsJ CCHP/PPRP N:_ EMERGENCY RUN: .��J•r)0 U} MEDI-CAL a: CODE 2/3 In OTHER: OXYGEN: (PER TANK) -�,�► P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �ll I DATES BILLED: — STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: . I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X NAME:JC_hA3.—_Ll.mm_e.d.5,L_ . RELATIONSHIP: �!C, U_ E.O.A.: (IF NOT REPLACED) '`• ,t ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP; C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE- 7 -C2l L DRY RUN: (AUTHORIZED) EMPLOYER:,Eu:..L OCCUPATtQN: OTHER: ADDRESS:. • c �` • u CITY: P,tt STATE: ZIP:— COMMENTS: IP:COMMENTS: v,',ilc__(L- n b i A ,t7 _ 1.0 3 TOTAL:- PATIENT OTAL:PATIENT RECEIVED BY:X O 8 Provider rrt,::., yf:.,. ,..1 r.:.: ..,r� Y,.: .. .. T �• � I . ISI a f� CONTRA COSTA COUNTY AMBULANCE A�� PRE-HOSPITAL CARE FORM I UNIT >3 AUTHORIZATION If l CHECK ON FILL INAPPROPRIATE SPACES DATE:O 7 /cr, 4 PATIENT'SNAME / _ O M ❑ F COMPANY N ADDRESS / AGE. CITY _ STATE ZIP- - DOB--- ❑ Sn O M O T 13 IN .O Th O F ❑ S DRIVER'S LICENSE N __--_----._-. . . ---...__._.-.. PHONE .. -.. NATURE OF DISPATCH hLr. A/, TYPE OF TRANSPORT: AMBULANCE O OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) n r TO SCENE- CALL RECEIVED N l l � r __ ❑ P.U._ TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 7 'A ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 1_ END TIME 10-98 } DOCTOR PMD/ER START_- TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME _.— ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE C�0 PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER n PATIENT CONDITION: DRIVER TECHNICIAN PAR C Hx: DISPATCH � -- �) CHIEF COMPLAINT: __ DRY RUN: E$ '❑ NO REASON FOR DRY RUN AUTHO Al ON FOR DRY RUN(EMS USE ONLY) qI/v PATIENT REFUSED SERVICES: (SIGNATURE) X-_-� MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO.OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: ( MEDI-CAL If: CODE 2/3 ( 1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) : DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) �l PHONE:` WORK PHO(VE: DRY RUN: (AUTHORIZED) — EMPLOYER: OCCUPATION: OTHER: I ADDRESS: CITY: _ STATE: ZIP:- . CO MEf}TS: -LY _ -� JTACif A6.yr (51 -- - -----_- - TOTAL:PAI - 0Q �� - 125 . • . If NI III ri IVI f)I1v X 1 • CONTRATA O C S COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION It q5; • . v• CHECK OR FILL IN APPROPRIATE SPACES DATE: l," � PATIENTS NAME SRO(^ SS NM l al �M t ,OnF\ COMPANY 0 ADDRESS '✓v L�j'� ��/�� • AGE .L CITY 1� T e f *7 STATE_1A.1 .= ZIP 4 �� r DOB�S3 o s<, o M ❑x o w-o rn,. o f yds---; DRIVER'S LICENSE# - PHONE 2"A-Z-'&?. NATURE OF DISPATCH Ulk>K tAf 41 t TYPE OF TRANSPORT: AMBULANCEV OTHER❑ .! STATION 1(A)_2(8)-3(C)_4(D)_5(E) 'kw."—a INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME-(24 HOUR C CK) ? r• 1. � 17 TO-SCENE- S.O.— CALL RECEIVED `•�"' . a O P.D. TIME 10-8 q PATIENT DESTINATION: FROM SCENE- O FIRETIME 10.97 1 _ �*� `` ❑ PSAP TIME•10.491�� MILEAGE: [] ❑ OTHER/PVT TIME 10-7 END �0 -1 TIME 10.98: .. •"'`� DOCTORLV PMD/9@• START TIME 10.22 r J '.�..:-I HOW CHOSEN: TOTAL, STANDBY TIME O NEAREST O FAMILY O TRANSFER ' I WAIT TIME I PATIENT D DIRECT ❑ OTHER CALL BACK K: AMBULANCE COMPANY: P . AMBULATORY? PATIENT TAKE TO AMBULANCE: S v. RESPONSE ZONE YES D NO D Wgl:<EO P GUERNEY O OTHER PATIENT CONDITION: DRIVER' VZ- 6 EMTOA r /I TECHNICIAN ( Io P nAMEDIC I .J H.- DISPATCHER: _ 4 /:In CHIEF COMPLAINT: �� 'c' DRY RUN: O YES 13.NO REASON FOR DRY RUN 1 ! 1 {- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) � 1 4 PATIENT REFUSED SERVICES: (SIGNATURE) X . MEDICAL COVERAGE: ` IAL/YES ❑ NO NO.OF PATIENTS: S.S. M ,`SJ � .. I HNtT_ NS. CO.: BASE RATE: L� ,./�•...�- =- f"r� KAI�SER p_ MULTIPLE PTS.BASE RATE M�• - �_ BLUE CROSS M: TOTAL MILES: X - MEDICARE M: E.O.B.ATT. ROUND TRIP:- ❑ YES ❑ NO ; ❑ YES -❑ NO NIGHT: (19:00-07:00) A81 CCHP/PPRP 0: EMERGENCY RUN: or---"� l d ti; MEDI-CAL 0: CODE 2/3 6f A:. _•.� :;; OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ONO NEONATAL: (INCUBATOR) _ ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "f= NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) DRUGS: (PER ADMIN.) X / NAME: 11' RELATIONSHIP:" E.O.A.:(IF NOT REPLACED) • ^ --'-- _ -r�'�!-- ADDRESS' 5_Lt ORAL AIRWAY: (IF NOT REPLACED)1 �—- CITY: STATE_ ZIP C-COLLAR: (IF NOT REPLACED) i�-= ~- PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: - - - -- ADDRESS: - CITY: STATE ZIP: -- - COMMENTS: l_,o UJ'S U TOTAL:- O© ' PATIENT RECEIVED BY:X -_ '" • 000 � .� -•;� Igor, y CONTRA COSTA COUNTY AMBULANCE [• PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M Y3 - CHECK OR FILL INAPPROPRIATE SPACES DATE: f7-- I _ n { PATIENT'S NAME u Iv ❑ M OF COMPANY# L/ �' _ ADDRESS _� `U • -1 u&1' )6 CJ 6,4 AGE c ore ' u� CITY_T� �1011)1�J CSTATE ZIP _—. DOB^__ O Sn 0 M D T 0 W 0 Th ❑ F DRIVER'S LICENSE q ._�.__.. ..___._.—_._ PHONE __...._ NATURE OF DISPATCH41Z/y�:7 1?-y TYPE OF TRANSPORT: AMBULANCE NOTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)' Y �a'&b$qAT/ giltP"-' .0o SCENE CALL RECEIVED- TO J CiD ❑ P.D. TIME 10-8 PATIENT DESTINATION: �— FROM SCENE ❑ FIRE TIME 10-97 ; ❑ PSAP TIME 10-49 k ` MILEAGE: 0 OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START— — TIME 10-22 f `• HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY 0 TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE S ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER._—lu`� t:' D o TECHNICIAN hitt Y�1 ' IC ,1 Hx: DISPATCHER: 11y[/ CHIEF COMPLAINT: DRY RUN: YES .Q NO REASON FOR DRY RUN S�O • ( �� 7 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES 0 NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER 0 YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: �� DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 0 alt+ p; PAIILNI HI.CL.IV.1 n 1+v X J r.r+rltlln r rl ,IAf:rilRltY AM1101ANCE n -7 PlIE-110SPI T AL CATiE FOMI UNIT r� AUTHORIZATION I.`') DATE: CHECK OR rfIA IN ArrnOPR+A rr SPACU', / ' / • I PAT IFNT'S NAME O M"Zb11F COMPANY y AnnRFSS AGE CITY. - '_!.1_` 1.1'�c_- -"�-�—STATEt-_— ZIP _ ._.-- DOEY__ Z � ❑ O S DRIVER'S LICENSE is __... _ _-..._ _ PHONEr�� —02 NATURE OF DISPATCH u O. �• - TYPE OF TRANSPORT: AMRUI.ANCF-g6 OTHER O iNfaf)ENT LOCATION: RESPONSE CODE: REOUESTEO BY; . TIME— (24 HOUR CLOCK) TO SCENE U S.O. CALL RECEIVED —LZI : '�", �_ .' -1L_4_LS rr.15� ► _ I_�el�_I r�Jc�'�1/ --._ ❑ P.D. TIME 10-8 011 PATIENT DESTINATION: FROM SCENE-'v O FIRE TIME 10-97 ,�Q_( �. 1 n ❑ PSAP TIME 10-49 '; �2 I cock — MILEAG :n O OTHER/PVT TIME 10-7 ��: ( END— o� TIME 10-98.,!7 _QZ rl DOCTOR - AK-1 ___ PMDj START . TIME 10.22 1 HOW CHOSEN: TOTAL - v` STANDBY TIME. —fat NEAREST O FAMILY O TRANSFER WAIT TIME 1 ❑ PATIENT 0 DIRECT . 0 OTHER CALL BACK N: AMBU CA)J E MPANY: r / r PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �!. ) RESPONSE ZONE Cl YES ANO Cl WAL•CED'9;GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER— _j C EMT-1A TECHNICIAN (� PARAMEDIC _ Hx �_ _ D l' Gl�)�J DISPATCHER: I I CHIEF COMPLAINT. _. C'.17�—C'—�r_.lJ_ DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE /INDUSTRIAL ❑ YES rNO NO.OF PATIENTS: S.S. a ._ �—!_ _._C� PRIVATE INS. CO.: ---_ I BASE RATE: KAISER a: — MULTIPLE PTS. BASE RATE / �.�•� () BLUE CROSS a'__. TOTAL MILES: .X SG_ �% x1r rY� O �. _... . � MEDICARE a: 7L-- J / E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO - - /-( �. ❑ YES Cl NO NIGHT: (19:00-07:00) ycOV� s CCHP;PPHP a: L -�� EMERGENCY RUN: �•f I 1(+ MEDI-CAL a:—___—.--_-.._ CODE 2/3 U, •�•+/•`{ OTHER: _-:__—._..___ OXYGEN: (PER TANK) �� I P O.E. STICKER 0 YES 11 NO NEONATAL: (INCUBATOR) DATES BILLED:— -- STANDBY: (OVER 15 MIN.) _r E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r J'KDRUGS: (PER ADMIN.). X NAMF ._.._—...... __ _. .____ RELATIONSHIP!,61QE.O.A.: (IF NOT REPLACED) AnORESS .__ 11� _...__...._ _ .__—..__-___.._ ORAL AIRWAY: (IF NOT REPLACED) CITY ._._._ / STATF C•COLLAR: (IF NOT REPLACED) PHONE - WORK PHONE. DRY RUN. (AUTHORIZED) EMPLOY (�`*�J%—__ OCCUPATION:— OTHER:," ' ADDRESS: -- -- j✓'. e✓�// CITY:— STATE: ZIP: COMMENTS--__. .---.•--.-. - -- _ ---- --_--- -- --- TOTAL: i� — �4= PATIENT RECEIVED BY:X 0 0 - (SIGNATURE) 0 0 0 1.4/ 2 r_I Iy�T Fya� " ITrui,fr•. �r•: r 4?ilr �•.i Pi•:: -^r•t 4rf�� Yr' r� - PATIENT'S NAME: MACKEY, Marilyn ADDRESS: 11 Sandstone Court Alamo, CA DATE OF SERVICE: 07/17/83 AUTHORIZATION NUMBER: 83-11690 ? AMOUNT DUE: $ 263.50 INCIDENT LOCATION: 11 Sandstone Court, Alamo PATIENT DESTINATION: CCCH s 00 000129 . �UNTRA COSTA COUNTY AMBULANCE"fPR -HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N 3 • V CHECK ON FILL IN APPROPRIATE SPACES DATE: ?- I -?- )<2 PATIENTS NAME 1 M ❑ F COMPANY N / + . ADDRESS AG ` 7 t CITY A STATE L2 ZIP 0 D0E83 13.M ❑ T OW ❑Th ❑ F ❑ S DRIVER'S LICENSE N _ - PHONE - ATURE OF DISPATCH !E?A TYPE OF TRANSPORT: AMBULANC THER❑ -- STATION 1(A 2(B)_31C)_4(D)_5(E)— INCIDENT LOC TION-'-"' _ RESPONSE CODE: E UESTED BY: TIME- (24 HOUR CLACK) ` E TO SCENE- O. CALL RECEIVED } v ❑ P.U. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10.97 -{ 6 ❑ PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10.7 • ��_ ' END TIME 10-98 DOCTOR G START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER I WAIT TIME -214:5,4TIENT ❑ DIRECT ❑ OTHER g CALL BACK N: AMBULANCE C,pM�ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YE51>� ❑ WALKED T3 ERNEY O.OTHER PATIENT CONDITION: DRIVER Fa I I EMT-tA ' TECHNICIAN; cl/ zs - PARAMEDIC t�Q Hx: wo Aag;(-;?j �W DISPATCHER: I CHIEF OMP AINT: DRY RUN: ❑ YES�NO REASON FOR DRY RUN (� �) / AUTHORIZATION FOR DRY RUN(EMS USE ONLYJ PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVER GE: INDUS IAL ❑ YES�JO NO.OF PATIENTS: fj�A>✓' _S.S.M PRIVATE IN CO.: I BASE RATE: "ILl." 1 Llj+- PTS. BASE RATE C BLUE CROSS N: TOTAL MILES: >I X MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES ONO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-COAL N CODE 2/3 7 OTHER: L 'rdrr�m�Gs' OXYGEN: (PER TANK) .O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �e DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) J O NEA ST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X UGS: (PER ADMIN.) X NA RELATIONS O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIOa: OTHER: ADDRESS: ' CITY: STATE: ZIP:- -" z� lam' COMMENTS:1` TOTAL: PATIENT RECf:IVFD BY' )I J _- L1� �� ) .._..__•' ., I•r••. for r�r, i.. N.•rr . ! .. t- ., .., .. . ISI(JA IIINI.1 1 I CM!•1 CONTRA COSTA COUNTY AMBULANCE "...<.',�. PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 018s CHECK OR flit IN APPROPRIATE SPACES DATE: "PATIENT'S NAME O M F COMPANY N I =� ADDRESS - AG 0 2- CITY 1 STATE ZIP DOB � QSn, M �T;OW OThOF Os._ �. DRIVER'S LICENSE N ' ' PHONE %33`4 2� NATURE OF DISPATCH .l ..,,. ..... ... V.•: TYPE OF TRANSPORT:. AMBULANCE OTHER❑ I STATION 11A 2(B)_3(C)_4(D)_5(E)_ •:.•� :' , INCIDENT LOCATION,: +� �: RESPONSE CODE!- UESTED BY:. TIME—(24 HOUR CLOCK). } f TO SCENE- 0. CALL RECEIVED ( `� P.D. TIME tab PATIENT DESTINATION:.. FROM SCENE AFIR TIME 10-97E --� - ❑ PSAP TIME 10-49 MILEAGE- 0 OTHER/PVT TIME 10-7 END TIME 10-98; ""- �iDOCTOR T /PM ER START TIME 16.22 HOW CHOSEN: —.. _ TOTAL _ STANDBY TIME 'Y30 NEAREST,? ❑ FAMILY ❑ TRANSFER � WAIT TIME ;JttzATIENT ❑ DIRECT 13 OTHER % CALL BACK N: AMBULANCE COMPANY: �ll - C ..J .. }= PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE ❑•YES iV-SIO,•., 0 WALKEQ-3ktUERNEY ❑ OTHER l I -_ PATIENT CONDITIONY "' DRIV I EMT-1A 0•Xg S'' „�`( TECHNICIAN PARAMEDIC Hx: DISPATCHER: CHIEF C P IN DRY RUN: ❑ YES IZ IVO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE:..._. INDUSTRIAL ❑ YES10 NO. OF PATIENTS: -I o 1 •.';:? PRIVATE INS, CO.: BASE RATE: ” KAISER c t MULTIPLE PTS.BASE RATE '�%• BLUE CROSS N: F ' " � TOTAL MILES: � X `F # MEDICAREM; E.O.B.ATT. ROUND TRIP: O YES 0 NO . �•:' O YES .O -NO NIGHT: (19:00 07:00) CCHP/PPRP N: r (� 1 EMERGENCY RUN.' �, Q MEOI-CALM C��r�O`1 S� ?_S 3 L '; t .. : CODE 2 3 OTHER: 1 .�� OXYGEN: (PER TANK) ..J . _ i i l •iJ 1 �..;?r��•:'. P.O.E.STICKER 0 YES ❑ NO NEONATAL: (INCUBATOR) 4.=_ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: - -- I.V.: (PER ADMIN.) X • DRUGS: (PER ADMIN.) X O'. ,,.,. rcl yin NAME:��G --RELATIONSHIP:_�� E.O.A.:(IF NOT REPLACED) •' ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) �.�r=• '----CtTY:~ STATE_ZIP C-COLLAR: (IF NOT REPLACED) ~- `' !' PHONE: WORK PHONE* DRY RUN: (AUTHORIZED) -:-EMPLOYER: - - OCCUPATION OTHER: ADDRESS: ,. --CITY- - STATE• ZIP* 4'`*-:'.—'COMMENTS:- :,fi • , t 1 ✓ TOTAL: l 7O V ... PATIENT RECEIVED BY:X kZ-� o o�3 JPn+v/dPr rvra(a Vhlti ..,! pr,: •,r� . 9o!t.rn ri ,;,, ni (SIGNATURE CONTRA COSTA COUNTY ' AMBULANCE n PRE-HOSPITAL CARE FORM I UNIT E AUTHORI TIJN N CHECK OR FILL IN APPROPRIATE SPACES DATE. U�� PATIENTS NAM_E ❑ M ❑ F COMPANY(N 1 G i-I ` J ADDRESS - AGE�, ``t , P.i ( r I CITY _ STATE ZIP DOB O Sn )vM 0 T O W ❑Th ❑ F O S DRIVER'S LICENSE Y __ _ PHONE ________ NATURE OF DISPATCH (1 S TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ _ __ STATION 1(A)_2(8)_3(C)_4(D)_6(E)_ INCIDENT LOCATION: I RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) _ O J Ce_v(-� TO SCENE- .O. CALL RECEIVED �• 1 `[ ❑ .D. TIME 10-8 + PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 - '1 < ❑ PSAP TIME 10-49 lo �ZL. On) ; ct.- _ j(_Po MILEAGE: ❑ OTHER/PVT TIME 10-7 4- END TIME 10.98 .DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL J. STANDBY TIME i O NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK N: AMQUL�A3CE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER tJ PATIENT CONDITION: DRIVER i �-� I) EMT-1A ' TECHNICIAN l. 1�II / PARAMEDIC Hx: uj(:Ph 'J") nrc,n C DISPATCHER:.. Y t ( I .. I. .~t CHIEF COMPLAINT: DRY RUN: P YES ❑ NO REASON FOR DRY RUN I'` ' �•I `�vI1C' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Llq ,/ PATIENT REFUSED SERVICES: (SIGNATURE) X r `�I MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO.OF PATIENTS: !� PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TAN C P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (IN BATOR) DATES BILLED: STANDBY: ER 15 MIN.) \ E.K. PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP• E.O.A.-(IF NOT REPLAC D) ADDRESS: ORAL AIiIWAY: (IF NOT REPLACED) CITY: STA ZIP: C-COLLAR: (IF NOT/REPLACED) PHONE: WO�-P ONE-.: DRY RUN: (AUTHORIZED) �U EMPLOYER: OCCUPATION OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 00 Il-, - ------- - 000132 PATIFNT REC[IVFn BY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: L �I PATIENTS NAME ^ 1 OM O F COMPANY N (� ADDRESS AGE CITY _ STATE ZIP DOB ❑ SnM OT OW O Th OF Os DRIVER'S LICENSE N _ PHONE _—,_� NATURE OF ISPATCH ' V TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ -- STATION 1(A)_2(B)-3(C)-4(D)_5(E)_ INCIDENT LOCATION:' I RESPONSE CODE: � UESTED BY: TIME– (24 HOUR CLOCK) 1' / r 5� Z, L n+ n TO SCENE- O. CALL RECEIVED iy `7 1 i'�C.A��n'(-� O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 `� ❑ PSAP TIME 10-49 Ib-`L7� ti.,nl 1 "'y��- r Q P MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 DOCTOR PMD/ER STAR TIME 10-22 I '" HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: 1�S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER (JJ�ISY �)-`)/� EMT-1A TECHNICIAN P RAMEDIC L Hx: I D- Ll- EN LI i _ f C.H G DISPATCHER: CHIEF COMPLAINT: y DRY RUN: 13 YES 13NO REASON FOR DRY RUN j AUTHORIZATION FOR DRY RUN(EMS USE ONLY) nI J PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N ' PRIVATE INS.CO.: / BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES ❑ NO �\ O YES .O NO NIGHT: (19:09'-07:00) CCHP/PPRP N: - \ EMERGENCY RUN: .� MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO `. NEONATAL: (INCUBATOR) DATES BILLED: `� STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE' 'bQY RUN: (AUTHORIZED) ce/ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: , TOTAL: O PATIENT RECEIVED BY X .._ c IJ Y •! CONTRA COSTA COUNTY AMBULANCE y� h� PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION- M`)-� r;;i; CHECK OR TILL IM APPROPRIATE SPACES DATE:r� TIENT$NAME /P��,1 L/%►�T � / fT�t�`-^'� O M Vd-E COMPANY N -L 9 ADDRESS �`�7 - l 7 T/1 7` AGE 7-5 ri t )(f 1 CITY STATE t ZIP (�` 008 / "vim❑ Sn M O T O fW O Th 13 F O $ DRIVER'S LICENSE M - PHONE f'�1- NATURE OF DISPATCH ��` TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_2(B)_3(CI_4(D)_5(E)_ ` INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) . TO SCENE- X40. CALL RECEIVED I ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 n7 - ❑ PSAP TIME 10-49 / o /�s�✓lf MILEAGE: ❑ OTHER/PVT TIME 10-7 ) / END �5�� TIME 10-98 : Z DOCTOR �Q_��L -/i PMD A START-==. TIME 10-22 �r HOW CHOSEN: TOTAL 2- STANDBY TIME { ,.L,• ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER ( CALL BACK N: AMBULANCE COMPANY: 3 PT. AM ULATORY7 PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES t5440 ❑ WALKEDUERNEY ❑ OTHER PATIENT CONDITION: DRIVER Ird Ii I TECHNICIAN ►11� PARAMEDIC I' Hx: DISPATCHER: 1.� CHIEF COMPLAINT: A.1 J•3• DRY RUN: O YES 'Q•NO REASON FOR DRY RUN J C i9�✓L/� f fil/"-' v,`- y/ !O— AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES:(SIGNATURE) X x r� MEDICAL COVERAGE: INDUSTRIAL ❑ YES bNO NO. OF PATIENTS: S.S. M S'�9 Ls y 7 PRIVATE INS.CO.: BASE RATE: 1 I KAISER M: MULTIPLE PTS.BASE RATE / � T��J BLUE CROSS Ni TOTAL MILES: `� X ' 1/'` ✓ "1 EDtCARE�M: ��- / '" 7�_4Z E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO i ❑ YES O NO NIGHT: (19:00-07:00) ,p r CCHP/PPRP N: EMERGENCY FJUN: oe. ms' MEDT-CALM: CODE 2(//3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: - STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X V[� DRUGS: (PER ADMIN.) X RELATIONSHIP: 9<<L E.O.A.: (IF NOT REPLACED) C ADDRESS: -S�� ORAL AIRWAY: (IF NOT REPLACED) -...-CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 7s WORK PHONE: DRY RUN: (AUTHORIZED) •-• EMPLOYER: OCCUPATION' i„ OTHER: ADDRESS: L_ •- CITY: STATE* ZIP: - /d CV, COMMENTS: TOTAL' 00134 •A YV— PATIENT RECEIVED BY:X�L''` ♦h�J ` Provider rlta!r. Nhite trd Pied r•pp .50taM Y.' 1.c f i! ink (SIGNATURE$ ILMS-1 ate`"'7 r. ,�`_ '• � .. , CONTRA COSTA COUNTY LAMBULANCE PRE-HOSPITAL CARE FOAM ! \ AUTHORIZATIONSx ! CHfCK OR ff((IN APORtt!'RM(f Sv4t'1 X PATIENT'S NAME. 1 / • .!,• �(� I ADDRESS 1...`Y "-~'- -.. `�� AGE ( o �� r 1, CITY_ Al STATE—C6 ZIP�1_� D08(=x ts n D T O W✓'D Th OF DS I DRIVER'S LICENSE ___._.___. _ ._ _____....... __.—_. PHONE�� JATURE OF ISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ IN ENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLO VN) i (' fCf Q. C� TO SCENE P.D CALL TIME 0 8 RECEIVED _ :Z� PATIENT DESTINATION: J FROM SCE - FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 ' Ift ILEAGE: O C (J ❑OTHER/PVT TIME 10.7 END / D TIME 10-98 DOCTOR . PMD/ER START—()-b.�-7, TIME 10.22 HOW CHOSEN: TOTAL _ • _� STANDBY TIME - ❑ NEAREST ❑,FAMILY ❑ TRANSFER l WAIT TIME -` ❑ PATIENT ❑'DIRECT OTHER �� , CALL BACK N: AMBULANCE COMPA 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) (• RESPONSE ZONE ES Cl NOJAL":ED ❑ GUERNEY' ❑ OTHER ._______ I PATIENT CONDITION. DRIVER_. EMT-1A 1 TECHNICI_. 7 C'PARAMEDIC / Hx: _ `�rL_ DISPATCHER: l CHIEF C !PLAINT _51a DRY RUN: ❑ YES O REASON FOR DRY RUN 1, JT ORIZATION OR DRY RU (EM USE ONLY) 7 t Cr - -- ----- PATIENT FUSED SERVICES: (SIGNATURE)X- ` (� 1. L W GE: L INDUSTRIAL ❑ YES NO.OF PATIENTS: S.S. PRIVATE INS.CO.: _ BASE RATE: } KAISER»: _ . MULTIPLE PTS. BASE RATE BLUE CROSS t7— _ TOTAL MILES: x MEDICARE a: h0-t- e W E.O.B.ATT. ROUND TRIP: O YES ❑ NO Y1 ev)eat 1 c i5v c, ❑ YES ❑ NO NIGHT: (19:00-07.00) "J CCHP/PPRP EMERGENCY RUN: ME _ L q: —� CODE'2/3 — . �. OTHE _ �- OXYGEN: (PSR TANK) • P.O.E. STICKER O YES114O NEONATAL: (INCUBATOr ' 1 DATES BILLED: STANDBY: (OVER 15 MI1�{ E.K.G.: (PER EPISODE) _ ( NEAREST RELATIVE/RESPON BLE PARTY: I.V.: (PER ADMIN.) - =� DRUGS: (PER ADMIN.) X NAME �.__ —___ __ RELATIONSHIP:—A.: (IF NOT REPLACED) ADDRESS: __ ._ ORAL AIRWAY: (IF NOT REPLACED) CITY _ ..�,_ STATE__ IP:_-_-_ C COLLAR: (IF NOT REPLACED) PHONE _= WORK PHONE DRY RUN (AUTHORIZED) E'•1FLC�'ER _ _ . .,__..___ OC CUP ION _._ OTHER ADDRESS:'" CITY: STATE: ZIP:___ Pf 7. 00 COMMENTS:_ N.J 1_1� _ '�� _ eni, Ais TOTA • fl . , ' — . PATIENT RECEIVED BY X 5;J �_-- !: .r r•�.. r •tri 'ir•' - •. rv• ..4�� f• ia.7 (SI(a TUBE Off I i. " CONTRA COSTA COUNTY 1 AMBULANCE J z PRE-HOSPITAL CARE FORM i 1 UNIT �Q� AUTHORIZATION 1t e CHECK OR FILL IN APPROPRIATE,SPACES1 t ' DATE: PATIENTS N ME - _. __ _-- O M COMPANY N r o� c ti �}I _ADDRESSS�� O L AGE'gf'rl nY CITY-4A§IIAX_— 'STAT — ZIP�+�� DOB r�� ___6 ❑ SnrlSPATCH__ ❑ T ❑ W ❑ Th ❑ F ❑ S , '\ -t., �-. ti p:.3 DRIVER'S LICENSE M __— .__..__...._-__. PHONE ..._ _._... ._.: _-.__ NATURE OF V TYPE OF TRANSPORT: AMBULANC OTHER❑ ....._--__. ._._.._.�_ ... INCENT LOCA C CTION: RESPONSE CODE: EQUESTED BY: TIME- (24 HOUR CLOCK) ' TO SCENE ^ O. CALL RECEIVED ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCEN5t__, ❑ FIRE TIME 10-97 — ❑ PSAP TIME 10-49 MILEAGE: ' ❑ OTHER/PVT TIME 10-7 ' END Lv TIME 10-98 DOCTOR PMCR5START—Q__� TIME 10-22 HOW CHOSEN: TOTAL _l STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT '"7HER �(-S v' I CALL BACK a: AMBULANCE COMPANY: ,e TT MBULATORY7 PA ENT TAKEN TO AMBULANCE: RESPONSE ZONE ES ❑ NO AL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I,AT-1A TECHNICIA - I ' �' PARAMEDIC q_-1-Z Hx: _ DISPATCHER: r CHIEF COMPLAI T: - { _ DRY RUN: ❑ YES 0 REASON FOR DRY RUN J „ate_ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) Cj PATIENT REFUSED SERVICES: (SIGNATURE) X-- 5� tCAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS: �� '~"• , S. • . t - - 1 1 / IVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE -) BLUE CROSS q: 9'� TOTAL MILES: X Ll E.O.B. ATT. ROUND TRIP: ❑ YES. ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 .;(% OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR)' DATES BILLED: STANDBY: (OVER 15 MIN.J •;ter,G U l E.K.G.: (PER EPISODE . NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) 7�U X (, DRUGS: (PER ADMIN.) X NAME:` ' '� ' r ( ' / I RELATIONSHIP:' E.O.A.: (IF NOT REPLACED) ADDRESS: -- ORAL AIRWAY: (IF NOT REPLACED) CITY: r ` f'' -__ STAT _. ZIP: C COLLAR: (IF NOT REPLACED) PHONE: WORK ONE. - -- DRY RUN: (AUTHORIZED) EMPLOYER: CUPATION: �- OTHER: ADDRESS: /'• CITY: STATE: ZIP: COMMENTS: _- "4'v\ Q, C P -- ��yo Q�•� 4n- S1 --- --- ------__: ----- - TOTAL.� _. L-- 01.36 t 4. -. C,_..:.. _.. ... PAIILNTHI:CFIVI'n11Y �. �� LtC- .x � . . �. I'r•i l.r ►a•r.r�•. v6, , ! 1"1 ,NA'i(INF) t! CONTRA COSTA COUNTY �' ' AMBULANCE PRE-HOSPITAL CARE FORM UNIT AUTHORIZATION N �3'l1800 % g i! 0 !-� CHECK OR PILL IN APPROPRIATE SPACES DATE: " /iJ 'PATIENTS NAME M ��OF COMPANY N ADDRESS 4g5- Q 6+•o&" Ld AGE r01 C c) I I(69v CITY STATE e ZIP G �00 DOB (��_- ❑ Sn M O T O W O Th CEpF DRIVER'S LICENSE N PHONE 93Y 37 _ NATURE OF DISPATCH h,�6aiZ' TYPE OF TRANSPORT: AMBULANCE OTHER❑ —_ STATION 1(A)-21B)._3(CI_4(D)_S(E)_ INCIDENT.LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) r , TO SCENE- S.O. CALL RECEIVED _T :-1 ` � QV �I�I �'C'� P.D. TIME 10-8 `f PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 l� O PSAP TIME 10-49 MILEAG 13OTHERIPVT TIME 10-7 END �0.0 TIME 10.98 );DOCTOR' A(tiffit PM R START TIME 10-22 HOW CHOSEN: TOTAL•? IV, 1• STANDBY TIME )' 13 NEAREST 13 FAMILY O TRANSFER �/• WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY- PAS OMPAN - t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER J4• PATIENT CONDITION: DRIVER�'I•Pr��w,! -�(fl EMT-lA / TECHNICIAN PARAMEDIC _ ' IIx: I A b6>7� DISPATCHER: 1 �L `>,•'i j 3 CHIEF COMPLAINT: 0•�`- DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) h -t.( PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: �;-� ��• S.S.N i PRIVATE INS.CO.: BASE RATE:: KAISER R: MULTIPLE PTS.BASE RATE BLUE S N: TOTAL MILES: X U Q OMCARN: 'LIE- ZAA E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO c O YES •❑ NO NIGHT: (19:00-07:00) la• Lt i I•j CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3. 1 OTHER: OXYGEN: (PER-TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) ti DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) --NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ',•; I DRUGS: (PER ADMIN.) X ='T NAME: RELATIONSHIP: WI E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ` CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) ' PHONE: WORK PHONE: DAY RUN: (AUTHORIZED) EMPLOYER: P_Q31 OCCUPATION: OTHER: ADDRESS: —CITY: STATE* ZIP* --COMMENTS: �Al. oa 000137 TOTAL: - PATIENT RECEIVED BY: (SIGNATURE) Xms-I 00 Avvider retoir. Phi to vrd Pink evpp . **turnYe:lcu -Ol'! t• tHS uhee Lil•in/ CONTRA COSTA COUNTY AMBULANCE �' ! PRE HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: v - aATIENT'S NAME _ _ _ _ O M F COMPANY# ADDR SS _ AGE / ' CITYMiun STATE-_- 21P___....___- DOBY__L�1 ❑ Sn /A M OT OW O Th ❑ F OS DRIVER'S LICENSE# _.__.. PHONE ...:.. .. .__... _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEPQ OTHER❑ _ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S.O. __ CALL RECEIVED _ ! O P.U._ TIME 10-8 PATIENT ESTINATI N: FROM SCENE - / ❑ FIRE -- TIME 10-97 i �GJ O PSAP TIME 10-49 - r MILEAGE: .0 OTHER/PVT TIME 10-7 kind m� END 6 3 TIME 10-98 DOCTORhjbL. PMD6 START- _ _ � TIME 1022 HOW CHOSE TOTAL STANDBY TIME O NEAREST O FAMILYTRANSFER / WAIT TIME O PATIENT 11DIRECT OTHER /% CALL BACK#: AMBULANCE COMPANY: _ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ;, RESPONSE ZONE_ + YES ❑ NO WAL`CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 7- EfaT-lA � 1 _ TECHNICIAN - PARAMEDIC H. _ _DISPATCHER: AHIF C IN _ _ _ ��DRY RUN: ❑ YES �NOREASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE UNLY)P TI NT REFUSED SERVICES: (SIGNATURE) ) MEDICAL CO ERAGE: INDUSTRIAL ❑ YES �NO NO. OF PATIENTS: _ i �_� I j S.S. # _ PRIVATE INS. CO.: t BASE RATE: ncv 1. KAISER#: _ MULTIPLE PTS. BASE RATE BLU #: _ TOTAL MILES: X U� CAR 61f /'//Y E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO (; =' O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: (o MEDT-CAL#: COD 2//-3 OTHER: __ OXYGEN: PER TANK) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED). CITY: _ STATE--ZIP:_. C-COLLAR: (IF NOT REPLACED) t' PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) ! EMPLOYER: _ OCCUPATION: _ OTHER: ADDRESS: t _— CITY: STATE:—.-ZIP:__ COMMENTS: l TOTAL - ---- -- _ . 0-00138 _-•_-. PAM NT FiI CFIVFn IiY X (iNA11I111.1 O 0 M.-1 f .... foNTRA COSTA COUNTY AMBULANCE 2 ) , - PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N /xJ'/ 7 CNECK OR FILL INAPPROPRIATE SPACE DATE: 7 , 12 !� PATIENTS NAME r O M.,,,O F COMPANY N ADDRESS AGE �� "W CITY STATE ZIP DOB O Sn O M )7 T/ OW O Th OF OS DRIVER'S LICENSE 0 _ PHONE _ __ NATURE OF DISPATCH 144 k. /!1 C-'i/'� TYPE OF TRANSPORT: AMBULANCE Q OTHER O STATION 1(A)_2(8)_3(C)_4(D)_5(E)_.._ ( INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) J`l SUO h /_ TO SCENE- '7 Q S.O. CALL RECEIVED i P.D. TIME 10•8 PATIENT DESTI�ATION� FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 _T END TIME 10.98 �T DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER - WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE CL�A�jANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ��}��}}V t ❑ YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER 3 PATIENT CONDITION: DRIVER Rol vbl + �1.' EMT-1A TECHNICIAN 'Y42Z)112�6 PARAMEDIC `j qq Hz: DISPATCHER: I�•� " � �' ' ' CHIEF COMPLAINT: DRY RUN: R YES /❑ NO REASON FOR DRY RUN L ()n() AUTHORIZATION FOR DRY RUN(EMS USE ONLY) //``// r PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO.OF PATIENTS: S.S. M <. PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES -O NO NIGHT: (19:00-07:00) J CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N.: CODE 2/3 IOTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: .(AUTHORIZED) cL0 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 040 39 ..-------- CONTRA COSTA COUNTY AMBULANCE �Z1 i PRE-HOSPITAL CARE FORM 1 UNIT ,t - AUTHORIZATION N c� CHECK OR FILL IN APPRO TATE SPACES DATE: PATIENTS NAME O O M F COMPANY N ADDRESS AGES C / CITY STATE ZIP 008 D Sn 0M )OT DIN O Th DF- DS DRIVER'S LICENSE N — PHONE -- NATURE OF DISPATCH��. TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ —. STATION 1(A)._2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME=(24 HOUR CLOCK) VI ' C TO SCENE- S.O. CALL RECEIVEDe- L _� r P.D. TIME 10-8 PATIENT DESTINATION: ~ FROM SCENE- ❑ FIRE TIME 10-97 �\l1 O PSAP TIME 10.49 )� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.99 DOCTOR PMD/ER START TIME 10-22 ? HOW CHOSEN: TOTAL I STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCECCO( ANY: P.T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE.ZON��E�� ❑ YES ❑ NO O WALKED Cl GUERNEY O OTHER PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN «�• _PARAMEDIC Hz: DISPATCHER: . 9 '1 CHIEF COMPLAINT: DRY RUN: 7 YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) L4 L/L/ PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL,COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: J'S S.S.N PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER DYES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN,) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: Y ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP* C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) r1IC�� EMPLOYER: OCCUPATION:` OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: .-��' 1 f 1 0 01 4 0 00 1- PATIENT RECEIVED BY: X I CONTRA COSTA COUNTY AMBULANCE I ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: N3 PATIENTS NAME. f U ❑ M ❑ F COMPANY N 4 ADDRESS. r AGE �� 1pre ' 1 1 CITY _ STATE ZIP DOB •❑ Sn .O M RT ❑ W ❑ Th ❑ F ❑S ., DRIVER'S LICENSE N _ _. PHONE _`__ NATURE OF DISPATCH 8;to ! TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ –_ STATION 1(A)_2(8)-3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME–(24 HOUR CLOCK) R• TO SCENE-'S 4S.O. CALL RECEIVED C` ID `4 i . O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE CQMPANY: ffi PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 17 YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER i^�n r EMT-1A TECHNICIAN PARAMEDIC _ Hx: DISPATCHER: % S CHIEF COMPLAINT: DRY RUN: 17YES( ❑ NO REASON FOR DRY RUN J HO RY RUN(E S U E ONL 1) 1l(/q PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL 8: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.)_ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.). X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR:.(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP. — COMMENTS: TOTAL: `z Z'_---- 00014-1- L 0014 1- Q __.___ __ __ _. PATIENT RECEIVED BY: X....._ / CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNIT _ AUTHORIZATION 0 �j9-3_/I"u SO CHECK OR FILL IN APPROPRIATE SPACES DATE: !2 PATIENT'S NAME_._.�1U VI_� .1 C. a_� '; �M 13f COMPANY /!�'� 7 ADDRESS 3 O l�/. /��'y__�"" '''� AGE /0013 / ) STATE ZIP_ DOB i lab O Sn ❑ M VIOw O Th OF OS DRIVER'S LICENSE'# _ PHONE _._ ____ NATURE OF DISPATCH TYPEOFTRANSPORT AMBULANCEPQ OTHER❑ I • t INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE-3 9,S.O. CALL RECEIVED _ O P.D. TIME 10.8 PATIENT DESTINATION! FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE ❑ OTHER/PVTTIME 10-7 •� , ENO.�� _. TIME 10.98 Lim: DOCTOR .____ Yl'f _____. PMO ER START�� TIME 10.22 HOW CHOSEN: TOTAL __,5 STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER _j CALL BACK#: AMBULANCE `C PANY: PT AMBULATORYY') PATIENT TAKEN TO AMBULANCE: RESPONSZONE ES ❑ NO A VVAL'-,ED ❑ GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER %bv"1` _ 6"? TECHNICIAN �'4) •PARAMEDIC Hx: ... - DISPATCHER:1 rry �T�� J` - CHIEF COMPLAINT. _LY.e-_,.a._e�.;�_._._ DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_-_-- -MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S S.a __ ` PRIVATE INS. CO. - BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: ? X - MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO \ ❑ YES ❑ NO NIGHT: (19:00-07:00) f�� CCHP/PPRP#: _ EMERGENCY RUN: c{J MEDI-CAL#: CODE 2/3 (... 1. OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I /7 DATES BILLED:-_ - _— STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '1 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:_--.--_-, ___— RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY ._ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE _ WORK'PHONE: __ DRY RUN. (AUTHORIZED) EMPLOYER: OCCUPATION OT_H€R: 77) ! �- CITY: STATE: ZIP: COMMENTS: el Ivo�� [_J _��snn..'o TOTAL: 1� 42 O PATIENT RECEIVED BY:X se. .n..-..;,?,,.. r,_._:. y,.:•,. ,.. . �- Fv� (SIGNATURE) e.,� p t 1 np LMS-1 CONTIP,4A COUNTY AMBULANCE PRE-HO90&ALCARE FORM I UNIT AUTHORIZATION 0 I 1 CHECK OR FILL IN APPROPRIA)E SPACES DATE: �/�?/?3 I 'PATIEN'T'S NAME *M OF COMPANY M ADDRESS � AGE CITY �L- ��I N/ STATE ZIP ~/� _D'OB/11� ❑"Sn 13M VT 13 IN O Th 13F O S DRIVER'S LICENSE 0 — PHONE �i NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE OTHER __ -- STATION 1(A)_2(B)-3(C)_,4(D)-5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVEDbjy. 4fmw 31 O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-� O FIRE TIME 10-97 ❑ PSAP TIME 10.49 �L Vi26e , MILEAGE: O OTHER/PVT TIME 10.7 END (7-�/ TIME 10-98 DOCTOR C - PMD®R START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY ❑ TRANSFER y -� WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER U CALL BACK M: AMB=COMPANY: PT. AM�UTATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES Q NO ❑ WALKED-91GUERNEY O OTHER PATIENT CONDITION: DRIVER O � s EMT-1A TECHNIc1AN� lI ICALM 1 1: PARAMEDIC Hx: �' DISPATCHER: < < CHIEF COMPLAINT: rf DRY RUN: ❑ YES N REASON FOR DRY RUN C f��Z LICE� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) . PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: IN US R L ❑ YESXNO NO. OF PATIENTS: S.S.« d�6o — 02 —/ , PRIVATE INS.CO.: f Vr• PAY BASE RATE: l Q•Rj KAISER 4: MULTIPLE PTS.BASE RATE or)BLUE CROSS 0: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES ONO O YES .O NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: / '`• MEDT-CAL N: CODE 2/3 Y r OTHER: OXYGEN: (PER TANK) od.L_J 1 P.O.E. STICKER OYES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ' E.K.G.: (PER EPISODE) NEAZ.— ELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAM � / RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 2 f J= STATE— ZIP: C-COLLAR: (IF•NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS' "CITY: STATE' ZIP: COMMENTS: ,.: --—f-- TOTAL:_ ®.14 3 PATIFNT RECEIVED BY X_ --- h'1 1%1(.NA 1111111 l) CONTRA COSTA COUNTY AMBULANCE y Q PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIIZ'�ATION N / � � I 1 •�, CHECK OR FILL IN APPROPRIATE SPACES DATE: ` _ `l K KA LLCN,L-ALr.. a . , X'-PATIENTS NAME L� �M iq F OMPANY N 1 S �� 6 ADDRESS AGE D CITY STATE ZIP _— DOB--% _ ❑ Sn D M } ❑ W D Th D F O s 1 DRIVER'S LICENSE M PHONE__._ __. .._.__.—.__ NATURE OF DISPATCH rL-SM TYPE OF TRANSPORT: AMBULANCOTHER❑ ..___._____.._.. _...___.. NCIDENT LOCATION: RESPONSE COD£: EOUESTED BY: TIME— (24 HOUR CLOCK) C� TO SCENE- S O. __. CALL RECEIVED ❑ P.D. _ TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1] P /1 G J,!t— ❑ PSAP TIME 10-49 :!' n MILEAGE: ❑ OTHERIPVT TIME 10-7 -7 END .TIME 10-98 DOCTOR PMD/ER START—1 TIME 10.22 MOW OSEN: TOTAL � STANDBY TIME erJ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �{ CALL BACK N: AMBUI C C rPANNY PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 Il') RESPONSE ZONE_ YES ❑ NO i1vWAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ .� �__._ I TECHNICIAN_Y'�'A3f1 ) PARAMEDIC Hx: if-tio DISPATCHER: �!+_'•C.l�l�!L; CHIEF COMPLAINT. DRY RUN: ❑ YES 10 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) C' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAU4OYERAGE: INDUSTRIAL ❑ YES v� o NO. OF PATIENTS: S.S.N K PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE / Al BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO- NIGHT: (19:00-07.00) 'L) CCHP/PPRP N: EMERGENCY RUN: v MEDT-CAL N:&q_h1 eS • CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X Sivk5 nOY-p,• DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: - E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: =s WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: Nome- OCCUPATION: 4 OTHER: ADDRESS: CITY: / STATE: 21P: COMMENT$:/" .r�f� .11j L c C._ •l !_/ _�. .!� Oo G • C l% o, !' TOTAL' LG C_rJ _�J_ Il ��. PATIENT RECEIVED BY X �• ; ISIGNATIIHE) Fhwidor rota:r, While ;�:.. 1,1,;. ••Fp ,t,,,, P. CONTRA COSTA COUNTY AMBULANCE I PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0_ 31 s 1 CHECK OR FILL INAPPROPRIATE SPACES DATE: I�r PATIENT'S NAME (� O M D F COMPANY N •-� ADDRESS AGE •� �J (.1'� CITY _ STATE ZIP DOB D Sn O.M T OW O ThO F O S DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH li/1[.,u1 (-to*L `\ TYPE OF TRANSPORT: AMBULANCE W OTHER❑ __ STATION 1(A)_2(B)_3(C)_4(D)._5(E)_ INCIDENT LOCATION: RESPONSE COO REOUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- �y AS.O. CALL RECEIVED = ' /A TO R ( V 3 ` O P.D. TIME 10-8 J. PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 11 k - (� �\ 13 MILEAGE: TIME 10.49 1` MILEAGE: ❑ OTHER/PVT TIME 10-7 �_ .�_ .• END TIME 10-98 _DOCTOR PMD/ER START TIME 10.22 1 =. o 1 HOW CHOSEN: TOTAL �\ STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT O OTHER Li CALL BACK N: AMBU`TOMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSy10NE O YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER ti !! I!. EMT-1A TECHNICIAN t PARAMEDIC k X. DISPATCHER: 1�. CHtU Q1�APLAINT: RY RUN: 19 Y•t=S NO REASON'fOR DRY RUN �• �`5�O`� C/(I �_ AUTHO ON F R DRY• UN S USE ONLY PATIENT REFUSED SERVICES: (SIGNATURE) X99 OVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATI NTS: =-.r' •!j S.M PRIVATE INS. CO.: BASE RATE: KAISER a<: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE II: E.O.B.ATT. ROUND T YES ❑ NO YES ❑ NO N : (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: I MEDI-CAL N: CODE 2/3 l OTHER: OXYGEN: (PER TANK) ! P.O.E. STICKER ❑ YES ❑ NOEONATAL: (INCUBATOR) DATES BILLED: ST DBY: (OVER 15 MIN.) E.K.G.: PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER DMIN.) X DRUGS: (PE ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT €PLACED) ADDRESS: ORAL AIRWAY: (II"N10T REPLACED) x. CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: "' WORK PHONE: DRY RUN: (AUTHORIZED) C�. I EMPLOYER: OCCUPATION: OTHER: 4 ADDRESS: 1 CITY: STATE: ZIP: COMME TS: TOTAL:—) V Q '2 4! PATIENT RECEIVED BY- X vv ✓ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT 4 AUTHORIZATION N 1-3 - 1/ 1510 I ) CHECK OR FILL IN APPROPRIATE SPACES DATE: 7 _` - 2 7—-,�•.. PATIENT'S NAME PIM OF COMPANY# I Cr�CJ ADDRESS —i 45:5 7 V�c/ c.� .� .,c. �l 3 AGE 3 5 A 1-7 •,D- a.0 t...._...� CITY S i' STATE ZIP 2 DOB to-3-4 7 O Sn OM 15T OW .O Th. Q F _ t DRIVER'S LICENSE# —___ PHONE A;6- 1 z 7 1 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE-V OTHER❑ _ --- STATION 1(Ab!C2(B)_3(C)_4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR LACK) ' TO SCENE- O S.O. CALL RECEIVED Q -2-Y4 3P.D. - JJ `PATIENT DESTINATION: 111(; ,h L;, FROM SCENE- z ❑ FIRE TIME 10-97 / O PSAP .TIME 10-49' �+! L' �S 1� MILEAGE: O OTHER/PVT TIME 10-7 END 5 ' TIME 10-98. DOCTOR .S 1_ f�� PMDAO START 7 4 - 1 TIME 10-22 ^� HOW CHOSEN: TOTAL 1 ' T I'l STANDBY TIME ❑ NEAREST ® FAMILY ❑ TRANSFER 1 WAIT TIME ' O PATIENT O DIRECT O OTHER G./� CALL BACK M: AMBULANCE COMPANY: T--- �J4S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE t 21YES ONO 59-WAL'CED ❑ GUERNEY O OTHER }�� / �l PATIENT CONDITION: DRIVER rc 11 11_,.1 -� EMT-1A ^tet TECHNICIAN G c t/�r—s - PARAMEDIC_M �_) Hx: t_ DISPATCHER: I: CHIEF COMPLAINT: 5c I akyc-• c--�-� rt. . L DRY RUN: O YES ff NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j (. • I PATIENT REFUSED SERVICES: (SIGNATURE) X -' j ( /- ; MEDICAL COVERAGE: INDUSTRIAL ❑ YES f9 NO NO.OF PATIENTS: S.S. k PRIVATE INS.CO.: BASE RATE: KAISER so: MULTIPLE PTS. BASE RATE BLUE CROSS b: TOTAL MILES: X r MEDICARE M; E.O.B. ATT. ROUND TRIP: O YES O NO , O YES ❑ NO NIGHT: (19:00-07.00) a'a•WJ , CCHP/PPHP C EMERGENCY RUN: 1 MEDI-CAL M: CODE 2/3 OTHER' .t�� .�. OXYGEN:. (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) – NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' DRUGS: (PER ADMIN.) X NAME: ��• 3 RELATIONSHIP: —1 E.O.A.: (IF NOT REPLACED) ADDRESS: S ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION, OTHER: ADDRESS: ' CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: - - TOTAL: 000146 PATIENT RECEIVED BY:X (SIGNATURE) �� , Provider retoic White vfl-n-d P : "OP* Fetkr. Ye'7•a• -nyv t• INS ubv Ei2'inq Dli-1 . s.! �. ...4 CONTRA COSTA COUNTY AMBULANCE �� I ' PREHOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR/ILL IN APPROPRIATE SPACES DATE: — — 3 "PATIENTS NAME _F__C'J• II-- F_ ��r�.� (^ O M O(F COMPANY ADDRESS i �[")• .. ./4 ( 14C�r- I AGE' 'Z� O / U ; CITY Q C+v%A S STATE Ca ZIP 9`I S Cc I DOB )-2�9 ❑ Sn O M g T O W 13 Th O F 13 8 ' DRIVER'S LICENSE M + PHONE 2-S 9_�LT�_ NATURE OF DISPATCH lhl V K'�+� ince �Cc4 TYPE OF TRANSPORT:; AMBULANCE OTHER — STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ ,INCIDENT LOCATION:' Y RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE-3 J4-S.O. CALL RECEIVED _ U �' ❑ P.D. TIME 10-8 PATIENT DESTINATION: -. ! FROM SCENE- ❑ FIRE TIME 10-97 ,.`� 13'f PSAP TIME 10-49 i "2 3 �- y1 Lt1�- �S MILEAGE: ❑ OTHER/PVT TIME 10-7 END—fin 1 '( TIME 10-98 :.�_ i.DOCTOR PMO(OSTART ,//b`te�t TIME 10-22 HOW CHOSEN: _. TOTAL X7_1_ _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME I gPATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: Chs PT. AMBULATORY? PATIENT TAK N TO AMBULANCE: RESPONSE ZONE E3YES ANO ❑ WALKED GUERNEY ❑ OTHER (r PATIENT CONDITION: DRIVER Lyv�� '� EMT-IA s1 TECHNICIAN W�I� � PARAMEDIC�_ • Hx: QUCwrLck DISPATCHER: U{Z 1�1c 1 l / CHIEF COMP�AINT: Z r'^4 DRY RUN: 13 YES XNO REASON FOR DRY RUN (� I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSE SERVICES:(SIGNATURE)X -' MEDICAL COVERAGE:. INDUSTRIAL OYES di,,NO NO.OF PATIENTS: S.S.0 PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS.BASE RATE E CRO : 110 CQS G � ct TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES .❑ NO NIGHT: (19:00-07:00) �D U CCHP/PPRP N: ' EMERGENCY RUN: [X! Ij MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) !J J� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) J DATES BILLED: STANDBY: (OVER 15 MIN.) j E.K.G.: (PER EPISODE) a. SC NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X J2 ✓'�� DRUGS: (PER ADMIN.) X /.SOU✓cj NAME: SC I RELATIONSHIP: - E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP• C-COLLAR: (IF NOT REPLACED) PHONE: —� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: •� a OCCUPATION: �- OTHER: ADDRESS: CITY: IG vj STATE: ZIP: MMENTS: 1 \ TOTAL: '7 7.5. 14 _ — PATIENT RECEIVED BY: X. 00 21 Pr, f•- rvraf- Vhfrr .r.f r:.: MIGNAt(IRE). .. CONTRA COSTA COUNTY AMBULANCE �/Cj,/ PRE-HOSPITAL CARE FORM I UNIT l AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: y _ ( PATIENTS NAME 7 OM ❑ F COMPANY N LC I.:J +�( L/ ADDRESS it'c u �(� AGE"-. C 0 R, K CITY - STATE ZIP DOB _ - ❑ Sn OM OT �W O Th OF- OS DRIVER'S LICENSE N _ PHONE _. NATURE OF DISPATCH L " TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ — __ STATION 1(A)_2(B)_3(C)-4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED L' `( y �� lC4> 3� [ {, .04aLI' � X�rrI CJ[cl. - // .77 3/ P.D. TIME 10.8 ��` L/ (,, PATIENT DESTINATION: J' "OM SCENE_ . ❑ FIRE TIME 10-97 —� O PSAP TIME 10.49 i h lz u X ) - MILEAGE: ❑ OTHER/PVT TIME 10-7 1 END TIME 10-98 DOCTOR PMD/ER STAR TIME 10-22 Y 3 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBUL&NCE COMPANY: %--I 5 7 L PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: (; RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 0t EMT-1A` L L I TECHNICIAN�^tL�t' r-�] I __L_ ' _ ARAMEDIC Hx: �c n A) ��-ii f�l C'C�)i `,;/J,�%l.:• DISPATCHER: �{ CI !(,t7=— DRY RUN: y❑ NO REASON FOR DRY RUN f� i CHIEF COMPLAINT: �� J��l h, Zl Z G t(c( J AUTHORI TION FOR DRY RUN(EMS USE ONLY) `� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS:~ S.S. M ' PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES -❑ NO NIGHT: (19:00-07:00) ✓ CCHP/PPRP 0: EMERGENCY RUN: MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: - ORAL AIRWAY: (IF NOT REPLACED) CITY: f STATE—ZIP. C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: - OTHER: ADDRESS: CITY: STATE: ZIP- COMMENTS: TOTAL: 14 8 PATIENT RECEIVE D BY'X 00-1-2.2 i — ----- — --mirmA iUifi CONTRA COSTA COUNTY AMBULANCE (� PRE-HOSPITAL CARE FORM i UNIT [:D AUTHORIZATION N 6 1 CNlCK OR FILL IN A,PPR�OPRJATE SPACE! M�'I L l .�'/ I •. �.. . .1.1. DATE: r ' PATiENT•S NAME t nr ttY C.U�' tIt �. • � � _ O F COMPANY N � 'i ADDRESS -I t 9,u O1A AGE _ r / CITY C7 STATE C ZIP 9 4 5�� , DOB 1 I.�L'1 ❑ Sn O M T W O Th OF O S , I .._. DRIVER'S LICENSE II ' PHONE -J"J _ NATURE OF DISPATCH Cl � (77, • TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ r _ STATION I(A)_2(8)_3(C)_4(D)_5(E)_ r a INCIDENT LOCATION:. RESPONSE CODE: REpUESTED BY: TIME—(24 HOUR COCK) ^� t S ci 110 I C1 hJ(r, TO SCENE- 0. CALL RECEIVED —� ) TIME 10.8 PATIENT DESTINATION: FROM SCENE- OFIRE TIME 10-97 O PSAP TIME 10-49 •'-'`L�_=' K1/�JG MILEAGE- 0 OTHER/PVT TIME 10-7 ' 1 T 1' END 3b�l 2 E r '3 TIME 10-98 0 DOCTOR ) PMO/ER START ��_ TIME 10-22 m HOW CHOSEN: JTOTAL ( �+ STANDBY TIME _O NEAREST ❑ FAMILY O ' RANSFER 1 WAIT TIME ❑ PATIENT O DIRECT O OTHER C�:1 i CALL BACK N; AM ULANCE COMPANY: �S 1 PT. A BU TORY? PATIENT T KE TO AMBULANCE: RESPONSE ZONE I ❑ YES NO O WALKED�UERNEY O OTHER i 3 PATIENT CONDITION: DRIVER lt L-� EMT-tA n TECHNICIAN Lr N 4PARAMEDIC 1l,,��- Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES O REASON FOR DRY RUN 7 c, AUTHORIZATION F R DRY RUN(EMS USE ONLY) j� c PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N PRIVATE INS.CO. T-}4f-1301 W OAK. r kJD:]— BASE RATE: KAISER xr' MULTIPLE PTS.BASE RATE cd BLUE CROSS M: TOTAL MILES: } X _ D _ . j.tri o MEDICARE M: �1 G -C:1� .L t1 l /1 E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) m CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL N: CODE 2(3 OTHER. OXYGEN: (PE<�TANK) �(�� ,J'J 14; O ; P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) a �_ E.K.G.: (PER EPISODE) i •r NEAREST-RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X O DRUGS: (PER ADMIN.) X O, NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) I CD PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) (I EMPLOYER: r OCCUPATION: OTHER: ADDRESS: _❑ CITY: STATE: ZIP: C COMMENTS: �-' `b r ��Ir .('�CPt.� C i A 149 �_ n M I`Y TOTAL _ 'Pt 111.1 r,c 2 C_A ;_. D A 1�, t-,ri-LL_. _ PATIENT RECEIVED BY:X (SIGNATURE) ) n Provider-toir. Write (.rd Pin; copy 4aturn Y�'!,,►, ;,•? r �4.' uhaq bit rn,J ►"� I . CONTRA COSTA COUNTY AMBULANCE �� f PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE:r 7 PATIENTS NAME J ❑ IJh�❑ F COMPANY N ADDRESS AGE i K �C I k/ CITY STATE - ZIP DOB E+_ 0 Sn 0 M 4T W ❑rr Th O F ❑ S DRIVER'S LICENSE N _ _ PHONE _ NATURE OF DISPATCH Al 1A_2_f'I TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ STATION 1(A)_2(8)_3(C)_4(D)._5(E)_ INCIDENT LOCATION: RESPONSE CODE: IMPESTED BY: TIME—(24 HOUR CLOCK) 1 TO SCENE- 0. CALL RECEIVED : 2 Mf) N L�i 3 ❑ P.D. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE-o ❑ FIRE TIME 10-97 / ) r ❑ PSAP TIME 10-49 --�-- �� MILEAGE: O OTHER/PVT TIME 10-7 S� END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 r� HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST 0 FAMILY 0 TRANSFER WAIT TIME ❑ PATIENT 0 DIRECT ❑ OTHER CALL BACK N: AMB}JL/a{J`E COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: , RESPONSE ZONE r' ❑ YES 0 NO ❑ WALKED 0 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER fVc- l EMT-tA (� [ TECHNICIA W1(_C ) PARAMEDIC Hx: (b'2Z K� l u� L DISPATCHER* d - ('l{ CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN f FOR OPY RUN(EMSUS NL Y)PATIENT REFUSED SERVICES:(SIGNATURE) V�HORIZATION J - ' MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO.OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PT RATE BLUE CROSS 0: TOTAL M S: X MEDICARE N: E.O.B. ATT. ROUN TRIP: O YES NO . Q YES 0 NO NIG TOT/ {19:00-07:00) CCHP/PPRP N: E AGENCY RUN: 1 MEDI-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR DATES BILLED: STANDBY: (OVER 15 MIN. EX,G.: (PER EPISODE) tt NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.:�VER ADMIN.) X DRUGS ER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF N REPLAC D) ADDRESS: ORAL AIRWAY: (F NOT REPLACED) CITY: STATE_ IP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPA7OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:- 50 ._ ,Cl:G..-.- —- _ -00 12,E , l v CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CAR�FORJ I UNIT "^ AUTHORIZATION# CHECK OR fICL IN APPR PRIA P s - DATE: � ;r PATIENTS NAME t; ��•7 L ' C'(+'111577/44 ❑ M XF COMPANY M,��_T— ADDRESS y AGE CITY STATE ZIP DOB— ❑ Sn ❑ M ❑T AW O Th ❑ F ❑ S DRIVER'S LICENSE# __ _____—_.__—_ PHONE__.._ ____—_ NATURE OF DISPATCH—� G TYPE OF TRANSPORT: AMBULANCE/W OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CCK) ,•� TO SCENE- CALL RECEIVED (J- -q— '51gAA1 ❑ P.D. TIME 10-8 H— PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME. ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �� ❑ PATIENT 13 DIRECT 13 OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: [RESPONSE ZONE ❑ YES ❑ NO ❑ WAL KED ❑ GUERNEY ❑ OTHER PATIENT,CONDITION: DRIVEROn47' `�V`nfj C� I t" EMT-1A TECHNICIAN l -ci1 r`� pARAMEDIC Hx: _ DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN t C� yZHORIZ TION FOR DY RUN(CM USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X < \ \ .� I r/ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER Q YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: '(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: _ _ 0.0015 .... __. _._ .. PA TIE NI NLCEIVEO LiY. X Isu;NAnINr.►" /1 y� ,'�• /'T qri alar 1'Pfnf r, Yhi fr .1�( l..�. -"1 r.r I rrr+. ?r TCNTRA COSTA COUNTY AMBULANCE G' PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR flLl IN APPROPRI A TE SPACES . ) DATE; PATIENT'S NAMF,_ /� O M O F COMPANY# ADDRESS AGE of CITY STATE ZIP DOB_ O Sn ❑ M OT W ❑ Th OF QS DRIVER'S LICENSE# _ _ .. _.-_-.. PHONE_-._.-. _...-.__ NATURE OF DISPATCH ((- TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- .O. CALL RECEIVED _ 1\ss ''(( �•!( J /� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE11FIRE TIME 10-97 -0 PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _ PMD/ER START TIME 10-22 } HOW CHOSEN: I TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY:^ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: <.� U RESPONSE ZONE --- O YES ❑ NO ❑ WAL'GED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �LC1 f l'� EMT-tA TECHNICIAN E 'PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY R//UN:- Cl,YES ❑ NO REASON FOR DRY RUN AU -F4 �1 FO DRY N(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X �' '��: i( 'L MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: z10 ,'t�� '�/�•' S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE._—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �2—W EMPLOYER: :-4 OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: , ----- TOTAL:-- ---- v �- -- ` ' 152 PAM N1 Of 1 IAVI 1) fly X ro CONTRA COSTA COUNTY AMBULANCE ' 01 , PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION'# / l CHECK OR FILL INAPPROPRIATE SPACES- DATE: PATIENTS NAME ❑ M O F COMPANY#�•�7 ,�;`/ ADDRESS AGEN, CITY--- STATE ZIP_ DOB—___ O Sn ❑ M ❑ T OW O Th OF O S DRIVER'S LICENSE# __.—.. PHONE _. _....__ NATURE OF DISPATCH._��- TYPE OF TRANSPORT: AMBULANCE ER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) / TO SCENE- S.O. — CALL RECEIVED NAN TIME 10-8 PATIENT DESTINATION: FROM SCENE— ❑ FIRE TIME 10-97 r 1 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHERIPVT TIME 10-7 _ T END TIME 10-98 DOCTOR PMD/ER START_ TIME 10-22 f HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME __ C ❑ PATIENT O DIRECT O OTHER CALL BACK C AMBULANCE COMPANY: / PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: � . RESPONSE ZONE ((Z__ O YES O NO O WAC,ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER !l� EMT-1A -1 1 TECHNICIAN LA �/�G �� -' PARAMEDIC _ Hx: +` DISPATCHER: l 11 Ll y(/ - CHIEF COMPLAINT: (� � V `' �' -= 1�( I�� - DRY RUN: 0 YES ❑ NO REASON FOR DRY RUN —_ A HORIZATIN FOf RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X._ {L � —��/2E,pa-� _.. L��. MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS.4 — TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: OYES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) 1� CCHP/PPHP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - - TOTAL:.------..._. - - - 00153 004 k. J fAll( N.l III faIVIfllly x CONTRA COSTA COUNTY AMBULANCE 8�/'(q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 I CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ` 1 OM ❑ F COMPANY p 1� y�- -Alf) / ADDRESS AGE CITY _ STATE ZIP--- DOB_ ❑ Sn 'OM OT //O//W O Th OF OS DRIVER'S LICENSE p __—._ .-._.____...__--._ PHONE_..--.. . _-_-.._.. NATURE OF DISPATCH.- TYPE OF TRANSPORT: AMBULANCE UV OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. _ CALL RECEIVED zL nl`1 N ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 :�v HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER (�� LA EMT-tA TECHNICIAN PARAMEDIC Hx: _ DISPATCHER: CHIEF COMPLAINT: DRY RUN: O YES ❑ NO REASON FOR DRY RUN AUTHORI TION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES' (SIGNATURE) X__ .__ - `_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:.(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: SPATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: 4 DRY RUN: (AUTHORIZED) EMPLOYER:. OCCUPATION: OTHER: ADDRESS: CITY: STATE:--ZIP: COMMENTS: - ---- -- - - TOTAL: -�'�{} --. ...---- V V 0154 00 .f VAI It N1 $gI'r:I'IVI Il I1Y X , . CONTRA COSTA COUNTY AMBULANCE L/ PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION N ` / v � t CHECK OR FILL IN APPROPMATE SPACES DATE: PATIENTS NAME N,lah a s*ah Sv- O M �F 36Q GE COMPANY M ADDRESS co/ - CITY CoflCCfW94:51 ��1 >�••'^_� - STATE ZIP9y� DOB�S Z6-S6 O Sn O M O T�W O Th,O F O'S-�j DRIVER'S LICENSE# S_1�L--+ PHONE SZ � -LNATURE OF DISPATCH I TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_2(B)_3(C 4(D)_5(E)�- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C4OCK) �] TO SCENE- S.O. CALL RECEIVED /�/ lo`r- �l; l 1 V. /� 1 Z� P.D. TIME 1Q-8 r.-- PATIENT DESTINATION: w FROM SCENE ❑ FIRE TIME 10-97 _ �3 1L� ❑ PSAP TIME 10-49 G c MILEAGE: 3 O OTHER/PVT TIME 10-7 END 6•^ TIME 10-98. DOCTOR PMD ER START 5a( TIME 10-22 HOW CHOSEN: TOTAL _ - STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 1 �: PATIENT ❑ DIRECT ❑ OTHER CALLBACK 8: AMBULA E C.O ANY: KY MBULATORY? PATIENT T EN AMBULANCE: RESPONSE ZONES ❑ N0 ❑ WALKED GUERNEY O OTHER PATIENT CONDITION: DRIVER -'-�• ,Pyilei�b� EMT-IA (` — TECHNICIAN:1 Iy& GOA(SO PARAMEDIC Hx: �I"c'.f' S J l� DISPATCHER: ` u.S-1- t> 'e— h, CHIEF COMPLAINT: DRY RUN: ❑ YES�NO REASON FOR DRY RUN 1 l� Y AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X fT I MEDICAL COVERAGE: INDUSTRIAL ❑ YESKNO NO. PATIENTS: r_. Y/ S.S. a l 1) —( 7Y,7 PRIVATE INS. CO.: BASE RATE:D KAISER a: MULTIPLE PTS. BASE RATE �� • ^,r, . � J BLUE CROSS#: TOTAL MILES: X 1 MEDICARE M: E.O.B.ATT. ROUND TRIP:' O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CJ CJ CCHP/PPRP C EMERGENCY RUN: D••0 ME DI-CAL M: CODE 2 3 � L•--.►J OTHER: OXYGEN: (PE ANK) II �. P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) J. DATES BILLED: STANDBY: (OVER 15 MIN.) E:K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X.- (� DRUGS: (PER ADMIN.) X NAME: RELATIONSHIPr'�-M E.O.A.:(IF NOT REPLACED) - `- ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:Arpmrtc' L STATS ZjP: C-COLLAR: (IF NOT REPLACED) - - - WORK PHONE: 4 DRY RUN:. (AUTHORIZED) EMPLOYER: O CUPATION%_ OTHER: - --`-• ADDRESS: ' U1 Zfi CITY: IAJ �j STATE: ZIP• COMMENT$: TOTAL• 7 uuHs PATIENT RECEIVED BY:X ��• ��G`C9�O'c►•�S h'N ; 001. (SIGNATURE) Def-1 `. ;, Provider rrta:, Nhite rd ►4ni c•opr Artue.i lr:(cW nrrpli t• OMS when Dil:inq ICONTRA COSTA COUNTY AMBULANCE P E-HOSPITAL CARE FORM I UNIT AUTHORIZATION a / Y CHECK OR FILL IN APPROPRIATE SPACES DATE: :2T70ZO�i PATIENTS NAME L U1 ❑ ll j'.❑ F COMPANY ADDRESS AGE i7 t� CITY _ STATE ZIP_ DOB_____—-. ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE q __—__ PHONE _._.._ NATURE OF DISPATCH— TYPE OF TRANSPORT: AMBULANC THER❑ _— ,_—_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLCK)p s- 0 TO SCENE- Ff-j S.O. CALL RECEIVED . ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE _— TIME 10-97 ❑ PSAP TIME 10-49 1 MILEAGE: ❑ OTHER/PVT TIME 1D-7 END TIME 10-98 DOCTOR PMD/ER START_ — _. TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 0 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT D OTHER CALL BACK a; AMBULANCE COMPANY:� � PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �- ❑ YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 6111 PAI EMT-tA TECHNICIAN . PARAMEDIC Hx: DISPATCHER: �n n CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTH TION F R TRU (EMS E l)NLY)_ PATIENT REFUSED SERVICES: (SIGNATURE) X_ �.L —j--� I MEDICAL COVERAGE: INDUSTRIAL D YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS, CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X MEDICARE a: E.O.B.ATT- ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) i CCHP/PPRP a: EMERGENCY RUN: I MEDI-CAL a: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: T' ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE—`ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: 00156 ADDRESS: _ CITY: STATE: ZIP: _ COMMENTS: TOTAI — QO- 10014 CONTRA COSTA COUNTY AMBULANCE S 0 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION ROPRIATE SPACECHECKORNLLINAPPG( DATE: II M 13 F COMPANY N `� �r •� .PATIENTS NAME ❑�.ADDRESS AGE , 0 k CITY _ STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH ZZ` :2� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE .O: CALL RECEIVED ❑ P.D. TIME 10-8 / PATIENT DESTINATION: FROM SCENE;i; ' -D FIRE TIME 10-97 ` I , ❑ PSAP TIME 10-49 " MILEAGE: , ❑ OTHER/PVT TIME 10-7 _77 _ END TIME 10-98 DOCTOR PMD/ER STAR-T---\ TIME 10 22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME Q PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPAN1jIY� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: L% RESPONSE ZONE ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER `�� 't' / EMT-1A TECHNICIAN PARAMEDIC— — Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: D YES ❑ NO REASON FOR DRY RUN A H ON FOR DRY RUN(EMS USE ONLY) r PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: - ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 000157 -•--.__-.�_�__�.. _ _-.. -.-- -_-...__. PATIENT RECEIVED BY: X.- CONTRA COSTA COUNTY ��} AMBULANCE ! PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 Ell cl � U CNECR OR FILL.IN APPROPRIATE SPACES DATE: , I PATIENTS NAME_ L9 L/I) ❑ M O F COMPANY A ADDRESS AGE CITY _ STATE ZIP DOB O Sn D M OT OW OF ❑S DRIVER'S LICENSE M _ - PHONE __ NATURE OF DISPATCH -� , TYPE OF TRANSPORT: AMBULANCE Q OTHER O — -- STATION 1(A),2(8)_3(C)_4(D)_5(E)_ �NCIPENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) �{ (,l1G�f fC►� �� W C TO SCENE- �'S.O. CALL RECEIVED O P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE O FIRE TIME 10.97 (07- 11 0ZO PSAP TIME 10-49 :t— �� 1 MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 I DOCTOR PMD/ER START TIME 10.22 O3 :Cs HOW CHOSEN: TOTAL STANDBY TIME O NEAREST_ ❑ FAMILY ❑ TRANSFER WAIT TIME _ O PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANY: cis PT.,AMBULATORY? PATIENT TAKEN TO AMBULANCE: `: I 1 RESPONSE ZONE YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT ON IT pN- DRIV R / "� I F ( EMT-1A 3p�� FCii clowrl TECHNICIAN -�''��^ (' ( ' PARAMEDIC Hx: Q w b0.tA -\v"Q_lvxT_,pl 6L, tt Ccci DISPATCHER: CHIEF COMPLAIN4)00-b le '= clv- O-MIrle DRY RUN: ®'VES ONO REASON FOR DRYRUN 0.S C' sko u h ckTjvlp AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT EFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N L�� PRIVATE INS, CO.: BASE RATE: JJ KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES .O NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL 4: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) ``,w, � PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) lay, EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: ```` STATE• ZIP: COMMENTS:— OC-U IC-' TG G b( o_;In TOTAL:- 0 O ------ --- -- 00015 PATIENT RECEIVEn QY: X .......- - - _ .. ;Glf)N•`••ISI I _. CONTRA COSTA COUNTY - AMBULANCE Q�/ )�� /•.�•�;^.• . Pff-HOSPITAL CARE FORM I UNIT AUTHORIZATION VV / CHECK OR FILL IN APPROPRIAT4SPACESDATE: 2` SO •• ' t PATIENT'S NAME 3:ry! �J._ - _ f�/�A ❑ F n COMPANY N I / nn -.-... ADDRES I l a C, AJQnt 4 Uil�1 _ 'j.�l7 AGE 1p 0' l U 12-163 I 1 CITY •L STATE ZIP -DOBtGLJ�LL ❑ S. ❑ M O ❑W [�O F-13'S• i DRIVER'S LICENSE q __rJ..`_ �__ — PHONE q3-47 (a NATURE OF DISPATCH rPVpt TYPE OF TRANSPORT: AMBULANCE Y OTHER _ •►� I INCIDENT LOCATION: L.11 At t CJ RESPONSE CODE: RRUESTED BY: TIME- (24 HOUR CLOCK) „t ft 1 a j I I �) TO SCENE- S.O. CALL RECEIVED-,j- '• _�Q.J t�_ O P.U. TIME 10-8 -, 1 •3� . ..,.. :. PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ; ..1. --10 ❑ PSAP TIME 10-49.. . •.�-�- �_-_ J MILEAGE: G ❑ OTHER/PVT TIME 10-7 . 3 y ENDb• TIME 10-98 DOCTORfER, START n TIME 10-22 :;.r.�•.3 HOW 9HOSEN: TOTAL ` STANDBY TIME.GK - NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULA CE COMPANY:: PT AMBULATORY? PATIENT TAKEN/_0 AMBULANCE: �G RESPONSE ZONE _ YES ❑ NO ❑ WAL:tED UERNEY ❑ OTHER ` t PATIENT CONDITION: DRIVER—Fe1 '1 60 15 EMT-1 . TECHNICIAN QC a - PARAMEDIC (f�'f Hx: �C\_laC._r�Fyifl DISPATCHER: (� / IEF COMPLA Cwt's_ S ok�S , OJe1"Q� ( 0�"� 1 _,�, DRY RUN: ❑ YES L9'NO REASON FOR DRY RUN � ��Q55 'AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) Xyl MEDICAL COVERAGE: (� I!NDUSTRIAL ❑ YES NO NO.OF PATIENTS: d`)`° S.S. a �� ( 0c(5 v I. PRIVATE INS.CO.: BASE RATE: -J1LL.ld .� KAISER R: MULTIPLE PTS.BASE RATE LUECROSSR CL C C'0 P30(i� 3�1-10- QIQj TOTAL MILES: (CARE a: ( D' (c E.O.B. ATT. ROUND TRIP: ❑ YES 13 NO >"�,. �,_ '•^I t ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 ( . Iv-, I(� CCHP/PPRP N: EMERGENCY-RUN: _� L � v7� MEDI-CAL a: COD�2)3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) l DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/R PONhSIBLLE PARTY: I.V.: (PER ADMIN.) - y Xt•-- ( V DRUGS: (PER ADMIN.) X NAME: Jw ►1 -RELATIONSHIP:_• E.O.A.: (IF NOT REPLACED) --- ADDRESS: �� ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE--ZIP' C-COLLAR: (IF NOT REPLACED)- .....----• _ PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �QO� EMPLOYER: �• OCCUPATION: OTHER: - V /p� ADDRESS: CITY: STATE: ZIP COMMENTS: TOTAL. 'PATIENT RECEIVED BY:X 0v (SIGNATURE) (� 13A Prelvider reta:r. White Pin, ropy Fetid+: Ye lvv EI.S uhrn biI:in EMS-I � CONTRA COSTA COUNTY AMBULANCE F3i20o _ PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION x CHECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME _ +,t—t2k O NL,❑ F COMPANYK ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M O T O W A*Th OF OS DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH fll:�-aj TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION 1(A)_2(B)_3(CI_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) ! r h jr$.-0 c e �' TO SCENE- ®s.0. CALL RECEIVED : ^ ❑ P.D. TIME 10-8 PATIENT DESTINATIO FROM SCENE- ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49 _ MILEAGE: ❑ OTHER/PVT TIME 10-7 1 END TIME 10-99 • DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ~ O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCCOMPANY:�S.� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c 1 RESPONSE ZONE S ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: `� �j� i �� DRIVER m e ( e�~ ( EMT-tA_.Z Z, p /0 -`, -,S'- e 1 !0- ✓ TECHNICIAN n (S c, n PARAMEDIC ;1 Hx: I N K ISPATCHER: i=I�' t" .,` 1 CHIEF COMPLAI DRY RUN: (AYES ❑ NO REASON FOR DRY RUN L0 SS PC' grl9 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 11 PA TENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY 1 MEDI-CAL C C 2/3 OTHER: EN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ,1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: '~ STATE ,ZIP; C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: (41"160 COMMENTS: 00 131 1) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION OPT-12- d /-1. CHECK OR FILL IN APPROPRIATE SPACES DATE: 2Z— r � PATIENT'S NAM 1 - O M � COMPANY M ADDRESS., I / AGE M00 Inv) ` CITY I STATE Z{P t �v DOB r - Sn O M D T O WO& O F S ` ! DRIVER'S LICEy$E p —_ PHONE __ NATURE OF DISPATCH-11-IffOlkM TYPE OF TRANSPORT: AMBULANCE THER❑ _ STATION 1(A),,2(B)_3(C)_4(D)_5(E)_•• INCIDENT LOCATION: _ RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C OCK) _ 1 �•.• (, 2- TO SCENE- O. CALL RECEIVED _ T. O P.D. TIME 10-9 y PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �C ) ,L , O PSAP TIME 10-49 e� ©kS/�o MILEAGE: �- ❑ OTHER/PVT TIME 10-7 Z y' � END y TIME 1098 -j DOCTOR x�_11 PML START :20.9 TIME 10-22 - I HOW CHOSEN: TOTAL. STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME -; TIENT O DIRECT O OTHER �.�. CALL BACK M: AMBULANCEOMPA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: � U RESPONSE ZONE i ES ❑ NO ❑ WALKED XdiUERNEY O OTHER ( PATIENT CONDITION: DRIVER �1 TECHNICIAN ��A M DIC ; c J ( ^ (_l Hx:� l DISPATCHER: �. =�I F ' �� CHIEF,COMPLAIN>: ilI � �^ DRY RUN: ❑ YES 13-.,NO REASON FOR DRY RUN ,1�• , 11 7 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ^ir,,nfrl1;`� (S PATIENT REFUSED SERVIC S:(SIGINATURE) X MEDICAL COVERAGE: INDUSTRIAL-O YES 12�NO NO.OF PATIENTS: &S. -�, i PRIVATE INS.CO.:kI l� - �' ✓_ BASE RATE: 1_1LLLF� KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS B: TOTAL MILES: X = � MEDICARE K: E.O.B.ATT. ROUND TRIP: O YES O NO O YES ❑ NO NIGHT: (19:00-07:00) - 1 I I CCHP/PPRP M: EMERGENCY RUN: c: MEDT-CAL K: CODF7'2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES d NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' r i j �;� DRUGS: (PER ADMIN.) X NAME: I' �! ) '� > RELATIONSHIP:1_L1. _ E.O.A.: (IF NOT REPLACED) ADDRESS: �- � �� - ORAL AIRWAY: (IF NOT REPLACED) CITY: ' _ STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: ._ OCCUPATIOM OTHER: - ADDRESS: CITY: STATE: ZIP: COMMENTS.R .- t,Y I - . ?� )b Or d fief 11P(_I 1l TOTAL' \ - •s1 A PATIENT RECEIVED BY:X ' - O O Provider reta_r White end M:: rorr 4otur+I Ye'-wr .nF, r• Mc r,n Dil-ing IG 41 URE} OSS-1 13 , CONTRA COSTA COUNTY ( AMBULANCE -- PRE -NOSP{TAl CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES E y I / DATE: ^� ^93 . PATIENT'S NAME K(_�C_ k"`!�.._�._`.�� . � / xv ,❑r F COMPANY M ADDRESS ? `' _ GC l/� AGE "� 3S 46 I, v <<-G'LC L /L '/y C Y_ STATE— ZIP DOBS—_ Sn ❑ M O T O W �TT� O FI O S. DRIVER'S LICENSE.$t ________ - _--... __.._ PHONE �__p.,&_(_l_(_NATURE OF DISPATCH J _. TYPE OF TRANSPORT: AMBULANCE ZKQTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ! 1 TO SCENE ❑ S.O._ CALL RECEIVED Nv l '� ❑ P.D. TIME 10-8 _1 PATIENT \ DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �R It �\�,1 e e i} �i __ ❑ PSAP TIME 10-49 . I 1 l.� MILEAGE ^, ❑ OTHER/PVT TIME 10 7 :. _ END TIME 10-98DOCTOR _-_ PMD/ER START A TIME 10.22 -J HOW CHOSEN: TOTAL J STANDBY TIME ❑ NEAREST ❑ FAMILY 51-1�RANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER .�+� � GALL BACK N;.., AMBULANTCAVP Y: PT AMBULATORY? PATIENT TAK N TO AMBULANCE: 'i RESPONSE ZONE YES ❑ NO O WAL':ED VTUERNEY ❑ OTHER y� PATIENT CONDITION: DRIVER Q M"� t`, ENiT-1A J n�n��/vA� ��G ,(t t/ TECHNICIAN �"' )ARAM DIC Hx: _� 1 DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES /t�NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X— ') .! MEDICAL CQY-ERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: - _ BASE RATE: ' 0•G?�'-1 KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ONO (� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP PPHP#: EMERGENCY RUN: 20 MEDT-CAL a: CODq 2./3 ) �l OTHER: _— OXYGEN: (PER TANK) --� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME, RELATIONSHIP:---- E O.A.: (IF NOT REPLACED) " ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:_-__.. ___...- ._._. STATE_--_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE - WORK PHONE. DRY-RUN: ,(AUTHORIZED) EMPLOYER: _._._ __... _ __ OCCUPATION:' OTHER: ADDRESS: CITY: __-__ STATE ZIP: COMMENT�G$/,_� I� L 1.�,►6' t1 s Tld 6.2 TOTAL: PATIENT RECEIVED BY:X - Pmvidrr mai% whit.. •xd Ti... •p} Fehr+ ir'C<t rn:•. �'." 1•hen ►i: in IS NATURE) DIS-1 00 137 CONTRA COSTA COUNTY 4 AMBULANCE I O (n PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 I,,I 6 / 1 � •1 I PATIENTS NAME OM OF COMPANY ADDRESS I U N AGE 1 " CITY _ STATE ZIP DOB - O Sn OM O T O W O F" ❑./S. DRIVER'S LICENSE k _ PHONE —__—_ NATURE OF DISPATCH RLAO -_I—T TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _ —_ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME—(24 HOUR CLOCK) _ t TO SCENE- O. CALL RECEIVED I(t CA(a( , v O P.O. - TIME 10-8 PATIENT DESTINATION: FROM SCENE( O FIRE TIME 10-97 Lf ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER STAR TIME 10.22 fir/ HOW CHOSEN: TOTAL STANDBY TIME Q NEAREST ❑ FAMILY O TRANSFER WAIT TIME (3 PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: n DRIVER 'll �Q M - EMT-1A �N 2U (' �� p TECHNICIAN �--�N� PARAMEDIC Hx: (U-2-'- DISPATC ER: U2 CHIEF COMPLAINT: DRY RUN: S O NO REASON FOR DRY RUN AUTHOR I TION FOR DRY RUN(EMS USE ONLY) I Itl� PATIENT REFUSED SERVICES:(SIGNATURE) X )( J MEDICAL COVERAGE: INDUSTRIAL ❑ YES O O. OF PATIENTS: l S.S. N f" PRIVATE INS.CO.: BASE TE: KAISER N: MULTIPL PTS. BASE RATE BLUE CROSS N: TOTAL MIL S: X MEDICARE k: O.B. ATT. ROUND TRI " 13 YES 11 NO ❑ S O NO NIGHT: (19:00 07:00) CCHP/PPRP N: EMERGENCY R N: MEDI-CAL k: CODE 2/ OTHER: OXYGEN: (PER TNK) P.O.E.STICKER ❑ YES 13 NO NEONATAL: (INCIZTOR) \ DATES BILLED: STANDBY: (OVER MIN.) E.K.G.: (PER EPISO E) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMI ) X NAME: RELA ONS IIP: E.O.A.:(IF NOT REPLA�ED) ADDRESS:, ORAL AIRWAY: (IF N REPLACED) CITY: ST E. ZIP: -COLLAR; (IF NOT R PLACED) PHONE: WORK P ONE, D RUN: (AUTHORIZ D) .1' EMPLOYER: _ OC PATION: ` OTH ADDRESS: CITY: STATE: ZIP: COMMENTS: -- TOTAL:—,�L?l/--- --- 00-0163 O O__ .�_`__._.__ _.• _ PATIENT RECEIVEn (iY X icir, ie� ,nr 1 AONTRA COSTA COUNTY AMBULANCE Q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 93 I 1019 -CHECK OR flLl INAPPROPRIATE SPACES 91� PATE: 'PATIENTS NAMEisp_ "Q O ) M F COMPANY N ADDRESS R-94 AGE CITY l0 c- - - A STATE_ ZIP 5y SVa_ DOBA14Lb ❑ Sn ❑ M ❑ T ❑W ❑ Th O S ' DRIVER'S LICENSE N _ I PHONE 93-1:IMl NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ — STATION 1(A)_2(8)_3(C)_4(D)_51E)_ - " I 2NCIDENT(LOCATION:" RESPONSE CODE: EE UESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ( �S,O. CALL RECEIVED L. to J -0 P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 13 FIRE TIME 10 97 ❑ PSAP TIME 10-49747 MILEAGE: II 13OTHER/PVT TIME 10-7 1-r- : ii END v0 '3 TIME 10-98 'DOCTOR ' 3800P PMD& START k , TIME 10-22 HOW CHOSEN: TOTAL �'�Q STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME i ,�4ATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMB�S E COMPANY: PT. AMBULATORY'► PATIENT TAKEN TO AMBULANCE: ::Z- RESPONSE ZONE YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER J ��t EMT-tA TECHNICIAN W t LL_I��^/1S •!'-?` t - ' PARAMEDIC Hx: DISPATCHER: ✓ 14 ' ^ L/r CHI9F COMPLAINT: N f DRY RUN: ❑ YES REASON FOR DRY RUN 3 S.Ot [Ac-Alo AUTHORIZATION FOR DRY RUN(EMS USE ONLY) q✓ ) :..; PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N /✓Ja)..i PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE LUE CROSS E Z` 3 2 TOTAL MILES: " X N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: "OG MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -' NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X - NAME:MILLf-9 CW-AAL-Dilf-RELATIONSHIP: E.O.A.:(IF NOT REPLACED) AlDRESS" 9 1;t ORAL AIRWAY: (IF NOT REPLACED) -- f -"CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 9c $i4 IS4 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: . - CITY: STATE• ZIP: L y COMMENTS: -- TOTAL: uuuvui_.�d> --- --� -- 6 S'C __. PATIENT RECEIVED BY: X... 1 -�1 u CONTRA COSTA COUNTY AMBULANCE �l`�ry PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION N �, lt ..VV CHECK OR FILL IN APPROPRIATE SPACES _ DATE: � 73 PATIENTS NAME R f OM ❑ F COMPANY N ADDRESSAGE 1% C,IK'y I CITY STATE ZIP DOB_-- '❑ Sn O M ❑ T ❑ W O Th F ❑S DRIVER'S LICENSE N _ _ PHONE ________ NATURE OF DISPATCH(a), TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) _ TO SCENE-� S.O. CALL RECEIVED C ' : Y 70 P.D. TIME 10-8 PATIENT DES (NATION: FROM SCEN O FIRE TIME 10.97 t ❑ PSAP TIME 10-49 Iyl MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10.98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N; AMBULANCE COMPAkY:� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE (�� O YES ❑.NO O WALKED 13GUERNEY O OTHER 1 � I PATIENT CONDITION: DRIV122AMT� � TECHNICIAN I-� ��f DIC Hx: _--- �JoI=� � DISPATCHER: r, �? CHIEF COMPLAINT: DRY RUN: kYES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: A/.-.10 %'' S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) ((( P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - TOTAL:.- -- -- C• t'��, - PATIENT HECEIVE0 IIY X /:II:NI T I rAl� CONTRA COSTA COUNTY AMBULANCE , h PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N •vim 14 CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME 1 O M O F COMPANY N - ADDRESS _ I j U iV AGE',- (^ CITY STATE ZIP DOB - ❑ Sn O M ❑ T O W ❑ Th Os DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH ' TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION I(A)-_2(8)_3(C)_4(D)_5(E)_ -INCIDENT LOCATION: RESPONSE CODE: RMUESTED BY: TIME- (24 HOUR CLOCK) ,�. � C Y I /►,,'+ TO SCENE- S.O. CALL RECEIVED ,(,04 lTO-Iyio- VMyV 0 v ❑ P.U. TIME 10.8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Q wap 13PSAP TIME 10-49 PJ, p MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 ' DOCTOR PMD/ER STAR TIME 10.22 HOW CHOSEN: TOTAL l J STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT 13 OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ✓ �.� RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER W(�I ^S "L '-' EMT-1A TECHNICIAN �YNr� r' �J PARAMEDIC Hx: Jy`2 r^� �" ' WC�� DISPATCH t•- AIJ f'' 'i CHIEF COMPLAINT: _ DRY RUN: E ❑ NO REASON FOR DRY RUN AUTHO TION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �I S.S. N PRIVATE INS. CO.: 191 AT KAISER N: L PTS. BAS RATE BLUE CROSS N: ILES- X MEDICARE C E.O.B. ATT. TRIP: ❑ YES ❑ NO ❑ YES ❑ NO . (19:00-07:00) CCHP/PPRP N: ENCY RUN: MEDI-CAL N: ODE 2/3 OTHER: : (PER TANK) P.O.E. STICKER ❑ YES ❑ NO TAL: (INCUBATOR) DATES BILLED- Y: (OVER 15 MIN.) ' (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: . . R ADMIN.) I X RUGS-. (PER ADMIN.) X NAME: RELATIONSHIP:-) ELATIONSHIP: E. A. (IF NOT REPLACED) i ADDRESS: ORAL IRWAY: (IF NOT REPLACED) CITY: r STATE- ZIP: C-COLL (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: UTHORIZED) ;J EMPLOYER: OCCUPATION, OTHER: ADDRESS: CITY: STATE: ZIP-.- COMMENTS: IP:COMMENTS: TOTAL: 6 PATIENT RECLIVED By X ----- --.. 1',u'.I,4i�iIII CONTRA COSTA COUNTY AMBULANCE -7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION If —' CHECK OR fILL IN APPROMATE SPACES DATE:_7 PATIENTS NAME `�}' 1{ l _ ❑ M ❑ F COMPANY M �' •� ADDRESS l AGE - �� CITY STATE ZIP--- DOB_`.__. � ❑ Sn 11M ❑ T ❑ W 13Th EYF ❑ S DRIVER'S LICENSE M ___.. _... PHONE .- __.__ NATURE OF DISPATCH- p-� " b1ea-4l�_I�r� TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: EQUESTED BY: TIME— (24 HOUR CLOCK) 1 � ' �, l , n TO SCENE- p �.S.0.�__.___ CALL RECEIVED C �1� . M f —`__ ---- J ❑ P.U. __ TIME 10-8 / PATIENT DESTINATION: FROM SCENE- ❑ FIRE ! TIME 10 97i -' :�� ❑ PSAP / TIME 10-49 MILEAGE: ❑ OTHEWPVT TIME 10-7 END TIME 10-98 DOCTOR _ PMD/ER START-:,:7 ��_ TIME 10-22 HOW CHOSEN: TOTAL _ - STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK n; AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE-- 0 YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER `_P-fR MT-1A TECHNICIAN _ 1P r Yl� 7 PARAMEDIC Hx: __ DISPATCHER: n <> CHIEF COMPLAINT: __ DRY R N: YES O NO REASON FOR DRY RUN 4 I/ AUT I A 10N F0 DR UN(EMS USE UNLV) �Ir7 PATIENT REFUSED SERVICES: (SIGNATURE) X __-_ - '_ _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. R PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS++: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP»: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 �. OTHER: _ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G:: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)__ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) 7,- CITY:_ —_ STATE—_ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE. _ DRY RUN:. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY. ` STATE ZIP:— COMMENTS: IP:COMMENTS: {�� V�t4s��Q v1 L� 5 4�Q h ,LjbvAA A-4Q-45�1,f+ a Itczl ` 6'7. 0 0 1 Qlor,20 i'A111 N I til UY X CONTRA COSTA COUNTY AMBULANCE t.- PRE-HOSPITAL CARE FORM 1 UNIT (�� AUTHORIZATION \'\l CHECK OR FILL IN APPROPRIATE SPACES DATE: '7 PATIENT'S NAME__lr�'1f=1� yC. C�� .iV X) M J�❑ F COMPANY ADDRESS - 2Z.3� F= � �1 AGE'*�_�!, ,/ ,....., CITYSTATE e ZIP DOB t-3)�71J 13Sn ❑ M ❑ T C3 W 13Th 0►F ,D S DRIVER'S LICENSE-# c___.__— PHONE_._— NATURE OF DISPATCH S17UQG TYPE OF TRANSPORT. AMBULANCE❑ OTHER❑ .__�_____—•_— I•, INCIDENT LOCATION: RESPONSE CODE: RE,01JESTED BY: TIME— (24 HOUR CLOCK) Y'7 No c�� /��,( ( �� TO SCENE- S.O. CALL RECEIVED ``� ` 1 1 _ ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 13 FIRE TIME 10-97 ��1 I�_ p' 2 13PSAP TIME 1049 L��'` MILEAGE: _ ❑ OTHER/PVT TIME 10-7 _ K - END TIME 10.98L� p� DOCTOR — PMD/ER START C-F _-A _ TIME 10-22 HOW CHOSEN:CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑.TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE WMPANY: PT. AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE ❑ YES NNO ❑ WALKED GUERNEY ❑ OTHER 2 PATIENT CONDITION: DRIVER C y QEMT-1A V trl Pl oZ 3 �- TECHNICIAN SAME IC '� • H. S��r�V�� ____. DISPATCHER: (�(,. l oy T ( . CHIEF COMPLAINT: 4_4OQc- -- DRY RUN: O WS ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /r YPATIENT REFUSED SERVICES: (SIGNATURE) X_ f J MEDICAL COVERAGE. INDUSTRIAL Cl YES ❑ NO NO. OF PATIENTS: J�S /U S.S. #.. / .. � PRIVATE INS.CO.: BASE RATE: KAISER a: — _ MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) —�—� CCHP/PPHP#:_ _ EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) i P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED. _ STANDBY: (OVER 15 MIN.) 54 { E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ` DRUGS: (PER ADMIN.) X i� NAME:___.._._ _ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:..---.- ORAL AIRWAY: (IF NOT REPLACED) CITY:___— _—___ STATE_____ZIP: C-COLLAR: (IF NOT REPLACED) PHONE ___�_ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:/'1 L _ OCCUPATION: T_ OTHER: ADDRESS: CITY:___(_tc..___ -- STATE:—ZIP:— `T COMMENTS. EMPLc7Y C�,_�Y S�FL_____ , TOTAL: 16 8 143 PATIENT RECEIVED BY:X F'mvidrr rrt,iic Whit, •rd P-1: •-1•+. cr••.—� � m^ r,•; 1..• G ATURE) EMS-I CONTRA COSTA COUNTY AMBULANCE n Yom" PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N' �'` 1- /2066- 1 J CNECK OR fILL IN AOGAOPNIATE SPACES `(l 77-7-• `)'1, (../4 1. 1 tJ DATE: 2--' . Z PATIENT'S NAME (L-- --�-- V-, R M O F COMPANY N ADDRESS / �(rj �,c�. AGEo2-3 CITY 0-- felt U"LoT-STATE na -ZIP_L_Z � DOB .L SY O Sn O M O T O W O Th 11WF p S... DRI VER'� LICENSE N �_� L PHONE —_ NATURE OF DISPATCH Irj�iZl'irn f "a;p 'TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ — — STATION INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) _ TO SCENE S.O. CALL RECEIVED L , c Ia L �,:� iv/!, S ' ❑ P.D. TIME 10-8 Q PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 Zia— O O PSAP TIME 10-49 -� MILEAGE: O OTHER/PVT TIME 10.7 11 END TIME /0.98 DOCTOR PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL __ STANDBY TIME , ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME.1 O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE C P PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ ❑ YES ❑ NO ❑ WAL'CED O GUERNEY O OTHER PATIENT CONDITION: DRIVER A -2 < 40, T-1 _ TECHNICIAN PARAMEDIC Hx: DISPATCHER: .I D L IAC 1 Q Ili fon CIoil/ CHIEF COMPLAINT: DRY RUN: 'jiWYES ONO REASON FOR DRY RUNTrTij;A (AUi AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I l�•f PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: o�C S.S. M PRIVATE INS, CO.: BASE RATE: KAISER n: MULTIPLE PTS. BASE RATE BLUE CROSS q TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES O NO NIGHT: (19:00-07:00) - CC P N: EMERGENCY RUN: r— - \ MFrn-r.At w• CODE 213 _. OTHE OXYGEN: (PER TANK) l�1• kt'P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) V DATES BILLED: STANDBY: (OVER/5 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) Y _ �'- -- = DRUGS: (PER ADMIN.) "' NAME: ` 4 ELATIONSHIP: S L E.O.A.:(IF NOT REPLACED) (' ' ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: z J� ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 0 DRY RUN: (AUTHORIZED) EMPLOYER: - OCCUPATION: OTHER: - - ADDRESS: \� CITY: STATE: ZIP: COMMENTS: TOTAL:�/0•�l - 000109 PATIENT RECEIVED BY:X (SIGNATURE) Provider.retain White v"d Pink ropy Return re:tow.Mmo t PIS when bi2:ing 01S-I I PATIENTS NAME: WYNNE, Brian ADDRESS: _ 3378 Walnut Avenue Concord, CA DATE OF SERVICE: 07/22/83 AUTHORIZATION NUMBER: 83-12079 I j AMOUNT DUE: 207.50 INCIDENT LOCATION: CCCH PATIENT DESTINATION: Walnut Creek Hospital j I 6 fd , 00 1 } 0 0 01'70 PATIENT'S NAME: ROSE, Tina ADDRESS: 1835 Wilcox San Pablo, CA 94806 DATE OF SERVICE: 07/22/83 AUTHORIZATION NUMBER: 83-12095 AMOUNT DUE: $ 223.00 INCIDENT LOCATION: 3rd & Bush, San Pablo PATIENT DESTINATION: BSH a 0001'71 00 14 I. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 S r-09 CHECK OR FILL IN APPROPRIATE SPACES - DATE: PATIENT'S NAME �M 13f COMPANY M ? Jam'"� C/"5 ADDRESS 1\V�Ivy Y' t Ci 1n I AGE '.�oL/ CITY LS ' STATE C ZIP QDOB 7 -3� O Sn OM O T OW O Th F 01S DRIVER'S LICENSE p __ _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_•• •• INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR C!,0(Z1K) D� TO SCENE- S.O. CALL RECEIVED -19 P.D. TIME 10-8 : PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 :� ❑ PSAP TIME 10-49 �- 1 MILEAGE: S O OTHER/PVT TIME 10-7 (� END 9' TIME 10.98 .�.� DOCTOR -- L G _ PMD6 START TIME 10-22 - HOW CHOSEN: �.•� TOTAL I� r, STANDBY TIME �Y NEAREST ❑ FAMILY ❑ TRANSFER 1 WAIT TIME /❑ PATIENT ❑DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPA tt A5 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �J T� RESPONSE ZONE YES ❑ NO ❑ WAL'(EDXGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER CT V (`^'l"4 I 0 UL•I EMT-lA r �J � TECHNICIAN ,C NE (r ' / t PARAMEDIC-� Hx: Q)O�.L;(t� -• • DISPATCHER: I_ J C CHIEF COMPLAINT: .��r)?UCS DRY RUN: O YESNO REASON FOR DRY RUN _ AUTHORIZATION XDRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COV RAGE: _ INDUSTRIAL 13YES ❑ NO NO. OF PATIENTS: S.S. # Sy , - PRIVATE INS. CO.:T� ^S� S O �/rL �� BASE RATE: ��L - KAISER R: MULTIPLE PTS. BASE RATE M BLUE CROSS p:. TOTAL MILES: `J X MEDICARE x: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO �U� OYES ❑ NO NIGHT: (19:00-07:00) % CCHP/PPRP k: EMERGENCY RUN: 1 MEDI-CAL K: CODE 2/3 ' OTHER: Ir1"`S i�x't, OXYGEN: (PER TANK) II.I P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) __I f DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X /!` 1 �,( RUGS: (PER ADMIN.) X NAME: '._�L!`� ! -6LATIONSHIP: (IF NOT REPLACED) - ADDRESS: rM ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONF�-�O= DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION_ OTHER: " 1r-01 v ADDRESS: c.!/ CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: �"ty 0 I 1'(ptyE TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) Du-1 O ,�y/t 7 Provider retain white rr.1 P;ri roPlo 4ttunl Yt'iv► nopy r• ENS own btu inp J.. 1 CONTRA COSTA COUNTY '1 AMBULANCE PRE-HOSPITAL CARE FORM IUNIT AUTHORIZATION M �J 1 CHECK OR FILL IN APPROPRIATE SPACES ` ` DATE: 2 A _ PATIENTS NAME OM OF COMPANY N ADDRESS AGES_ �. �`•� CITY STATE ZIP DOB - O Sn OM OT OW O Th OF 1 s DRIVER'S LICENSE M _ PHONE � NATURE OF DISPATCH 1 TYPE OF TRANSPORT: AMBULANCED OTHER O _ STATION 11A)_2(B)_3(C) 41D)_51E)_ INCIDENT LOCATION:' RESPONSE COO REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- - rS.O. CALL RECEIVED _447Q '•� P.D. TIME 10-8 PATtE RESTINATION: FROM SCENE- O FIRE TIME 10-97 O PSAP TIME 10-49 V MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 L' HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME _— O PATIENT O DIRECT O OTHER CALL BACK N: AMBULA>CE C 14PANY:� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C� RESPONSE ZO J ❑ YES O NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER 1 ��I EMT-1A TECHNICIAN '� PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN:*YES O NO REASON FOR DRY RUN I Q LL fiRr ScIg/-CFO ' 1 f�' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) en rC i � PATIENT REFUSED SERVICES:(SIGNATURE) X r(5,- re MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO.OF PATIENTS: 5 S.S.M PRIVATE INS.CO.: BASE RATE: KAISER c MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES O NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: L MEDI-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP" C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) 7 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP• COMMENTS: TOTAL: ��•� O�} I- PATIENT RECEIVED f3V X ISI000173 v ' !':� I, .,r�.� r~r.,r. ►n ,.. ..r (1N�t.I,IrI . CONTRA COSTA COUNTY t AMBULANCE f� j PRE-HOSPITAL CARE FORM I '.r' UNIT AUTHORIZATION N� l` CHECK OR FILL IN APPROPRIATE SPACES 1 DATE: PATIENTS NAME. % �� h Om ❑ F COMPANYN ADDRESS AGE�� (IS) „ CITY STATE ZIP DOB ^ O Sn OM OT OW O Th O F ' DRIVER'S LICENSE N _ PHONE -- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE O OTHER O _ — STATION 1(A)_2(8)_3(C)X 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: ff�, (O/DUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- "S.O. CALL RECEIVED / �1 (� «��<jjjjj P.U. TIME 10-8 •: PATIENY DESTINATION: FROM SCENE O FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR ) PMO/ER START TIME 10-22 a :1 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK_»: AMBULANCE CO PANy: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SIU RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY O OTHER � PATIENT �CON DI/ION: J ) DRIVER JI(I /�L-y/SL�� `'=n^EMT-1A ra /� /'�� TECHNICIAN ? / Z�'-� �- PARAMEDIC Hx: "`�•d I DISPATCH �' I q CHIEF COMPLAINT: T, v IDRY RU LYES NO REASON FOR DRY RUN ? AUTHORI OR DRY RUN(EMS USE ONLY) (J ' PATIENT REFUSED SERVICES: (SIGNATURE)X �5 MEDICAL COVERAGE: INDUSTRIAL 13YES O NO NO. OF PATIENTS: a- ' S.S. » PRIVATE INS.CO.: BASE RATE: KAISER»: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE»: E.O.B. ATT. ROUND TRIP: YES ❑ NO O VES ❑ NO],�E HT: -07:00) CCHP/PPRP N: GENCY RUN: MEDT-CAL N: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE P TY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: t WORK PHONE- ' _ DRY RUN: (AUTHORIZED) s.2 � EMPLOYER:. * OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: • I -�_- TOTAL:-` - -- -- 174 PATIENT RECEIVED BY X . r•'If.ru •tn(1 CON IFIA COSTA COUNTY AMp LANCE PRE-HOSPITAL CARE FORM 1 1 uN AUTHORIZATI N N 4 CNECK OR FILL IN APPROPRIATE SPACES DATE; PATIENT'S NAME ,\ _- � �M ❑ F COMPANY M({ 4 ADDR SS �-��!y'-� STA Q ��L AGE ` n t CIT Z�/1'v' . ZIP ` DOBE O Sn O M O T O W 0 Th O F q1r.' DRIVER'S LICENSE p — PHONE� (�/ NATURE OF DISPATCH- ,� TYPE OF-TRANSPORT: AMBULANC 'OTHER❑ _ _ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ -- INCIDENT LOCATION: RESPONSE CODE: REO ESTEO BY: TIME— (24 HOUR CLACK) y " TO SCENE- O. CALL RECEIVED y O P.D. TIME 10-8 5 PATIENT DESTINATI FROM SCENE ❑ FIRE TIME ?0-97 / J ' / ❑ PSAP TIME 10-49 ` MILEAGE: 61 O OTHER/PVT TIME 10-7 } ' END TIME 10-98 I 1 DOCTOR y PM /ER START TIME 10-22 *, HOW CHOSEN: TOTAL `> STANDBY-TIME •' NEAREST ❑ FAMILY ❑ TRANSFER / WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER,/,,'4'+)f pry r r CALL BACK N: AMBULANCE COMPAN1" � YE eMBUL9TORY? PATIENT TAKEN,TO AMBULANCE: RESPONSE ZONE �__ ❑ WAL'(ED kGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �� EMT-1A ✓J — TECHNICIAN n PARAMEDIC Hx: _ DISPATCHER: �(Jy CHIEF COMPLAINT DRY RUN: ❑ YES W1/NO REASON FOR DRY RUN jh AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIEN REFUSED SERVICES: (SIGNA RE) X �." MEDICAL COVERAGE: INDUSTRIAL ❑ YES ArNO• NO. OF PATIENTS: S.S. p .4 .. rt ^ PRIVATE INS.CO.: BASE RATE: .1LL1 -,�. .,�• \ KAISER ar_ /��'� MULTIPLE PTS.BASE RATE -' (,cL BLUE CROSS x: TOTAL MILES: X �= 07 fi • E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ---- *YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 t v� OTHER: OXYGEN: (PER TANK) - - f P.O.E. STICKER ❑ YES &rNO NEONATAL: (INCUBATOR) G /// DATES BILLED: STANDBY: (OVER 15 MIN) If E.K.G.: (PER EPISODE) (� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 1 t NAME4JJ ,* • 7 a� DRUGS: (PER ADMIN.) X - �/YNS£�I -,, R�EL�AT�IONSHIPa !�' E.O.A.:(IF NOT REPLACED) ADDRESS: a2 3 NAtfto_A_Lam'- ((// ORAL AIRWAY: (IF NOT REPLACED) CITY: 021N _'A _ STATE(.'-" ZIP: C-COLLAR: (IF NOT REPLACEq)- ' PHONE: - 02''L��77 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYERry* Cl OCCUPATION: OTHER: ADDRESS: V CITY: STATE'_ ZIP: COMMENTS:. • ,O TOTAL: 01 PATIENT RECEIVED BY: 0® ., :•J (SIGNA RE) DSS-1 Provider nta:r• White crd Pink . Retur+i Ye.Io+.• mph t• �a v+u� bila `c ov, CONTRA COSTA COUNTY �' AMBULANCE PRE-HOSPITAL CARE FORM Il UNIT AUTHORIZATION 0 1 CNECX OR illi IN APPROPRIATE SPACES DATE: '1 / PATIENTS NAME_ ❑ M ❑ F COMPANY M ADDRESS AGE P t CITY STATE ZIP DOB " ❑ Sn O M OT ❑ W O Th O F l(S DRIVER'S LICENSE M _ PHONE _— NATURE OF DISPATCH JnO►'1 I�tUG1 �c' TYPE OF TRANSPORT: AMBULANCE OTHERO _ — STATION 1(A)_2(B)_3(C)W(D)_5(E)_ k) INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) I ��ec,� TO SCENE- $.0. CALL RECEIVED S,,T Ift��+��` . �LlJ,C �� ❑ P.D. TIME 10-8 '1 c PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �— ❑ PSAP TIME 10 49 7 t)�Y `•' �D EC [ MILEAGE: ❑ OTHER/PVT TIME 10.7 \ END TIME 10-98 ?— DOCTOR PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ,; 13 FAMILY O TRANSFER WAIT TIIM�E� 13 PATIENT ❑ DIRECT O OTHER CALL BACK S: AMBUC 1 p PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I� RESPONSE ZON C ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER ..l PATIENT CONDITION: DRIVERr `I EMT-1A � I-C>.) TECHNICIAN n 2�S�h �i�7 PARAMEDIC Hx: t - DISPATCH CHIEF COMPLAINT: DRY RUN: DYES NO REASON FOR DRY RUN Ill L .c��2Q8,r e L AUTHORI FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: . S.S.N PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES 11 NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E, STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED.) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: fly - ---- ---�..-- 01'76 00 __._._.__. ._. ._ _ PATIENT RECEIVED BY- X __... ..___.. .. ___._ • • `:u: • mfl CONTRA COSTA COUNTY 4 ) AMBULANCE /G? PRE-HOSPITAL CARE FORM 1 I, 1 UNIT AUTHORIZATIO M CHECK OR FILL IN APPROPRIATE SPACES DATE; - . *' l��nC_ ��'_L/Jr � ,��.rC, _�LS�[" 11 F COMPANY a PATIENT'S NAME_ l /+/ -7 a ? cl CITY _ -_— STATB(/—'?A-- ZIP (J,— DOB�� Q ❑ Sn ❑ M O T OW O Th OF S• DRIVER'S LICENSE a ..___._.- PHONE�2 � '.SO_._ NATURE OF DISPATCH x if TYPE OF TRANSPORT: AMBULANCE THER INCIDENT LOCATION: RESPONSE CODE: UESTED BY: TIME— (24 HOUR ,CLOCK) ? D , '�L TO SCEU 5- .O. CALL RECEIVED P.D. TIME 10-8 J PATIENT DE8TIN TION. FROM NE- O FIRE TIME 10-97 O PSAP TIME 10-49 MILEAG ") O OTHER/PVT TIME 1D-7 �1 6L_ rs / END-----/ TIME 10-98 DOCTOR >n .lJ'�_—___. PM /EA START 1� TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER ) CALL BACK M: AMBUl�V�ES'.DMPAI�Y: P MBULATORV') PATIENT TA E TO AMBU E: PONSE ZONE ES ❑ NO ❑ WL I':EDK.C�UERNEY OTHER �'L✓� r� PATIENT CONDITION. DRIVER—/-- _ _ZW EMT-jA/_ _1LC 4NICIAN__ _ A94MEDIC % Hx: _ �- --� nl� � .-—,-/%NISPATCHER: Z (. I f/qn i 100 ( , " CEIF COh P -T: f�rJLl >r,24Z�^- __ DRY RUN: O YES NO REASON FOR DRY RUN _ AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: SERVICES: (SIGNATURE) X MEDICAL COVERAGE.. INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. CO.:--. BASE RATE: �,ctr KAISER a: ___ MULTIPLE PTS.BASE RATE BLUE CROSS p:— _ TOTAL MILES: �'� X N '�� /��• j MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ONO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: f C MEDI-CAL o/—A_ CODE 2/3 OTHER —r___—___—_.. OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) I i DATES BILLED:____._______ — STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X �GRKATION HIP;�� E.O.A.: (IF NOT REPLACED) ADDRESS S- �2_�- - -� _ ORAL AIRWAY: (IF NOT REPLACED) CITY STATE_—ZIP:—_ C-COLLAR: (IF NOT REPLACED) PHONE __ WORK PHONE. __.—._ DRY RUN: (AUTHORIZED) EMPLOYER.T___.._.-...____—_. OCCUPATION:_ OTHER. _ ADDRESS. CITY:_ _ _ STATE: ZIP: r /I-,: C A!AENTS: �11J_..C?��lzarAl TOTAL: 75' S� - - PATIENT RECEIVED BV:X.� Yr,,vid.r r c,:. �•: r.:, :p ;ct.r. i:' •.�;: k (SIGNATURE) -N' whon F:I"iro0C as-1 �V Aw CONTRA COSTA COUNTY �� _ AMBULANCE �> 7 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION IV CHECK OR FILL IN APPROPRIATE SPACES DATE:�� PATIENTS NAME L AC��7�, �Y�2 11 q O M COMPANY N ADDRESS C.7 O- O �A AGE-2–i ��' i �I• 1 S h C'�kt� CITY STATE ZIP °� DOB _ ••O Sn OAA ❑ T OW O Th ❑ F S 2 "7'DRIVER'SLICENSE M �' — PHONE �_�_�_ NATURE OF DISPATCH ~� TYPE OF TRANSPORT: AMBULANCE OTHER❑ --- STATION 11A)_.2(B)_3(C)-4(D)._5(E)._ INCIDENT LOCATION: RESPONSE CODE: REP�dESTED BY: TIME– (24 HOUR CLOCK) •r R� � i��L TO SCENE- � S.O. CALL RECEIVED I �• ❑ P.D, TIME 10.8 � r PATIENT DESTINATION: FROM SCENE_- ❑ FIRE TIME 10-97 A013 / O PSAP TIME 10-49 l ' 013 �.� a MILEAGE: ❑ OTHER/PVT TIME 10-7 ' r' END TIME 10-98 DOCTOR 1 PMD/ R START TIME 10.22 HOW OSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER ` �� CALL BACK M: AMBULANCE O ^ PANY: PT. AMBUt1j�RY? PATIENT TAKEN/0 AMBULANCE: =.� RESPONSE ZONE ❑ YES NO ❑ WAl'CEO GUERNEY ❑ OTHER f J �� PATIENT CONDITION: DRIVER t\,kl' / ! t- I -� �� ` EMT-1A TECHNICIAN �� 1 i, S ��` u PARAMEDIC Hx. I J N DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES 0 NO REASON FOR DRY RUN ' J- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) C I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: f S.S. w PRIVATE INS. CO.:��.. BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS K: TOTAL MILES: `� X L/' •-%`�1 `'� MEDICARE 4: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO t �l c.� L=, _I ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) G P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE– ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: `' �OR � '- �� DRY RU (AUTHORIZED) EMPLOYER: �-- � OC ATI0 : 0 6Afff L ADDRESS: Z�0 I CITY: 5 F STATE: ZIP: ClMMENTS: � ,1 1. 1 TOTAL: - T _57Ift . �H� H9_. s_..c -��,� - _-��00178 `TEAR s, PATIENT RECEIVED BY X ��i.a ni.lrr rvt.r!� Vli n .l r••. r,. .r:.,.. i ... r ('iIf:NAIi:U I ,N i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N Z SS CHECK OA fill IN APPROPRIATE SPACES DATE: - PATIENTS NAME �^ /� O M F COMPANY M / •'1 ADDRESS (o Src�/^! AY= AGE " ( /� 1� s•' ) CITY ` STATE co . ZIP 9i.- DOBG Q_ 1-50 Sn O M O T O W O Th O F brS , DRIVER'S LICENSE N _ PHONE�Q�3f3 1NATURE OF DISPATCH C- TYPE OF TRANSPORT: AMBULANCE)S OTHER 0 __ — STATION 1(A)_2(B)_3(G 4(D)!5(E)_ 1 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) rr TO SCENE- 955.0. CALL RECEIVED �S��l �y✓�� 1`t � IA-�� O P.D. TIME 10.8 PATIENT DESTINA ION: FROM SCENE ❑ FIRE TIME 10.97 O PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 D C/ END 70. 6 TIME 10-98 T DOCTOR ]LCfZ- PMD/& START G-2, TIME 10-22 HOW CHOSEN: TOTAL �_ STANDBY TIME �• ' O NEAREST 13 FAMILY O TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER ( I�) CALL BACK 0: AMBULANCE COMTANY: C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ +�� RESPONSE ZONE ❑ YES V NO ❑ WALKED 10 GUERNEY ❑ OTHER I PATIENT CONDITION: . DRIVER - i EMT-tA / TECHNICIAN_ �� '•' PARAMEDIC Hx: `00 ffl DISPATCHER: t,t L`t t __ t7• i ]• 957 CHIEF COMPLAINT: _ C lDRY RUN: ❑ YES t(NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qN �-x . ; PATIENT REFUSED SERVICES:(SIGNATURE)X �j n T✓ 2_ MEDICAL COVEt y �� INS STRI L YES NO NO.OF PATIENTS: cZ S.S. 0 b _a PRIVATE INS.CO.: BASE RATE: �'u 9LUE IEA`_*! - ,�!d -eoe) ' L ` MULTIPLE PTS. BASE RATE C 7- TOTAL MILES: i X ,'z�ICAREM: - .O.B.ATT. ROUND TRIP: O YES ❑ NO Cl YES ❑ NO NIGHT: (19:00-07:00) Cl. CCHP/PPRP R: EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 )1 �� OTHER: OXYGEN: (PER TANK) = T a7 P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -rte �r -0// `"NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X � DRUGS: (PER ADMIN.) X NAME: L'L ?pzbs L�& c) RELATIONSHIP:�_ E.O.A.: (IF NOT REPLACED) ADDRESS: E ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE LSIZIP- C-COLLAR: (IF NOT REPLACED) PHONE: �$ _ ` Z WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: 17 CITY: STATE: ZIP: COMMENTS: �. 0 o TOTAL: 0179 Ofl �''? _ PATIENT RECEIVED BY: X _ _._ ISIGNATURF) Prrv�ia� nt,r!• YF,i�•. r i... .. . . ., . CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 uNlr AUTHORIZATION M CHECK ON fILL IN APPKOMATE SPACES DATE: PATIENTS NAME_ YU C.t H Om OF COMPANY• S ` V ADDRESS AGE r .CITY _ STATE ZIP DOB _ -O Sn O M OT/O/W O Th O F S DRIVER'S LICENSE M _ PHONE _.—_ _—_ NATURE OF DISPATCH L /Al �" ��'( C r% TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A)-2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) r!1 j ' Y( l L,_� IQ, / n ' TO SCENE- S.O. CALL RECEIVED''•� (/�/�` D P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE- FIRE TIME 10-97 :_L ❑ PSAP TIME 10-49 _ a� I MILEAGE: O OTHER/PVT TIME 10-7 .�T END TIME 10-98 DOCTOR - I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 13 PATIENT 13 DIRECT ❑ OTHER CALL BACK C AMBUSA E,COMPANY: PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5'V RESPONSE ZOONE Jam_ ❑ YES 13 NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER "S ✓ 2'� T-1A TECHNICIAN A-J:41et PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN NOL le c� 7 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) �y P.O.E. STICKER .❑ YES ONO NEONATAL: (INCUBATOR) 0 DATES BILLED- STANDBY: (OVER 15 MIN.) \� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR:. (IF NOT REPLACED) PHONE: a WORK PHONE: _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: C' p {�((��'''' 0180 V V�_ �, ____..._�___.,_.`- - -- _ PATIENT RECEIVCn Illy X __... ►x ®,- : CONT A COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION 0 CHECK 01 Fl L/N dPPROPRIATE SPA ES DATE: IENT'S NAME 8u�r�tiS -1r1 ( �` O M F COMPANY I r NT RES AGE 1 r+ Oct _ ��Q STATE ZIP ` OOB[/-r1F Sn O M O T �O-W; O Th O F O S J DRIVER'S LICENSE 11 PHONE -- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 11 A)._20_3(C),4())_510, INCI NT LOCATION:, I RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR�f CK) 5 y + TO SCENE- .O. CALL RECEIVED 24 V ❑ P.D. TIME 11}8 f PA ENT DESTINATION: . .. FROM SCENE-0 O FIRE TIME 10-97 1 ) '] (3PSAP TIME 10-49 [� f l 9 JMJ� t 1 MILEAGE. ❑ OTHER/PVT TIME 10-7 END r TIME 10-98 T1_ 7DOCTOR /n PMD J R START +•� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST 13 FAMILY TRANSFER l WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER J CALL BACK N: AMBUJ,A E COMPANY: AMBULATORY? P TIENT TAKEN TO AMBULANCE: SIU RESPONSE ZONE N2-7- . YES ❑ NO D V GUERNEY ❑ OTHER 11 s � � _ PATIENT CONDITION: DRIVER � ��`'"� EMT-tA `A 1 TECHNICIAN ` I PARAMEDIC (� Hx: DISPATCHER: jin LT is, A,V 1 'I -I� CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS:. S.S.$ I / �► PRIVATE INS. CO.: BASE RATE: �'Uy KAISER R: MULTIPLE PTS. BASE RATE 12� UEC S CD TOTAL MILES: X «' MEDtCAREM: E.O.B. ATT. ROUND TRIP: OYES �1 N0 ❑ YES O NO NIGHT:(19:(0 32 CCHP/PPRP 1f: EMERGENCY RUN: MEDI-CAL ti: CODE 21/31) OTHER: - - -- - OXYGEN: (PE1ANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -NEAREST RELATIVEIRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: / �d� �� 7 CITY: STATE:—,ZIP: • - C MMENT � ►Jim ( e r iIL o � • - TOTAL. We 177!4; - ' PATIENT RECEIVED BY. X_ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N _ 12� CHECK OR FILL IN APPROPRIATE SPACES DATE: Z33 PATIENT'S NAME ❑ M ❑ F COMPANY N 0 A-1 S ADDRESS AGE- (7 O f,-'L.) n� CITY _ STATE ZIP DOB ❑ M ❑ T ❑ W O Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE —__ NATURE OF DISPATCH qjoAC ( if TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ t INCIDE LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) _ o TO SCENE- S.0. CALL RECEIVED I A u (��. C \o ❑ P.D. TIME 10.8 PAT ENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 C� ( (1 ElPSAP TIME 10-49 ky Ct`�" MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START 1CLME 10.2Y 113_ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER /� WAIT TIME 13 PATIENT ❑ DIRECT 13 OTHER �``� CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 7 ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PAT T CONDITION. DRIVER F-A« Y' 1''^ EMT-tA TECHNICIAN �S 1�t j�C��^IZ(1, ::PARAMEDIC Hx: DISPATCHER: / J CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN 40-21 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) {t� PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: v. ( C I S.S. N PRIVATE INS. CO.: BASE.RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: 13YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) / DATES BILLED. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X r NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: - STATE_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: 1� STATE: ZIP: - COMMENTS: --- TOTAL: - 00018.2 PATIENT RECEIVED BY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION M o J CHECK OR/ILL IN APP PRIAT!SPACLIS DATE: �L I "PATIENT'S NAME f Wo OM ❑ F COMPANY N ADDRESS AGE CITY _ _ STATE ZIP DOB Sn ❑ M O T ❑hW ❑ TA ❑ F O S DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH [ J TYPE OF TRANSPORT: AMBULANCE 0 OTHER El STATION I(A)_2(B)_31C1-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) Ce l q ir BC96l4 WL TO SCENE- -7 V S.O. CALL RECEIVED / -71 : �J't ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 1 CRY MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 "DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 13NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER S ' CALL BACK K: AMBULANCE COMP NY: PT. AMBULATORY7 PATIENT TAKEN TO AMBULANCE: t- RESPONSE ZONE O YES 13 NO 13 WALKED O GUERNEY 13 OTHER ,'� PATIENT CONDITION: DRIVER rop EMT-IA TECHNICIAN e - PARAMEDIC Hx: DISPATCHER: �'dl_' T.f...A �' " '^� CHIEF COMPLAINT: DRY RUN: YES 13 NO REASON FOR DRY RUN `nom �J� C (/ ?� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ll7 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: 5z S.S. # PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 r OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X _ DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) –T CITY: STATE– ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: 1 DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP; COMMENTS: Q, -01 TOTAL: 83 83 PATIENT RECEIVFII DY. X CONI IIA COS IA COUN TY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ( � AUTHORIZATION N ! 'r'-c� ;2- C 5 C#if CK OR Illi IN APPROPRU If SPACES DATE: PATIFNT'SNAME.1.�' rZ(i..�L . � tSA O F COMPANY ADDRESS ' U__._.._w_.__.I�.-�! _-- AGEol CITY I_ _,� // / -�.� ll-._ STATE-&-'A A ZIP_ DOB J__LLj_.619 Sn /U M OT OW OTA O F OS DRIVER'S LICENSE qPHONE _—___—_ NATUAE OF DISPATCH TYPE OF TRANSPORT' AM� OTHER❑ __ STATION 1(A)_2(0)_3(C)-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: EOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - , ❑ FIRE TIME 10-97 /� / 7 " V 5 O PSAP TIME 10-49 ' -- -- MILEAGE )C-ATHE PV• TIME 10-7 END 0 TIME 10-98 DOCTOR _—��-�J_ _ PMD& START_.,L� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 0--NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT O DIRECT O OTHER (' �:• CALL BACK N: AMBULANCE COMPANY: --C-4 S PT AMBULATORY1 PATIENT TAKEN TO AMBULANCE: C�jn RESPONSE ZONE !i�'ES ❑ NO �-WAL:ED ❑ GUERNEY O OTHER 7 PATIENT CONDITION. DRIVER.__f�_ 1�-� I' MT-1A x - �i TECHNICIAN PARAMEDIC Hx5.--_—y Y S 1910 DISPATCHER: CHIEF COMPLAINT��I�CZ-LC-p—L y c-- DRY RUN: O YESCE-1-NO,I REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL O YES �m-10 NO. OF PATIENTS: n\V � l PRIVATE INS. CO. BASE RATE: KAISER a MULTIPLE PTS. BASE RATE. BLUE CROSS#: TOTAL MILES: X _aLL lS/ MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ONO O YES ❑ NO NIGHT: (19:00-07:00) ��r,�v�� CCHP,'PPHP a: EMERGENCY RUN: ti.L r _ MEDT-CAL CODE 2/3 OTHER:_ OXYGEN: (PER TANK) P.O E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X DRUGS: (PER ADMIN.) X NAME L7�N_F S--!'V1._� L.�RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS 7�%__.1-S�c_��.Vl.��,-- ORAL AIRWAY: (IF NOT REPLACED) CITY STATE__ZIP: C•COLLAR: (IFNOT.REPLACEO) PIIONE --- WORK PHONE1,'-u DRY RUN: (AUTHORIZED) {? EMPLOYER C•/�L__5 et, CCUPATIONIJQ `L:-iV- &HER: BILLED CZE ADDRESS: Lff �Z.1� /"-�� CITY: 1 �/ .� STATE:__rI�IP: COMtAENTS:--J57r-rir-L-a y— ray 'y TOTAL: _ PATIENT RECEIVED BY:X (SIGNATURE) O(l, !s. 1 � lrcc:•'r- rcrai� L;btc .r: P:•,: pp .irt..•� 1r'irl r .. !^t- L'hre t:i iap Ln5-1 �`jj t r, ✓ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT I AUTHORIZATION 0 3 aC o CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME f. N N 'S XM ❑CFF COMPANY N ADDRESS l_7 791 C' I✓)V ! tiL /��]L�E AGE ' a. (� 1 .2-9.0 r..-.... CITY �1 H✓tn F. l4 STATE G r ' 71P c . SO -'�-7`"'�' ._...' DOB AtSn ❑ M ❑T ❑W ❑Th .O F O'S DRIVER'S LICENSE k _^_ PHONE cam• �� NATURE OF DISPATCH •9/+K�'1L) 8 1121 (; ` TYPE OF TRANSPORT: AMBULANC17 OTHER❑ _ STATION 1(A)_2(B)_.3(C)_4(D)._6(E)� ��.. INCIDENT LOCATION: I' RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) r � TO SCENE- S.O. CALL RECEIVED _2Z :��5 T�& /1Cx,e; �°/j'F7/� Z O P.D. TIME 10-8 't: PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 _� ❑ PSAP TIME 10-49 2' i MILEAGE: ❑ OTHER/PVT TIME 10.7 1/G� .�,� --� �i END_.___,��''� TIME 10-98 .LZ,:�•,'�� DOCTOR PMDR J START_ ' TIME 10-22 I ---1 HOW CHOSEN: �� TOTAL `J • STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME I: '.EATIENT ❑ DIRECT ❑ OTHER C) CALL BACK M: AMBULANCE CO,v PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE - O YES KO O WALKED CigrUERNEY ❑ OTHER Y PATIENT CONDITION: DRIVER 1 ,cu'r1 30FL T-1e _ /�itJ�y q 1 1 o } PARAMEDIC Hx: TECHNICIAN�`� �S f piL�''! NA DISPATCHER: uR.1RE 110 j' CHIEF COMPLAINT: 2� ��- I IJ DRY RUN: ❑ YES A'�NO REASON FOR DRY RUN '- ` / r,,5im s? T�s c•'Ir AUTHORIZATION FOR DRY RUN(EMS USE ONLY) y C (`, PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YESLrkNO NO. OF PATIENTS: S.S. q PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: (p X _.s[ MEDICARE N: E.O.B. ATT. ROUND TRIP: 0 YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) !----•-r/� CCHP/PPRP N: EMERGENCY RUN: 1�•�{,S T— MEDI-CAL N: CODE('2)/3 J OTHER: OXYGEN: (PER TANK) �yI P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) r X'' j DRUGS: (PER ADMIN.) X NAME: P Nov► RELATIONSHIP: C �• E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE– ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: 2 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: =4 OCCUPATION$ _ OTHER: ' - ADDRESS: . �l`, 1J //.. .� /• / CITY: STATE: ZIP' COMMENTS: elP�ss p/mak �2D/1" '> T�1 �C�QIw,•%f r�C1_ ilE f1 R-�.f T 1J 1'li aJ No PATIENT RECEIVED BY:X (SIGNATURE) 00 160 Provider ntair white rrd Pint ropk Peto.r.o Te'Iw trop? I FPC Our" biVing EMS-1 CONTRA COSTA COUNTY AMBULANCE _ / >L `��- PRE-HOSPITAL CARE FORM I - UNIT M AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: .� PATIENT'S NAME 1 �� OV O F COMPANY I ADDRESS; AGE�.s� CITY- --•STATE ZIP -- DOB 'O Sn O M OT OO Th *O F O S N DRIVER'S LICENSE --1 PHONE NATURE OF DISPATCH ff ' TYPE OF TRANSPORT:`AMBULANC OTHER STATION 1(A)_2(BI_31C) 41D)_5(E)— INCIDENT LOCATION: I RESPONSE CODE: R UE�TED BY: TIME-(24 HOUR CLOCK) - r TO SCENE- a s-q C _— CALL RECEIVED ;)Y . ' PD. TIME 108 ,: PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10.97 - !\\ ,�{1 I O PSAP TIME 10-49 ` .U�17'' f► iA) ) MIL E: 13OTHER/PVT TIME 10-7 D^ ____�_� TIME 10-98 DOCTOR S T 1 ' 1 PMD/ER START. TIME 10-22 on l� HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT 13 DIRECT .13 OTHER CALL BACK M: AMBULAN l�v� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE T. ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER -1.. PATIENT CONDITION: ? DRIVER �U EMT-1A TECHNICIAN PARAMEDIC i Hx: -- DISPATCHER: s o CHIEF COMPLAIhST: CA 1 z Ld /L / 7� DR�RUN�Ql'ES _❑ NO REASON FOR DRY RUN Ct'U f!<'C •t/IJ�J 4 Ae l/217 iGJ/kU AUTIAORIZATION FOR DRY RUN(EMS USE ONLY) I/,[/�,/�// PATIENT REFUSED SERVICES: (SIGNATURE) X `i`�T MEDICAL COVERAGE:_ INDUSTRIAL 13YES 13NO NO.OF PATIENTS: J�✓'" ell S.S.M PRIVATE INS.CO.: BASE RATE: " KAISER pr ' MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: 1 X MEDICARE K:' _j E.O.B. ATT. ROUND TRIP: '❑ YES ❑ NO ❑ YES :❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:r' r ' EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 ` - OTHER: 1' OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —NEAREST RELATIVE/RESPONSIBLE PARTY: - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 4 STATE__ZIP C-COLLAR: (IF NOT REPLACED) PHONE: :& WORK PHONE. DRY RUN: (AUTHORIZED) "'EMPLOYER: OCCUPATION - OTHER: ADDRESS: CITY: STATE• ZIP: "-COMMENTS:' TOTAL: r_hZ�CIL j � O - PATIENT RECEIVED BY: X I$iON�,ugEl Pr-t f,fir rvlofa /rhfe. .r f rti-t q` M�r�r-• r. . ,. r.. ! EMS-I CONTRA COSTA COUNTY AMBULANCES .�� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION K /pQ CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME COMPA_NyY/NA ADDRESS AGE�4 2-31. ............ 4 1�v`rCITt, ? STATE ZIP �!yti�,�, DOB O Sn M OT OW O Th OF OS � Y 11 �� DRIVER'S LICENSE q __ _ _ PHONE „yv,C __ NATURE OF DISPATCH LA E Cry L \ TYPE OF TRANSPORT: AMBULANCE)O' OTHER O __ - STATION i(A)_2(B)_3(C)_4(D)_5(E)._-.- . INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY:' TIME- (24 HOUR CLOCK) 0�I TO SCENE- O S.O. CALL RECEIVED 1 C� .} DE.,1,_ � � ❑ P.D. TIME 10-8 ' ' �5 4 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 ` _12-jGZ d MILEAGE: �OTHER/PVT TIME 10-7 _zuz :.1_,z— END I L TIME 10-98 DOCTOR _ �>Z PMDpR START , �T (L TIME 10-22 HOW CHOSEN: ((��// TOTAL STANDBY TIME NEARES ❑ FAMILY ❑ TRANSFER WAIT TIME Q PATIENT ❑ DIRECT ❑ OTHER 1, CALL BACK M: AMBULANCE COMMPANY: ... 7_ 3 LP �BULATORY? PATIEW"A(�EN TO AMBULANCE: �I/ RESPONSE ZONE YES ❑ NO (f.7 WAL! Dl❑ GUERNEY ❑ OTHER V t PATIENT CONDITION: DRIVER K£ UAT-1A x I TECHNICIAN l�'ITI��(•T� 27� -PARAMEDIC Hx: I I 1 (� '.��' �( d) r,�) DISPATCHER: 14 U' - L�` CHIEF COMPLAINT: N 1111 N T'►C710 DRY RUN: O YES _ REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES (NO-) NO. OF PATIENTS: 6!� f � S.S. PRIVATE INS.CO.: BASE RATE: /2- KAISER a: MULTIPLE PTS. BASE RATE _ BLUE CROSS M: TOTAL MILES: "� X b' y MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES O NO STAV() �jO aN5 ❑ YES ONO NIGHT: (19:00-07:00) �� CCHP/PPRP p: EMERGENCY RUN: -_ - , MEDI-CAL N: CODE 2/3 '• -- 1 OTHER: OXYGEN: (PER TANK) 1 P.O.E. STICKER ❑ YES(13 N NEONATAL: (INCUBATOR) ( I DATES BILLED: STANDBY: (OVER 15 MIN.) 11 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:��- (� ��' I g T l i l A _ RELATIONSHIP:�� .E.O.A.: (IF NOT REPLACED) i0 ADDRESS: '� ORAL AIRWAY: (IF NOT REPLACED) M CITY: _ STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: - OCCUPATION- OTHER: ADDRESS: CITY: STATE• ZIP:— Q►'J COMMENTS: fLV.,,,AJ! 'i'`•�Lf E' - i>�I)Tt��.R 1 1-$ / X11 C A(t k 0 -1 N-S TOTAL: 712 sem. PATIENT RECEIVED BY:X -• ( GNATUQE) as-1 00 16- 12, 6- 12, Provider nta:r. Vhite rrd 1'i r.: roJ`} .4et�rn Ye';(,•u Mp. I, ^/f when bit-ing t CONTRA COSTA COUNTYAMBULANCE PRE-HOSPITAL CARE FORM I UNIT , AUTHORIZATIO r - Y CHECK OR P/LL IN APPROPRIATE SPACES DATE: 7P__pp j AilENT'S NAME O M SOI F COMPANY 0 lr� ` ADORES3.�=.y_?�; AGE- ` CITY $TATE��-ZIP�_ DOB ' •O Sn eM O T O W O Th O F O S ! DRIVER'S LiCENSi N '•• ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:;AMBULANCE 19 OTHER 0STATION I(A),2(BI_3fC 4(D)_5(EI_ j INCIDENT LOCATION:ovp'�� RESPONSE CODE' REQUESTED BY: TIME-(24 HOUR CLOCK) _ Q �.-- ,1 )TO SCENE- 2 WS.O. CALL RECEIVED 1226 M6z)V �V k ✓ , O P.D. TIME 10-8 PATIENT DESTINATION:. t FROM SCENE- 13FIRE TIME 10-97Gv ❑ PsAp TIME 10-49 1- ��T�r`l ��'L• ` �U� MILEAOTHER/PVT❑ OTHER/PVT TIME 10-7 „I L, END TIME 10-98 7 `' nbOCTOR P`r7T.2 PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME L ?O NEARESTr;� O FAMILY ❑ TRANSFER WAIT TIME j O PATIENT ' O DIRECT O OTHER CALL BACK M: AM�At�ICOMPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE- 13 YES ONE❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER- : I .- PATIENT CONDITION;,' DRIVER 237 EMT-1A L TECHNICIAN�(' _2 Cz -8U RAMEDI Hx:- DISPATCHER: 0 () I oO CHIEF COMPLAINT: ' DRY RUN, YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) {{{ yyj 1.!i PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE; . .. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: • S.S.N PRIVATE INS.CO.: BASE RATE: KAISER(1: ' MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) CCHPJPPHP tl:^ ' I I EMERGENCY RUN: `l MEDI-CAL M: ) 1 CODE 2/3 y OTHER: i(,(} 1 OXYGEN:; (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) i DATES BILLED: STANDBY: (OVER 1S MIN.) E.K.G.: (PER EPISODE) -NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "'-NAME-- - - -RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ' ORAL AIRWAY: (IF NOT REPLACED) -CITY: -, --STATE ZIP• C-COLLAR: (IF NOT REPLACED) PHONE: a WORK PHONE' DRY RUN: (AUTHORIZED) --1-71 66A - -EMPLOYER: - OCCUPATION: - OTHER: ADDRESS: -CITY: STATE•- ZIP- -COMMENTS: 10-27- olU APUNAL •• TOTAL: - PATIENT RECEIVED BY:X ►'r,rf.br evrnf.. Whit. .,..11•: . ..,... .:1 i•',, (SIONAfURE) tM5-I �} '�'", ` �; 'A�'X �•` * CONTRA COSfA COUNTY AMBULANCE 2� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: ' PATIENTS NAME � 1„/�A/�f O M xd'F COMPANY N 1:2- 5 j�qq�/ ADDRESS AGE /) o/_2 6 t CITY_ STATE ZIP DO %� ❑ Sn O M'$T ❑.W O Th O F O S DRIVER'S LICENSE-# __� _ PHONE Z�02 NATURE OF'DISPATCH I•--•.• TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR LOCK) 2 � /n1�-� TO SCENE- ❑ P.D. TIME 0-8 EIVED 3 -- �� PATIENT DESTINATION!' FROM SCENE-. ❑ FIRE TIME 10-97 rl •`2-.'L� .... ��n J 11PSAP TIME 10-49 ,[. r ' `7 ` MILEAGE: ❑ OTHER/PVT TIME 10-7 n-r vo L - i END 2-SO TIME 10 98 :� r DOCTORPMD�j�F START TIME 10-22 HOW CHOSEN: �cJ TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 53:'PATIENT ❑ DIRECT ❑ OTHER ��) CALL BACK N: AMB CCOMPANY: _ J t , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES 11 NO ❑ WALKED �GUERNEY ❑ OTHER s PATIENT CONDITION: DRIVER TECHNICIAN PARAMEDIC I Hx: DISPATCHER: IV.I rl I n s d� CHIEF COMPLAINT: �� DRY RUN: ❑ YESZ$NO REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ;' Il. PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL CO ERAGE: INDUST IAL ❑ YES NO NO.OF PATIENTS: �1 S.S. # f2- 33-- �37� PRIVATE INS. CO.: BASE RATE: 150 i J KAISER# MULTIPLE PTS. BASE RATE / BLUE CROSS#: TOTAL MILES: G' X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: L'v(,,./ 3f!9-_' f 3 - 3 EME GENCY RUN: /P _ O ��C0DE 2 3 ` OXYGEN: (PER TANK) (4-7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) T DATES BILLED: STANDBY: (OVER 15 MIN.) .0 I E.K.G.: (PER EPISODE) .) v/ NEAREST RELATIVEIRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 3 � DRUGS: (PER ADMIN.) X �� i �S•Lj� 0 �'FI NAME: RELATIONSHIPW,2 .,�� E.O.A.: (IF NOT REPLACED) . y ADDRESS: A ORAL AIRWAY: (IF NOT REPLACED). CITY: v _ STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: - WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:T OTHER: / J ADDRESS - CITY: STATE* ZIP: COMMENTS: TOTAL-a/c/, Z•89 ... PATIENT RECEIVED BY:X 00 Provider retain white .?id rin4 enrp Retum Te:lw ropy to ENS when biding (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE L PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CNECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT S NAME l� �� ! I tQt., ❑ MF COMPANY 0.- /�J S�'� • . ADDRESS �/a • AGE.e?l CITY Cite STATE�J r ZIP OOB��7 ❑ Sn ❑ M T ❑W .❑Th OF J , •r!T n DRIVER'S LICENSE Y — _ PHONE '33 !v NATURE OF DISPATCH 56f'3'�- r�Q$ �4tr TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_2(8)_.:3(C)Z4(D)_•5(E) ,.: INCIDENT LOCATION: RESPONSE CODE: EQUESTED BY: TIME—(24 HOUR CKS TO SCENE S.O. CALL RECEIVED -� -� O P.D. TIME 10-8 iTa PATIENT DESTINATION: FROM SCENE- 3 ❑ FIRE TIME 10-97 ❑ PSAP JIMF,10-49i/i�7 / N •� r - �'Y v MILEAGE: 13OTHER/PVT TIME 10 -7 ;• END r TIME 10-98 DOCTOR _ I-, ti�e PM /ER' )STARTt,� - 1 TIME 10 221 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST .FAMILY ❑ TRANSFER ' WAIT TIME '� 7•�..�T )&I-PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBO E OMPANY:y''' '• ° '•' PT. AMULATORY? PATIENT TA EN TO AMB ANCE: f� RESPONSE ZONE ❑ YESNO ❑ WALKED GUERNEY OTHE� r PATIENT CONDITION: DRIVER 'r C EMT-1A S; �� TECHNICIAN o 'I n S PARAMEDIC , Hx: / � - /! i_ DISPATCHER: fJ(f CHIEF COMPLAINT: �J✓ DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X -J)Ujq(1`: MEDICAL COVERAGE: INDUSTRIAL ❑ YES �NO NO.OF PATIENTS: ` S.S.k f 10 PRIXATE INS. CO.: BASE RATE: - ` l� c.c c�3�_ �_A)S ) MULTIPLE PTS,BASE RATE �.•T. ?� ..�(� .,ja.��,• BLUEXROSS#- TOTAL MILES: X MEDI�1 -3�77',f� E.O.B.ATT. ROUND TRIP: "❑ YE& NO r \, ❑ YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: ,- MEDI-CAL N: CODE 2/� �'1 I 1 7 C �H fy;:i x':i` OTHER: OXYGEN:' (PER TANK) l. Od P.O.E. STICKER ❑ YES ❑ NO "NEONATAL (INCUBATOR);T)M' ') DATES BILLED: STANDBY: (OVER 15 MIN.)i l E.K.G.: (PER EPISODE) ;�y i•• NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) - ••--X•-- =�-- �' DRUGS: (PER ADMIN.) X / NAME- -`�< <'�'t'� RE TION HIP: E.O.A.:(IF NOT REPLACED).•---- ADDRE S: `1 -� u t;O Y:1 ORAL AIRWAY: (IF NOT REPLACED) CITY: ?° -STAT ZIP: _ C-COLLAR: (IF NOT REPLAC -- �- PHONE: SSP 7+�L�� WORK PHONE: - DRY RUN: (AUTHORIZED). EMPLOYER: OCCUPATIOIJ' OTHER: - •• -- .• _�-. -, - ��++�- ADDRESS: _ q. CITY: STATE' ZIP* COMMENTS: TOTAL: , . 00 _ r+ PATIENT RECEIVED BY. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: —2 G vc PATIENT'S NAME e'I_�- e 1�ZC� f IL f'�M ❑ F COMPANY N ADDRESS Q •�,r �L, AGE CITY- 14 . STATE � S DOB IZ Lv 4o t✓ O Sn O M QCT. O W ❑ j)1 O F 136— DRIVER'S g ""•'DRIVER'S LICENSE b ____ PHONE It")T 4 Z-3!1_ NATURE OF DISPATCH 5P .gt h > �'""• TYPE OF TRANSPORT: AMBULANCER OTHER❑ _ _ STATION 1(A)_2(8)_3(C)_4(0)_5(E)_L INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR 9CLOCK) p �- Y 7 TO SCENE- 3 ,a S.O. CALL RECEIVED •� O O' L l U�' -h-0.c•rl Yl 1C�(5 N S ❑ P.D. TIME 10-8 • PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 -Z.4- 11PSAP TIME 10-49,.-. �1� MILEAGE: ❑ OTHER/PVT TIME 10-7 J� END Z TIME 10-98: . DOCTOR - , _ki 5k C lle-D PMO/® START TIME 10-22 -} HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME D. PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: -. EAMBULATORY? PATIENT TAKEN TO AMBULANCE: S V RESPONSE ZONE ' � J YES ❑ NO ❑ WALKED A GUERNEY ❑ OTHER t PATIENT CONDITION: DRIVER � J I1 PI/ 3Xs EMT-IA t TECHNICIAN 1,r_d / U PARAMEDIC Hx: . `'`''^ `' DISPATCHER: n (�- ) '( CHIEF COMPLAINT: 1.1 yp c t,t•,.f. I P►•C r1 - DRY RUN: ❑ YES X NO REASON FOR DRY RUN I e_"c, v- t'- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) / PATIENT REFUSED SERVICES: (SIGNATURE) X_ /� MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS: s.s. b PRIVATE INS. CO.: BASE RATE: 150' - f KAISER b: MULTIPLE PTS.BASE RATE BLUE CROSS b: TOTAL MILES: I X 0•--I / MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO ,14L ❑ YES ❑ NO 'NIGHT: (19:00-07:00) Ir CCHP/PPRP b: EMERGENCY RUN: MEDI-CAL b: CODE 2(/3 I OTHER: OXYGEN: (PEATANK) STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ---� DATES BILLED- STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) ` X - DRUGS: (PER ADMIN.) X NAME: CA(t'<a RELATIONSHIP:lLC4 W r E.O.A.: (IF NOT REPLACED) ADDRESS: 5•A , ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION OTHER: - ADDRESS: CITY: STATE* ZIP. • COMMENTS: hCG IhSv�ic.��t L� !'� uv�a,� 1•C r-- TOTAL: ' Tu1 O PATIENT RECEIVED BY:X -- (SIGNATURE) pt-1 Provider rota:r. Aire crd Pi.K Cor} Aetrr+i Te'luv nj, t vApn hi 7:my CONTRA COSTA COUNTY AMBULANCE3,F1- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N f-SJ oC_ V �.J CHECK OR FILL 1NAQP�P�ROPRIATf 3 07 e2 SPACES j t��c.�•I i i1 r:' � GATE: C 7 Y PATIENTS NAME%J�!��C�I/. `'�-1! ` O M ❑ F COMPANY N - J ) / ADDRESS , 35 /,�� / Z AGE 92G CITY /264 —sraTE (f/9 — ZIP t f DOB a�J 6 ❑ Sn ❑ M 12-T O W O Th O F O S'`j DRIVER'S LICENSE# PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE CS,OTHER❑ _ STATION 1(A)4_2(B)_3(C)-4(D)_5(E)_-." INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL•Q(3K)3 Y loco R/�JCJ�`� 5 J9 TO SCENE- WS.O. CALL RECEIVED ! ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ PSAP TIME 10-49. r MILEAGE: OTHER/PVT TIME 10-7 ` U 2 i ENO TIME 10-98 DOCTOR J PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL r STANDBY TIME., ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COyAiAk ~• PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5D RESPONSE ZONE �,� ^J ❑ YES ❑ NO*(.tis) ❑ WAL!<ED 0 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER V EMT-tA TECHNICIAN J�' PARAMEDIC Hx: 5<14tk r fD K01 DISPATCHER: �> (/ CHIEF COMPLAINT: DRY RUN: ❑ YES J NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) / PATIENT REFUSED SERVICES: (SIGNATURE) X -� MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: - S.S. « S Ste- 13 9 363 PRIVATE INS.CO.: BASE RATE: KAISER X: MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: X r�(�•-'' MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES "❑ NO NIGHT: (19:00-07:00) CCHP/PPRP q: EMERGENCY RUN: �• / {i MEDI-CAL N: CODE 2 t3 OTHER: OXYGEN: (PER TANK) ' P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME JeZb_4&1 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:,fUDO LYI/.cfLs sem` ORAL AIRWAY: (IF NOT REPLACED) CIITpp�YS:: 5 �• �_ STATE. ZIP: C-COLLAR: (IF NOT REPLACED) - 1'IONE: _� .1ta/ WORK PHONE: DRY RUN:. (AUTHORIZED) EMPLOYER: ,z OCCUPATIOK OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:"G""__' 000192 PATIENT RECEIVED BY:X "r 0`{ Provider retain White lyd Pig: ropy Feturn Ye:2vu -nv, t• M^ uhee biVivp (SIGNATURE) Qts-1 l 00 161 1 CONTRA COSTA COUNTY f AMBULANCE R-3 PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION M . CHECK OR FILL IN APPROPRIATE STAGES _ DATE: PATIENTS NAME .- OM OF COMPANY* NJ ADDRESS AGES ) CITY STATE ZIP DOB ' ❑ Sn ❑ M OT OW O Th ❑ F O S DRIVER'S LICENSE M PHONE NATURE OF DISPATCH &5— N' aXke>a 9N • 4S. TYPE OF TRANSPORT: AMBULANCE D OTHER 0 — STATION 11A)-2(B)-3(C)_4(D)_5(E)_ INCIDENT LOCATION: -�� Z '(' RESPONSE CODE! REPUESTED BY: TIME—(24 HOUR CLOCK) ' TO SCENE- Md S.O. CALL RECEIVED L� � ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL._ STANDBY TIME 27.j D NEAREST.''L ❑ FAMILY D TRANSFER WAIT TIME O PATIENT O DIRECT D OTHER CALL BACK M: AMBULANCE COMPANY: • � f EY AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ES .O NO: O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: EMT-1A :);4X �' ' TECHNICIAN � '� �� PARAMEDIC Hx: DISPATCHER: e _te CHIEF COMPLAINT: DRY RUN: 2-" ES ❑ NO REASON FOR DRY RUN Xj-Lr t Tallt AUTHORIZATION FOR DRY RUN(EMS USE ONLY) • PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE:- - INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.M r. i PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE T BLUE CROSS M: TOTAL MILES: X MEDICARE MI. E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES O NO NIGHT: (19:00-07:00) ` CCHP/PPHPEMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: ') % I OXYGEN:, (PER TANK) P.O.E.STICKER O YES ❑ NO NEONATAL: (INCUBATOR) - DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -NAME: -RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: #' STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP. COMMENTS: TOTAL: CI °' PATIENT RECEIVED BY: X k`.) /1.+vi.4r r• . !. 4'4i.,. .. _ .. (SIQNATURF) rw..: 1. i • . <// ;; 1 I; s� CONTRA COSTA COUNTY AMBULANCE (� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION ( I CHECK OR FILL INAPPROPRIATE SPACES DATE: cy - PATIENT'S NAME O M ❑ F COMPANY M co lZ �A. ADDRESS 91 2`_V ).. . ..f i AGE ' CITY `----STATEN ZIP DOB ❑ Sn O M ❑T O W O Th OF O S v' : DRIVER'S LICENSE N _— ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:.AMBULANCE 0 OTHER — STATION i(A)_2(8)_3(C)._4(D)_5(E)_ j INCIDENT LOCATION:' RES&NSE CODE] z QUESTED BY: TIME—(24 HOUR CLOCK) ,,��rr f TO SCENE- S.O. CALL RECEIVED : 7_L_ '� —) ,•'t.' =3 1 ❑ P.D. TIME 10-8 PATIENT DESTINATIO -- -� FROM SCENE- 13 FIRE TIME 10-97 O PSAP TIME 10-49 ' MILEAGE: ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 ADOCTO�is !�—,^� PMD/ER START TIME 10-22 HOW CHOSEN: -- TOTAL STANDBY TIME MI.- .❑ NEAREST,'Z 13 FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK K: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE rr♦gv 131-YES ❑ NO ., O WALKED ❑ GUERNEY ❑ OTHEW �. ATIENT CONDITION: ; DRIVER �'� / DO EMT-1A TECHNICIAN PARAMEDIC Hx: -- ' DISPATCHER: CHIEF COMPLAINT: I DRY RUN: ❑ YES. ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X S MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.# PRIVATE INS.CO.: BASE RATE:' ' KAISER M!' ' MULTIPLE PTS.BASE RATE BLUE CROSS K: . TOTAL MILES: X MEDICARE C I E.O.B.ATT. ROUND TRIP: OYES ❑ NO /fir ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP*:!I f , EMERGENCY RUN: MEDT-CAL 0: _ CODE 2/3 t _ I OTHER: } I I OXYGEN:I (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) P.. . DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) `NEAREST RELATIVE/RESPONSIBLE PARTY: - `— I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 'NAME: — 'RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: STATE_,ZIP! C-COLLAR: (IF NOT REPLACED) PHONE: i WORK PHONE: DRY RUN: '(AUTHORIZED) • . —EMPLOYER:' OCCUPATION: OTHER: ADDRESS: CITY: STATE- ZIPa "COMMENTS:— TOTAL: Ctl �• v PATIENT RECEIVED BY' X -- fSIONATURE) � Iti.wirf.� ntn?., vtii+• ...a ri-t •� 4.t.� ... ., • CONTRA COSTA COUNTY AMBULANCE �3 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION I#q-3 � `'jam i• y,R•_ 1:" , " ECK OR FILL IN APPROPRIATE SPACES DATE: - -�-�•` 4 ^w PATIENT'S NAME/ ^U�' "`" ��`` 5�-�I I l� M 4F COMPANY /��"�n� ADDRESS Uw- �G P Jv . AGE*j O/ �Jl 1 CITY/f✓� C� STATE ZIP DOB `'^/'� `� D sn D M D-T,W W O Th E3 F S•_'! DRIVER'S LICENSE a _ PHONE u 3r-33--2-(;NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEV OTHER 13 _ STATION 1(A)._2(B)_31C14-4TD)_5(E)�-:._: ` . s INC[ ENTLO ATION: RESPONSE CODE' REQUESTED BY: TIME-(24 HOUR CLOCK) jJ �� TO SCENE- S.O. CALL RECEIVED T / OC!!1 ❑ P.D. TIME 0-8 1 f ' PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 1) v ❑ PSAP TIME 10-49-r-��d_ ; �� crx,4i Z MILEAGE: CYOTHER/PVT TIME 10-7 I ENDf TIME 10-98 7 DOCTOR PMD/e START_ / TIME 10-22 :�- HOW CHOSEN: TOT STANDBY TIME_—.: D NEAREST Cl FAMILY ❑ TRANSFER c WAIT TIME O PATIENT O DIRECT Q OTHER(T CALL BACK a: AMBU COMPANY: ..r, C. LS PT. AMBULATORY? PATIENT TATO AMBULANCE: -- 5 O [RESPONSE ZONE �7 YES ❑ NO ❑ WALKED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER -� V'� MT-1 - TECHNICIAN�. _ � pA U RAMEDIC Hx: �I * DISPATCHER: CH)I<F CjMPLA1 �- /Cl DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY1 PATIENT REFUSED SERVICES:(SIGNATURE) X EOICAL CO GE: L UST�R�'°'L ❑ YES NO NO.OF PATIENTS: S.S. a ✓ �3�! f-. I- PRIVATE INS.CO.: BASE RATE: KAISER a: .MULTIPLE PTS.BASE RATE BLUE CROSS a: TOTAL MILES: I X�t+ MEDICARE a: E.O.B.ATT. ROUND TRIP: •O YES 0 D�,- �; •'f ❑ YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPHP a: EMERGENCY RUN: , ag. G-� MEDI-CAL a: COD �;1i.. ..•!.:"':a , i...�...1 I OTHER: BILLED ED GO OXYGEN: fWA TANK) P.O.E. STICKER DYES NO (.{ NEONATAL: (INCUBATOR) _ �,��•,.,�,. � DATES BILLED: STANDBY: (OVER 15 MIN.) RNs= E.K.G.: (PER EPISODE) NEAREST RELATIVEJRESPONSIBLE PARTY: - I.V.:'(PER ADMIN.) X_- - ,77- -.-...- DRUGS: (PER ADMIN.) X NAME: ft�tniP j ��'` RELATIONSHIP 4"�' E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: I -T��`�� STATE-_ZIP: C-COLLAR:-(IF NOT REPLACED) PHONE: 311_1 . L}3 MI WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIOAI: OTHER: - - -_ _ ~--• �•� - ADDRESS: CITY: STATE ZIP' COMMENTS: - TOTAL: 3 S� PATI ENT.RECEIVED B17-0 Provider retair. White rd Pir.+ roPl, Returm Te:Iw mpy !• 94.5 when biking DIS-i n ` CONTRA COSTA COUNTY 11 AMBULANCE C�y. PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N r' J �" !� /O CHECK OR FILL IN APPROPRIATE SPACES DATE: ILI PATIENT'S NAMEUJ ( � M ❑ F COMPANY N A ADDRESS C l AGE)JO _ 1 CITY ) STATE ZIP r DOB �O D Sn D M D T. E3 Th D F D g "1 r DRIVER'S LICENSE M ------- _ PHONE NATURE OF DISPATCH' TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_2(8)_3(C)_4(D)_5(E)__._ ) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—124 HOUR CLOCK)S� - TO SCENE- A S.O. CALL RECEIVED Q ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 � ❑ PSAP TIME 10-49 1^� /�' •; -_� �- MILEAGE: �j D OTHER/PVT TIME 10-7 END / TIME 10-98 c r DOCTOR �� fZ- PM / R STARS cy TIME 10-22 HOW CHOSEN: TOTAL /E-` STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFE WAIT TIME _ ❑ PATIENTL DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AM-1 NCE: C) RESPONSE ZONE YES ❑ NO WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVE hraMS loo. 11 i TECHNICIAN PARAMEDIC Hz:l ! 1 t _ DISPATCHER: �?�l i.. f 1A l 100, CHIEF C MPLAINT: I z DRY RUN: O YES REASON FOR DRY RUN ( 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) • (li'aLnWIENT REFUSED SERVICES: (SIGNATURE) X_ i MEDICAL OVERAGE: INDUSTRIAL ❑ YES P.NO NO. OF PATIENTS: —0 I ►,III-�,_�j, (7(D �. S.S. I, _ .._ . PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N TOTAL MILES: 7 X 5 �� 50 MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES Cl NO _ ❑ YES 13NO NIGHT:(19:00-07:00) =D'C'J CCHP/PPRP N: EMERGENCY�UN: 7L ��Gi•'� MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) _ .. IP.O.E. STICKER O YES NO NEONATAL: (INCUBATOR) _ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: g. STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 3+ WORK PHONE: DRY RUN:, (AUTHORIZED) EMPLOYER: OCCUPATION OTHER: - ADDRESS: - CITY: STATE: ZIP: COMMENTS-.. ( - t tL l 1 TOTAL: 0. 15 -01,9 b^ � z PATIENT RECEIVED BY:X r'1 (SIGNATURE) �- O 0 Provider retG:r. YhiLe vd Pir.w opt .4etw+ Ye'Ivu mp:, I• 9IF when FiZ:inp �If-1 i...-� CONTRA COSTA COUNTY AMBULANCE �_ r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION !^�'; ' � � � !-/" /._ \, � • .) I � SCJ CNECA'OR FILL IN APPROPRIATE SPACES DATE: (2 /`-e PATIENTS NAME a r�h1 v, Flo F�' ��y !'T� S C�M O F COMPANY N % "l 1 > r ADDRESS -128 [tn�.,71�.. ra • Tt9 sl ,( �c^ AGES CITYSctiu PC-b-1 n STATE 6�� ZIPy _CLDOB�14 L-0 ❑ Sn O M O T O W AD Th OF OS DRIVER'S LICENSE x , � PHONE NATURE OF DISPATCH 1 � TYPE OF TRANSPORT: AMBULANCE OTHER O _—_ STATION I(A),�C2(BI._3(C)_4(D)._5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) S TO SCENE- ❑ S.O. CALL RECEIVED _L _14 O P"D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑fIRE- TIME 10-97 / S f% ❑ PSAP TIME 10-49 MILEAGE: -N OTHER/PVT TIME 10-7 LLL i END f ;�2 Sc r. P ALU TIME 10-98 ` DOCTOR. [lJ PMD/ER START__LZ_� TIME 10-22 HOW CHOSEN: TOTAL (: -T— STANDBY TIME •B NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER l , CALL BACK N: AMBULANCE COMP NY: C~ s IXIPT . AMBULATORY? PATIENT TAKEN TO AMBULANCE: c ! RESPONSE ZONE —�— YES ❑ NO ❑ WALKED A GUERNEY ❑ OTHER N�- PATIENT CONDITION: DRIVER Sc_1j ell- P T-1 TECHNICIAN PARAMEDIC Hx: fT K-- P,LL 5 —Tj DISPATCHER: - CHIEF COMPLAINT: /SO DRY RUN: O YES 12 NO REASON FOR DRY RUN :�o:v Q TD "T<•'L( h."r, s r (r AUTHORIZATION FOR DRY RUN(EMS USE ONL Y) PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL O YES V NO NO. OF PATIENTS: 412 S.S.N S!z =6-1 k9:_— PRIVATE INS:CO.: BASE RATE: KAISER x ~ �'' ' e > MULTIPLE PTS.BASE RATE E CRO N: F 1 X TOTAL MILES: / X C<• _SiQs•LO EQ7CApE N: `� < / `i E.O.B. ATT. ROUND TRIP: O YES O NO " ..'r ; {-� / ) .-" / ❑ YES j0 NO NIGHT: (19:00-07:00) ry� CCHP/PPRP N:—;,, EMERGENCY RUN: t�S[ MEDT-CAL N: CODE'2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER YES --D NO NEONATAL: (INCUBATOR) 'IATES BILLED: STANDBY: (OVER 15 MIN.) - E.K.G.: (PER EPISODE) NEAREST RELATIVEJRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X (DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: y'; E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: =_ OCCUPArT10N: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:T' - ` 50, 00 01.97 TOTALI'c %i7 ` i / r PATIENT RECEIVED By X___ l '4_ 1 �� 1 (SIGNATURE► O0 172 Y►vVi'/uP rf Cgtr, Yhi fy •.It�J 1•I q%c .•,•(ry .4vluni Y'r,'i�v •h� f Ott; Uhrn 1•i 1 iryr Lm% I CONTRA COSTA COUNTY AMBULANCE -- T PRE-HOSPITAL ARE FORM 1 UNIT 7 L' AUTHORIZATION N L&'o- /Ll , LC—HECK OR FILL W AiPROIRIAre SOAcEs DATE: ' + I I r' t PATIENT'S NAME 001' NlI (� �� ❑ M D(F COMPANY N ADDRESS Y N�� C AGE �7 `�1 " ) CITY _c �� STATE ZIP ��`,LD DOGB�L��pJ—©2O Sn OM OT D W '6d�Th OF O$ 1 DRIVER4LICEN m _ PHONE�-j_! '�Ta NATURE OF DISPATCH 1 TYPE OF TRANSPORT; AMBULANCE,111 OTHER —._...._._._ ._._ ... STATION 1(A),2(8)._3(C)N�_4(0)_5(E), INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) (, Ifo SCENE- S.O. CALL RECEIVED I " RIc4,I I� S :---� I ❑ P.U. TIME 10-8 � ! •� I PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 + �e/ , O PSAP TIME 10-49 �D 14 Y✓ MILEAGE: ❑ OTHER/PVT TIME 10-7 ,T, :�t 1•� END - TIME 10-98 R r,DOCTOPMD&ji START` � TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME iq NEAREST O FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: CA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i, RESPONSE ZONE O YES .Q NO O WALKED GUERNEY O OTHER PATIENT CONDITION: DRIVER—P-6 �� EMT-1A c r TECHNICIAN 4 ) PARAMEDIC t' Hx: (JIG F�{f 17 P DISPATCHER: I I CHIEF COMPLAINT: ;{` �� .n DRY RUN: O YES NO REASON FOR DRY RUN l� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERA INDRIAL ❑ YES `�I NO NO. OF PATIENTS: S,S, N 0 PRIVATE INS.CO.: BASE RATE: KAISER is: MULTIPLE PTS. BASE RATE ' 8 OSS1# TOTAL MILES: �� X �• �' �`�' EDICA aft �` " E.O.B. ATT. ROUND TRIP: 13 YES ❑ NO -❑ YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN; EDI_ AL )� CODE 2/3 ?HER. OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X " 'NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) 'CITY: & STATE._ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ^r WORK PHONE:' DRY RUN: (AUTHORIZED) -'EMPLOYER: OCCUPATION:_ OTHER: ADDRESS: ��•�� .CITY: STATE: ZIP: 1 CQMM TS: 1J t nr) _.... TOTAL r �U Mk/IgaC� 4,, roe fi__._ PATIENT RECEIVED BY:X Provider tair. White Lrd /'inK co . 4atum wi..0 (SIGNATUREI testi 1 Fh •�,i'% I ' tTt." uhrn t 1 iu;, --'V` 17 �`� '�'� • CONIRA COSTA COUNTY AMDULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M � — 12 �f CHECK OR FILL IN APPROPRIATE SPACES DATE: -7 PATIENT'S NAME 1?�M ❑ F COMPANY N ADDRESS _2.1._I.>, a�.� ��f �2-1 AGE 31 -'.)'-• ' CITY LC��.�� STATE_(�� ZIP t� 0 63 DOBf�/_4r ❑ Sn ❑ M O T ❑Wtt? ❑ F O S'. DRIVER'S LICENSE b MfIdNE' !_(¢ �c �(( _ NATURE OF DISPATCH �� '2 � ! TYPE OF TRANSPORT AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE' REOUESTED BY: TIME— (24 HOUR CLOCK) j TO SCENE- i .0. CALL RECEIVED ..11I,L44-_ A?_d ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _Al :-47- 13 -L7- ❑ PSAP TIME 10-49 `.CC MILEAGE:. ❑ OTHER/PVT TIME 10-7 ' DO _ ��L PM START_END TIME 10-98 CTOR _ M DE� TIME 10-22 r HOW CHOSEN: TOTAL STANDBY TIME r ❑ NEAREST ❑ FAMILY ❑ TRANSFER �_ _ WAIT TIME PATIENT ❑ DIRECT ❑ OTHER 1 } ::::: J CALL BACK k: AMBULANCE COMPANY* _ c I PT AMBULATORY? PATIENT TAKErj TO AMBULANCE: RESPONSE ZONE- -+ - YES ❑ NO ❑.WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIV iA �UU EMT-1A I �A. n TECNICIl 5 a / 0 PARAMEDIC f Hx: f.j�- t�— �1 ---- DISPATCHER: a CHIEF COMPLAINT: _-4L -Pnlz 7W 6-'(3V DRY RUN: ❑ YES �41NO REASON FOR DAY RUN !" AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i' PATIENT REFUSED SERVICES: (SIGNATURE)X- 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES>16NO NO. OF PATIENTS: S.S. « ��—-- PRIVATE INS. CO.: BASE RATE: [ C�•L?�.- KAISER a: _ MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP;PPHP a: EMERGENCY RUN: 30,Ca ��• GorFDI-CAL u CODE 2 3 j OTHER OXYGEN: (PEWtANK) C•G"��!, P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I /I DATES BILLED._ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) f NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X I /'� DRUGS: (PER ADMIN.) X NAME:_L.l _Ll11 .b5.41L!A6'_f-RELATIONSHIP:-JaLFN E.O.A.: (IF NOT REPLACED) ADDRESS:-1 3 -S� -M Q £ _ ORAL AIRWAY: (IF NOT REPLACED) '- CITY ..�_n __. STATE CA _ZIP: C-COLLAR: (IF NOT REPLACED) PHONP T J9 7-LY. WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: ( .� t o _ OCCUPATIO OTHER: II ADDRESS. r� e CITY: STATE: ZIP: COMMENTS: ~ — TOTAL: l » • PATIENT RECEIVED Y V O Provider rrtair White rrd Pin= nru Fotur. vo'Jw M:•, n.• :.tion r:; (SIGNATURE) DtS-1 174 CONTRA COSTA COUNTY AMBULLANNCCE� (� I PRE-HOSPITAL CARE FORM 1 UNIT 1 1�_1! AUTHORI TION N \f" CHECK OR PILL INAPPROPRIATE SPACESDATE: PATIENTS NAME�r- j O M l3YF COMPANY N �t/ i i'• / �, 1 AD DRES �v ; { ^ AGE ��''�,--_�� '-I ��' Ll CITY C STATE �� ZIP C `' DOBI�5 O Sn ❑ M ❑ T ❑ W ❑ F ❑ DRIVER'S LICENSE N PHONE �'NL-- __ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION 1(A) 1B)_3(C)_4(D)� )_ I INCI NT LO ATION: 1 RESPONSE CODE: R,EQTEED BY: TIME— (24 HOUR CLOCK) 1 n � TO SCENE`v S.O. CALL RECEIVED I� ❑ P.D. TIME 10-8 h PATIENT ESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 :�j- 1 / c O PSAP TIME 10-49 MIL 11-OTHER/PVT TIME 10-7 ' ENDTIME 10-98 DOCTOR Tl� PMO/®R STAR _1 _ TIME 10-22 HOW OSEN: TOTALSTANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 13 PATIENT O DIRECT 11 OTHER ) CALL BACK N: AMQLJLpNCECOMPANY: KJ1 PT.,AMBULATORY? PATIENT TAKEN T AMBULANCE: i RESPONSE ZONE YES ❑ NO ❑ WALKED UERNEY O OTHER PATIENT CONDITION: DRIVER7 __\ 1 EMT-tA TECHNICIAN ��' PARAMEDIC Hx: DISPATCHER: z F CO L IN DRY RUN: ❑ YES O REASON FOR DRY RUN .� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r PATIENT REFUSED,SERVICES: (SIGNATURE) X MEDICAL COVERAGE: tt�[QUSTRIAL ❑ YES 0114101, NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: - X MEDICARE N; E.O.B. ATT. ROUND TRIP: O YES O NO •�� }•t-� Le- ❑ YES ❑ NO NIGHT: (19:00-07:00) J CCHP/PPRP N: EMERGENCY RUN: (W MEDI-CAL C CODE 2/3 J�r OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: /4OL4 Zb W10L' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: _,Vj,�D —� - -- — V L 200 PATIENT RECEIVED UY X 1%IGNATI-1.'1 IM\ Prqi.br rvtoin Vhi t.• n./ q-I t.r,.n .. nn , �.-- CONTRA COSTA COUNTY AMBULANCE - s PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N I CHECK OR FILL INAPPROPRIATE SPACES DATE: -7 Af 5 PATIENTS NAME -1 ❑ M ❑ F COMPANY N .- j ADDRESS (� AGE J 'r-. ICITY STATE ZIP DOB O Sn O M ❑T O W ❑Th-hF,* b S DRIVER'S LICENSE N " PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANC THER❑ INCIDENT LOCATION:.. (-or i�1 C� RESPONSE CO E: REOUESTED BY: TIME-(24 HOUR CLOCK) r N / V� ' TO SCENE- S.O. CALL RECEIVED 0 1� Y_�- ❑ P.U. TIME 10-8 PATIENT DESTINATION: 1. . -. FROM SCENE O FIRE TIME 10-97 '� n u �n ❑ PSAP TIME 1G-49 y \ MILEAGE: ❑ OTHER/PVT TIME 10-7 f ...YYYY END TIME 10-98 DOCTOR '-' PMD/ER START TIME 10-22 _E?Z_ :.2-f- t _ i HOW CHOSEN: TOTAL STANDBY TIME ' 0 NEAREST• ❑ FAMILY ❑ TRANSFER WAIT TIME I ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: ,.r PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO . O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN gfiAMEDIC `1 ( � Hx: DISPATCHER: C.� - CHIEF COMPLAINT: ' DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 41 T PATIENT REFUSED SERVICES:(SIGNATURE)X �r MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: - KAISER N: MULTIPLE PTS. BASE RATE • BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: 13YES 11NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) - P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) Z �. . EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: CO MENTS: `r n 2 01 i 5 v- TOTAL PATIENT RECEIVFn BY•X- 0V .gin N,i•, + r• 4..._.-_ ....•� I51(1NATIInf1 _ , CONTRA COSTA COUNTY AMBOS CSE / PRE-HOSPITAL CARE FORM I UNITAUTHORIZATION N CHECK OR fllL IN APPROPRIATE S Aces DATE: PATIENT'S NAM rM ❑F COMPANY M ADDRESS ^ t�sfu ; 11hAG CITY ' SIe4,T� ZIP OOB D O $n O M O T_O w .O O g DRIVER'S LICENSE:# PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION I W_2(B)_3(C)_4(D) 5( INC DENS OCA ^ RESPONSE CODE: EOUESTED BY: TIME—(24 HOUR K) �•r '� ��( n TO SCENE- S.O. CALL RECEIVED l! ❑ P.D. TIME 10-8 ' PATIENT_DESTINATION: FROM SCENE '(n 13 FIRE TIME 10-97 ❑ PSAP TIME 10.491 o ' MILEAGE ^� O OTHER/PVT TIME 10-7 : END + TIME 10-98• 1 «""1 DOCTOR PM START TIME 10-22 HOW CHOSEN. TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME4mll ): ATIENT ❑ DIRECT ❑ OTHER r CALL BACK 0: AMBULANCE S!!P7,Y- ---....� PT. AMB LATORY? PATIENT TA N TO RESPONSE ZONE ❑ YES _p'f4O --� ❑ WALK UERNEY ❑ OTHER t PATIENT CONDITION: DRIVE EMT-1A f TECHNICIAN '+ PARAMEDIC Hx: 7U e4a DISPATCHER: 'c -� r �) CHIEF CO AI DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j PATIENT REFUSED SERVICES: (SIGNATURE) X (� r.--• MEDICAL COVERAGE: INDUSTRIAL 13 YES O NO NO.OF PATIENTS: l S.S.rt PRIVATE INS.CO.: BASE RATE: `"--� KAISER It: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X to• 'lfJY--J MEDICARE C E.O.B.ATT. ROUND TRIP:'❑ YES O NO OYES ❑ NO NIGHT: (19:00.07:00) CCHP/PPRP II: EMERGENCY RUN: EDI-CAL K: CODE 2/3 / 1 - OTHER: 1 I OXYGEN: (PER TANK) O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) 1� E.K.G.: (PER EPISODE) ( J EAREST EL TIVE/ SP NSIBLE PARTY: IN.: (PER ADMIN.) X ! �, DRUGS: (PER ADMIN.) X NAME: ( TIONSHI _ E.O.A.: IF NOT REPLACED) -' ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— IP: 5� OyLI,AR: (IF NOT REPLACED) " '• - _ PHONE: 42 WO PHONE DRI�V; (AUTHOR12ED) r• EMPLOYER: CCUPATION- ADDRESS: CITY: STATE' ZIP* COMMENTS: X02 TOTAL: PATIENT RECEIVED BY:X Provider rete Nhite Grd Pi..: ropp ,4rtLrn Ye:lou ropy t• 945 when til:irt9 (SIGNAT E OlS-1 CdNTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION It CHECK OR FILL IN APPROPRIATE SPACES DATE: ` 3 PATIENTS NAM�Ef ��f C.�L G l" M ❑ F COMPANY M ADDRESS v S O' , �� AGE CITY.,gC h An' I- STATE 21P Z DOB /r ❑ SnI ❑ M ❑ T ❑W ❑ Th .%F ❑S DRIVER'S LICENSE N _ PHONE _?3.`-Z:t5�*ATURE OF DISPATCH 2P R/�S I••^ TYPE OF TRANSPORT: AMBULANCE OTHIER _ STATION U )>1 ,2(B)_3(C)_4(D)_-5(E)_ INCIDENT LOCATION: �1 ( 1 I RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) , TO SCENE ❑ S.O. CALL RECEIVED ' ' IN C 1✓L�� P (� ❑ P.D _ TIME 10-8 -T! PATIENT DESTINATION: FROM SCENE - ❑ FIRE 'TIME 10-97 L o� ❑ PSAP TIME 10-49 Oiy�T—AM S�Q MILEAGE: Et OTHER/PVT TIME 10-7 t END TIME 10-98 DOCTOR _ PMD/ER START G `��' 'TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ;I ❑ NEAREST ❑ FAMILY Jff TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER / I,I CALL BACK K: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANC . '� �)�I �' RESPONSE ZONE, ES ❑ NO 11 WALKED 14GUERNEY ❑ OTHER 02:i ti:, PATIENT CONDITION: DRIVERE ( e 7-4 A1`T� ` TECHNICIAN_1�f'�l''P y 1 -1 ( PARAMEDIC (n� Hx: _ � Z DISPATCHER: Ct) ' � I `I ' CHIEF COMPLAINT: DRY RUN: ❑ YES $ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) >: PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVE AGE: INDUSTRIAL 11 YES IL NO NO. OF PATIENTS: tynf� 77, S.s. » day - 2 vi It 3a_ PRIVATE INS.CO.: BASE RATE: Azi,QV ( KAISER R: MULTIPLE PTS. BASE RATE \ BLUE CROSS 0: / TOTAL MILES: X 32 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO l ❑ YES ❑ NO NIGHT: (19:00-07:00) I CtpA PHPN:g` b5�- /, -O/014U42 0EMERGENCY RUN:EL K: CODE 2/3 =R: OXYGEN: (PER TANK) y( P.O.E.STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: S`a'`T-�� RELATIONSHIP: E.O.A.: (1F NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ` CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:T— OTHER: ADDRESS: - CITY: STATE: ZIP: COMMENTS: (" TOTA VL` \\ V 0203 PATIENT RECEIVED BYX ,�1_1. -20-11 l R vuidor regain Yhita ,nd Ti.a .•.q,y hYtYt+� 1"✓:lr� .•,,�.� I . 'N' uh:,i l it i.,,r ISIC,NATU11t) tn% I j ` 1 CONTRA COSTA COUNTY AMBULANCE �� PRE-HOSPITAL CARE FORM I NIT © AUTHORIZATION 0 t r, Z 3 CHECK OR FILL IN APPAOPAIA7E SPACES � DATE: PATIENT'S NAME �-t L COMPANY M ADDRESS i �� AGE I CITY ^, STATE •ZIP If DOB ./7O Sn O M O T O W O ThXF 0$ j DRIVER'S LICENSE —_ -U �T PHONEQTURE OF DISPATCHSLa TYPE OF TRANSPORT: AMBULANCE OTHER O _ -_ STATION 11 2(B)_31C1_4(D)_5(E)=.. } •' INCIDENT LOCATION: RESPONSE CODE: REOUESTEO BY: TIME- (24 HOUR�LPPIO _ TO SCENE- .O. CALL RECEIVED _L_ !' �� `" /�► `- L_ ❑ P.D. TIME 10-8 1?, PATIENT DESTINATION: FROjL�CENE- O FIRE TIME 10-97 : ❑ PSAP TIME 10-49 _Z MILEAGE: ❑ OTHER/PVT TIME 10-7 END p� TIME 10-98 1�•�:� i DOCTOR ��1't PMD/ER START��2- TIME 10-22 H W CHOSEN: TOTAL STANDBY TIME , EAREST ❑ FAMILY O TRANSFER \ WAIT TIME + ❑ PATIENT ❑ DIRECT ❑ OTHER ! CALL BACK N: AMBULANC NY: -i-- PTT MBULATORY? PANT TAKEN TO AMBULANCE: , t� RESPONSE ZONE u YES ONO Id WALKED ❑ GUERNEY O OTHER - PATIENT CONDITION: DRIVER =- L SZU -tA LT�HNICIAPARAME.? / Hx: GDI PATCHE ..�.,.i CHIEF COMPLAINT: (U D��Y RUN: ❑ YES O NO REASON FOR DRY RUN L&'� Cts AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL O YES tJ0 NO. OF PATIENTS: S.S. 20 PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE �` BLUE CROSS A: TOTAL MILES: X, rJ d--j' ' MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ONO , - !! OYES .O NO NIGHT: (19:00-07:00) • _I CCHP/PPRP 4: EMERGENCY RUN: MEDI-CAL 4: CODE 2/3 ' -- ( �` OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) - DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELAPVIYRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: n 0 (,L r HELATIONSHIPIJr) E.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: - WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: ` � OCCUPATIONS_ OTHER: ADDRESS: CITY: STATE: ZIP: l (� COMMENTS: JF I L"I- lQ �J C TOTAL: 000204 s4�_ PATIENT RECEIVED BY:X (SIGNATURE) 00 Provider rrta f Mite cxf r,r.: .•ori i.tnr� i� ?.w vpy AW ubn MI"ink OSS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPR/O�PRUTE SPACES DATE: / PATIENTS NAME.' ^tJ f?- , +T CWA5 F COMPANY M-A)11 2-3 4� ADDRESS �� pil' ST RICH CITY_ (�ZC�I _� f� STATE ZIP. OOBZ O Sin ❑ M ❑ T O W ❑ ThF` S DRIVER'S LICENSE N _ PHONE X31 16 3-15--L NATURE OF_OL FATCH =11-e-1 TYPE OF TRANSPORT: MBULANCE HER❑ __ __,.._ _. TATION 1(A (B)_3(C)_41D)_5(E)_ INCIDENT LOCATION: (.TCN IniNTAL H4At.711 RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) V � + TO SCENE- O S.O. CALL RECEIVED O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ^� O FIRE TIME 10-97 , v' ❑ PSAP TIME 1049 `' d4L :L_ MILEAGE: 13 OTHER(g) THE PVT TIME 107 CI.(.t� CGISIS END V S c' TIME 1098 7 DOCTOR��C S PMD/ER START a' t-rC -TIME 1022 HOW CHOSEN: TOTAL 'nl t A(t'd/i STANDBY TIME O NEAREST ❑ FAMILY/ TRANSF ('(TA(_S 14 WAIT TIME O PATIENT 13DIRECT THER CALL BACK C. AMBULANCE COMPANY: BULATORY? PATIENT TAKEN TO AMBULANCE: �. RESPONSE ZONE M Y ONO O WALKED 03 GUERNEY O OTHER PATIENT CONDITION: DRIVER TECHNICIAN (L5 Hx: PL01 >uS IlM N IAL CbN O , DISPATCHER: " 1gHIEF COMPLAINT: 19P AT-1 J '4L S I AT*P(&L RY RUN: O YE N REASON FOR DRY RUN _ RTA l S AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1L� PATIENT REFUSED SERVICES: (SIGNATURE) X AL COVERAGE: INDUSTRIAL ❑ YES NO. OF.PATIENTS: S. (-,o 6-1 PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE rI/ BLUE CROSS C TOTAL MILES: X MEDICARE 0: c�' ,2 C? E.O.B. ATT. ROUND TRIP: O YES 91 NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP P q:' EMERGENCY RUN: '4EDI-CA d7r,o- -95 64 7� - �(-Gl CODE 2/3 HER: OXYGEN: (PER TANK) / P.O.E. STICKER ❑ YE N NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -NEAREST RELATIVE/RESPONSIBLE PARTY: LA14 t7 I.V.: (PER ADMIN.) X L-DIYO DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS 5 AC (�n IN%-01 SIC" Qoki ORAL AIRWAY: (IF NOT REPLACED) CITY: z STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) ` EMPLOYER- OCCUPATION: _ OTHER: ADDRESS: CITY; STATE: ZIP: COMMENTS: TOTAL: �I PATIENT RECEIVED BY. X oYrouider retcir, Aita old Pin+ ropk ,46rtum Yr'l,, .ti,p� I . P.v: c,h.•n hi! n,I [Ms-1 T07-1 [ i'A'' CONTRA COSTA COUNTY AMBULANCE g7 PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION 093 7 �1 •. . • CHECK OR FILL IN APPROPRIATE SPACEScv 93 DATE: PATIENT'S NAMEI) t f U ! -. OM OF COMPANY• L L ..1 . ,lDDRESS •- ....} AGE\ _ R CITY •T r j�`'� -ESTATE _.�, ZIP .r DOS ^ O Sn OM OT OW O Th ,1@ F O S"' DRIVER'S LICENSE'M -- 1 PHONE ______t.,_ NATURE OF DISPATCH TYPE OF TRANSPORT:.AMBULANCE OTHER ' STATION 1(A)_2(B)_3(C)_4(D)_5(E) INCIDENT LOCATION RESPONSE CODE! REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE. S.O. CALL RECEIVED g i C�. -- ='' "•;; P � • U P.D. TIME 10-8 PATIENT[DESTINATION:. . FROM SCENE- 13FIRE TIME 10.97 I \1 ''ll �,� ❑ PSAP TIME 10-49 ` MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10-98 ! •:Z7Si b0CTOR I T _r PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME 'M,O NEARESTJ,: O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK 4: AMBULANC CQPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES O NO r O WALKED O GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �� ? 0") 5 EMT-1A 3166 L , % i ` TECHNICIAN erg PARAMEDIC ( ' Hx: - _� DISPATCHER: CHIEF COMPLAINT: •,. ...L. DRY RUN: 1.9 YES O NO REASON FOR DRY RUN ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `r. A.t.!17:..;PATIENT REFUSED SERVICES:(SIGNATURE)X ' y MEDICAL COVERAGE: t .. INDUSTRIAL O YES O NO NO.OF PATIENTS: S.S.N f,T l 1 i. PRIVATE INS.CO.: BASE RATE:-- KAISER 0,1 ' MULTIPLE PTS.BASE RATE - t, BLUE CROSS N: ' - , TOTAL MILES: X MEDICARE 0; E.O.B.ATT. ROUND TRIP: ❑ YES ONO ! _ O YES O NO NIGHT:(19:00-07:00) CCHP/PPRP#;C.T r I EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER:-: " ( I OXYGEN:. (PER TANK) ' r P.O.E.STICKER O YES NO NEONATAL: (INCUBATOR) I ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPO BIBLE PARTY: - - - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:' RELATIONSHIP• E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ""CITY: r - STATE__ZIP• C-COLLAR: (IF NOT REPLACED) PHONE: ORK PHONE DRY RUN: (AUTHORIZED) ' %•. ` EMPLOYER: OCCUPATION: OTHER: ADDRESS: "l CITY: TATE• ZIP: _ 206 —COMMENTS: -- TOTAL:'.f,5V.G 'r PATIENT RECEIVED BY:X 00 181 irovlJ.r rota/n VAi r. ,„.l •.r,,,••. ,. , . . .••• ..., , ;, ,. (810NAt1IgF.) .. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I EM UNIT AUTHORIZATION Al CHECK OR FILL IN APPROPRIATE SPACES DATE: �~ 1 PATIENTS NAME��'-/I' U1 L�,.n Irl G gM ❑❑ F `` COMPANY A_ , 123 15 ADDRESS `I L_� G 2yl S AGE C G'P 1 Z U CITY ��K�G`y1 cTATE ZIP „��''�� DOB O Sn C3 O T O W O Th .❑ IF DRIVER'S LICENSE N __ _ PHONEt: -? S Z- NATURE OF DISPATCHP Gt TYPE OF TRANSPORT: AMBULANCE OTHER❑ — STATION 1(A)_2(B)_3(C) 4(D)_,_6(E)�-..... J CI INCIDENT L//t�CATION:I RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR08 K) TO SCENE- O. CALL RECEIVED -�� iii,G'1 ('<.r �(( / CL /1. ❑ I TIME 10-8 PATI IQT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 l l ❑ PSAP TIME 10-49. _ 1 "u SLI MILEAGE: , O OTHER/PVT TIME 107 // END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 low HOW HOW CHOSEN: TOTAL STANDBY TIME .. ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME i ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULA C MPPANY: t PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ,c RESPONSE ZONE ;'(YES ❑ NO ❑.WALKED ❑ GUERNEY O OTHER v �j PATIENT CONDITION: /' DRIVER C �iNT-1A _ J TECHNICIAN' I ` c PARAMEDIC �•f Hx: -r2 Z'l/ /�'' 7 DISPATCHER: Ki (C'(� I t CHIEF COMPLAINT: D UN:N❑ CRY ON FOR DRY N THQRI`Z (EM 1 J "1 PATIENT REFUSED SERVICES: (SIGNATURE) X L. -t MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO. OF PATIENTS: S.S. N. PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X --� MEDICARE C E.O.B.ATT. ROUND TRIP: O YES ❑ NO _ ❑ YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: �-•1 MEDI-CAL N: CODE 2/3 -•- -•� OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.). E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: V45rcff h C:14`RELATIONSHIP' E.O.A.: (IF NOT REPLACED) ADDRESS: S - -7 ORAL AIRWAY: (IF NOT REPLACED) CITY: <<' Lt -� _ STATE- ZIP C-COLLAR: (IF NOT REPLACED) - '`- PHONE: 26 ��-$ PHONE. DRY RUN: (AUTHORIZED) �E EMPLOYER: OCCUPATION��_ OTHER: ADDRESS: CITY: STATE: ZIP• ” COMMENTS: 2 O TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) 00 1-82 .C. Providor rrto'n A'te I'd Pira ropy Return r.: w Zropy t DV.S when bii'inp Dlf-1 2. 10 CONTRACOSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT Z[ AUTHORIZATION 0 CHECK OR FILL IN APPROPRIAT!SPACES DATE: -T- w-N,% PATIENT'S NAME OM ❑ F COMPANYN 1,;2 ADDRESS ,,,-, 3,� � JZ i) AGE L o'e 7rK U �✓ ► V CITY STATE ZIP DOB 'O Sn OM OT ❑ W O Th OF AS DRIVER'S LICENSE N -- PHONE NATURE OF DISPATCH Mn I Art e- /-. . TYPE OF TRANSPORT:; AMBULANCE OTHER STATION 1(A)_2(8)_3(C)_41D)._6(E)_ INCIDENT LOCATION' ?iJ RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) //► pp TO SCENE- �(S.O. CALL RECEIVED L 3-�Z- ❑ P.D. TIME 10-8 ��- PATIENT DESTINATION:. FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 1D-7 " ' I END T_ TIME 10-98 P.DOCTOR-t'` PMD/ER START TIME 10-22 Q Q_ : LZ� HOW CHOSEN: - TOTAL, STANDBY TIME ❑ NEAREST- O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: 21 _ PT. AMBULATORY? PATIENT TAKEN TO.AMBULANCE: lO RESPONSE ZONE O YES O NO ❑ WALKED O GUERNEY ❑ OTHER I PATIENT CONDITION: ` DRIVER A[ 61 AL f-s 130 LI TECHNICIAN 110 / PARAMEDIC / Hx: u- DISPATCHER: BELE �3 nn'I' rJ CHIEF COMP NT: ' DRY RUN: 9 YES O NO REASON FOR DRY RUN in-7 7 ��c'��►7 C f ( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ►t o.�it -1,1PATIENT REFUSED SERVICES:(SIGNATURE) X 0/.�a MEDICAL COVERAGE: -...- INDUSTRIAL P YES ONO NO. OF PATIENTS: S.S.« + 1 PRIVATE INS.CO.: -_ BASE RATE: KAISER 0: MULTIPLE PTS.BASE RATE BLUE CROSS 0: i1 TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ONO O YES -O NO NIGHT: (19:00-07:00) CCHP/PPRP#P_.t +r EMERGENCY RUN: MEDI-CAL 0: - J i'` CODE 2/3 ,V1. OTHER:'l�'' j OXYGEN; (PER TANK) x `• P.O.E.STICKER O YES• O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '-•"NEAREST RELATIVE/RESPONSIBLE PARTY: - - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "^'-NAME: - - RELATIONSHIP:__i;- E.O.A.: (IF NOT REPLACED) Y ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) �^CITY: . STATE-_ZIP• C-COLLAR: (IF NOT REPLACED) PHONE: w WORK PHONE' _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION OTHER: - ADDRESS: --CITY: STATE• ZIP. --COMMENTS: - O• 11C � (� TOTAL: �52r PATIENT RECEIVED BY: X P....r Llar r-.�,•l• t/i.i., .. , c: .. (SIONAT,IRF) /... PATIENT'S CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONCNECK OR FILL IN APPPI1ROPRIATE SPACES DATE: — �� NAME 0 A N Af �J- I`I �� O F COMPANY N 5� / `5DRESS �-��._ iM(3NTP%/L /1 �� AGE CITY Ali/ PAA 'STATE(_ ZIP f_q2LLI�_ DOe0-01_390 SI, ❑ M ❑ T ❑W ❑ Th O F DRIVER'S LICENSE N-. PHONED-42 y _ NATURE ATCH TpMs(7,� K )AC)i1L TYPE OF TRANSPORT/AM BULAN E OTHER❑ _- -- TATION 1(A) (8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) , ,AA ,,, � � iV11S 1 TO SCENE- -� ❑ S.O. CALL RECEIVED I. LA �� ❑ P.D. TIME 10-8 j PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10.97 1�- N�Q W ❑ PSAP TIME 10-49 i {` a-�►`� V1'ln nlTpL,yt(�1 C)p S MILEAGE- 12 OTHE PV TIME 10.7 (,1 LAI,& END r S 1 TIME 10.98 DOCTOR >- PMD R START 7 7 C C TIME 10-22 HOW CHOSEN: TOTAL c> STANDBY TIME ❑ NEAREST O FAMILY TRANSFER ll WAIT TIME _ ❑ PATIENT O DIRECT ER I /:I i CALL BACK N: AMBULANCE COMPANY: r PT. AM TO Y? PATIENT T TOA LANCE: \ I 1 .1 RESPONSE ZONE El YE O WALKE&P GUERNE11r OTHER t PATIENT CONDITION: DRIVER J��')- X� , s L. Y.� G TECHNICIAN ✓1AS1-j, IZ PARAMEDIC Hx: C_3kAOtiPlJc:Tfr DISPATCHER: • CH`IFF COMPLAINT: L DRY RUN: ❑ YES REASON FOR DRY RUN 7� -1-(`�F t Q 1 n N Elti 4:V/7 1-( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X_ ME MCAL COVERAGE: INDUSTRIAL ❑ YE 6 NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS: BASE RATE BLU S N: TOTAL MILES: _ X I EDICAR . f S 7 - S 6 - 66 qQ ,-�—E.O.B. ATT. ROUND TRIP: O YES N jOb ❑ YES ❑ NO NIGHT: (19:00-07:00) CCH P P N: EMERGENCY RUN: EDI- b'� -�'7 -C�( 7� ' 3 I -n' ( CODE 2/3 i HER: OXYGEN: (PER TANK) P.O,E:STICKER OYES P51 NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r ►� DRUGS: (PER ADMIN.) X NAME: t9AN RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS 1514A ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: PT Utn A e;�_t --- _ 00209 ---- TOTAL:. _•., �._ .i_.... ----- _ �_._..____._ .._. ___.-. ..• A ._ .. PA T IF.N1 HICCIVF.D BY X ;j. l� � •�\ ).,..•�)Q l . O 0 n (SIONATI)fII 1 lXi rT'Ni/aP fv lol r, oaf., !'i a: I,b 4:•f rr�, 'i.•'( •. u 4, , I ►M' t . 4e 41 yr CONTRA COSTA COUNTY ' AMBULANCE f PRE-HOSPITAL CARE FORM I I '�rr1 UNIT AUTHORIZATION N N 2 6-j CHECK 011 FILL IM APPgOPNIA TE SPACES DATE: (0(fE�ct PATIENTS NAME Gn fk M ❑ F COMPANY N ADDRESS AGE CITY STATE ZIP DOB' 13 Z( ❑ Sn ❑ M ❑T ❑ W ❑ Th ❑ F *S DRIVER'S LICENSE N _ I PHONE-7NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 1(A)_2(B)_3(C)_4(D)_5(E INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY:. TIME- (24 HOUR CLOCK) a 4 ) !� TO SCENE- �7 Q�S.O. CALL RECEIVED � _ I n V ��`1�S '� ❑ P.D. TIME 10-8 1, PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 /J-)[ :1L A[1 / (� ❑ PSAP TIME 10-49 C `T ` MtLEAGE:_77 S ❑ OTHER/PVT TIME 10-7 END `' TIME 10-98 DOCTOR e PMD/W START 20. 2 TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME 0,31YEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME V ATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPS I- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c.,I r� RESPONSE ZONE �� l 1 rs. ❑ YES ECNO ❑ WALKED GUERNEY ❑ OTHER _, PATIENT CONDITION: i DRIVER (�-) r EMT-IA ~ TECHNICIAN 1} I;L • PARAMEDIC L� Hz: DISPATCHER: �l'-:�--� :-C'_ �i •tl !`^I^) CHIEF COMPLAINT: I CA DRY RUN: Cl YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) MEDICAL COVkRAGE: INDUSTRIAL ❑ YES h NO NO.OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE , BLUE CROSS M TOTAL MILES: X =��) LZ__=�•d MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 0✓ 6,v o -?3 I'OX flb-YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN: MED-CAL N: �� U( CODE 2/3 l OXYGEN: (PER TANK) d,7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED- STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) y` NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X , 1111 DRUGS: (PER ADMIN.) X NAME: a ki Rf LATIONSHIP.1r<�_ E.O.A.: (IF NOT REPLACED) ADDRESS: q IU^s ORAL AIRWAY: (IF NOT REPLACED) CITY: m l STATE- ZIP. C-COLLAR: (IF NOT REPLACED) PHONE: ( : ;?��T_.WORK PHONE: _ y DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ` n�1n210 TOTAL: - PATIENT RECEIVED BY: X 00 85 - -. ISIGNATURF) , l+rnvi:br rvtorr. vh;rr I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N a 27) CHECK OR FILL IN APPROPRIATE SPACES DATE: :Sl_n�� PATIENT'S NAMLLL1 ))1 B'M O F COMPANY N �� /7 ADDRESS -XIA `) '11) I'S _ �� L ( � !' �1 AGE CITY l - 7 STATE _C / _ ZIP DOB11C �` Sn 0 M O T D W O Th O F 6� 1 DRIVER'S LICENSE q _�'`� , r 13 - �'�-f fFj ' ::!!j<( —!�--_-__. TT�� PHONTU E OF DISPATCH � ' SIS t "Zj7� 1_[DNA � ,.q i/if . 6A TYPE OF TRANSPORT: AMBULANCE D OTHER O _ -- STATION 1(A)_2(B)-3(C)_4(D)_5(E),• ' INCIDENT LOCATION: RESPONSE CODE: REE . ESTED BY: TIME-(24 HOUR CL�jCK) C Q � TO SCENE �❑//S.O. CALL RECEIVED L A '�- ' ' I 'O P.D. TIME 10-8 • / a' PATIENT DESTINATION: FROM SCENE:� 0 FIRE TIME 10-97 wo - •., _ ❑ PSAP TIME 10-49 1 MILEAGE: O OTHER/PVT TIME 10.7 END _ TIME 10-98 DOCTOR1► PM /ER START--s TIME 10-22 =� HOW 'OSEN: TOTAL STANDBY TIME NEAREST 0 FAMILY ❑ TRANSFER WAIT TIME' ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: - P_T MBULATORY? PATIENT TAKEN�AMBULANCE: 510 RESPONSE ZONE YES ❑ NO ❑ WAL'<ED ❑"GUERNEY ❑ OTHER - PATIENT CONDITION: DRIVER 580 (P§M -1A TECHNICIAN , ARAMEDIC ��----� Hx: _•-- _►1 IIh� DISPATCHER: D f ._._._ CHIEF COMPLAINT: - DRY RUN: O YES 0 NO REASON FOR DRY RUN(AA '-• I 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I f C/• PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES 0 NO NO.OF PATIENTS: f SCJ �) �.__.•I S.S. # PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE i BLUE CROSS N: TOTAL MILES: ` X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO O YES 0 NO NIGHT: (19:00-07:00) 1 CCHP/PPRP N: EMERGENCY RUII: MEDI-CAL d: CODE 2/6,! _ .� OTHER: OXYGEN: (PER TANK) t/ ❑ :• .� ,) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) V DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) _ 1 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X I AME L�f �'�rJ �V lI IJ ELATIONSHIP� E.O.A.: (IF NOT REPLACED) _ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE- ZIP: C-COLLAR: (IF NOT REPLACED)-_. _ __ / PHONE: - WORK PHONE: DRY RUN: (AUTHORIZED) I EMPLOYER: OCCUPATION; OTHER: ADDRESS: CITY: STATE: ZIP: CRRM'�M�ENTS: Y I �• i�� 1 1 � �•' � t� �LI � � �• './ _� /CJ. �7 t 'j\Yo 1 Q!--I I-A Z. TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) 00 186 Provider retc*c White •rs d rlir; r.+p�. .9etldrn Te:i • mpp t• Pfr when bit:'inp 1. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I i 'n AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: —7 �+ PATIENTS NAMELLSo_Vv �V _t,).�_Q ❑ M F COMPANY M / 9 ADDRESS l� 1^i L". S_L�?'L� AGE CITY IL l��1 STATE ' ZIP DOB -1� 040 Sn O M ❑ ❑�WC ❑ Th OF O S DRIVER'S LICENSE M _. PHONE 2.33 WSNATURE.OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ . . __.. INCIDENT LOCATION: RESPONSE CO REOUF TED BY: TIME (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED TIME 10-8 PATIENT DESTINATION: FROM SCENE -- ❑ FIRE'— TIME 10-97 ❑ PSAP TIME 10-49 l MILEAGE: ❑ OTHERlPVT TIME 10-7 M END v V TIME 10-98 DOCTOR �1 1. �� PM /ER START/t� TIME 10-22 HOW OSEN: TOTAL Y A �� - STANDBY TIME NHEAREST j5<AMILY ❑ TRANSFER ?, WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER¢ . �,1 / ( �/ CALL BACK N: AMBULANCE COMPANY:. PT AMBULATORY? PATIENT TAKO AMBULANCE: r i RESPONSE ZONE ❑ YE 0 ❑ WAL",ED'51&UERNEY ❑ OTHER (�(� _ PATIENT CONDITION: W (�RIVER_=[_- 'n P�•TECHNICIAN -x PARAMEDIC Hx: v,'RL` �1V�1T1�IV ,fU�rY1lC DISPATCHER: sr"p _'1�`i • CHF COMPLAINT: —_y_�s_ �; _ DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN -1&w V c ��c AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X M CA �gVERAGE: I DUSTRI AL 11 YES ❑ NO NO. OF PATIENTS: S.S. h'� RIVATE INS. CO.: BASE RATE: Ad&lyj KAISER n,. MULTIPLE PTS. BASE RATE /v �CROSS7n 5 0� O �x 1 TOTAL MILES: f X Ii cflL 0,.;) E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL a; CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) " DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �GDRUGS: (PER ADMIN.) X NAME: RELAjION IP. 1'•1.. E.O.A.: (IF NOT REPLACED) AQDRESS: ^� - ORAL AIRWAY: (IF NOT REPLACED) CITY: k STATE-CID-ZIP: C-COLLAR: (IF NOT REPLACED) , PHONE: 3 Z L4- ' (WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: vl ADDRESS: " CITY: STATE: ZIP: COMMENTS: TOTAL c� S •0 0 0 0 212 T .. PATIENT RCCEIVFD BY: X00 !'nrui:!•rr M1rtdlr, Ml�ifd :,r.( rir,: .r.,lrre+: 1'r'. :, rel I l CONTRA COSTA COUNTY AMBULANCE 7 PRE-HOSPITAL CARE FORM I UNIT L AUTHORIZATION •CNfCK OR FILL IN APPROPRIATE SPACES DATE: g I?AYIENTS NAME O'M OF COMPANY N 6"Y v ADDRESS-, ; ; ' AGE CITY- _ STATE�.,,.�_ ZIP DOB ❑ Sn OM O T O W O.Th ❑ F O S DRIVER'S LICENSE 0 ( PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A1,2(B)_3(C)_4(D)_,5(E)_ INCIDENT 1<OCATION:1 1 ~ RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) -' "�_ TO SCENE- 3 S.O. CALL RECEIVED 2=2 �C.d�> 10< t�.ILe 1•y 1 ❑ P.D. TIME 10-8 • �1" PATIENT DESTINATION: FROM FROM SCENE- 13 FIRE TIME 10.97 Q� ' . ❑ PSAP TIME 10.49 �� ?'t'1 `•) ` '� MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 ;i DOCTOR PMD/ER START TIME 10.22 -LI HOW CHOSEN: TOTAL STANDBY TIME 7!:-j- ❑ NEAREST.4 ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 rG RESPONSE ZONE ��. O YES 13 NO 13 WALKED 13GUERNEY 13 OTHER ! PATIENT CONDITION: DRIVER L5 10 EMT-1A 4 1 E' TECHNICIAN 385 PARAMEDIC�• Hx: y DISPATCHER: 0(.-).,_l. CHIEF OMPLAI T: Sei�S�'� - r��. DRY RUN:-&YES ❑ NO REASON FOR DRY RUN $S3 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED.SERVICES: (SIGNATURE) X S�MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N PRIVATE INS.CO.: BASE RATE: }: KAISER Nz MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X - MEDICARE N�' E.O.B.ATT. ROUND TRIP: OYES ❑ NO ❑ YES '❑ NO NIGHT:(19:00-07:00) CCHP/PPHP N:'1 ' I EMERGENCY RUN: MEDT-CAL N: CODE 2/3 ` OTHER: OXYGEN:. (PER TANK) P.O.E. STICKER 13YES ❑ NO NEONATAL: (INCUBATOR) ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: "' I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X RELATIONSHIP! E.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) "CITY: STATE__ ZIP' C-COLLAR:,(IF NOT REPLACED) ^/ PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) "'EMPLOYER: OCCUPATION OTHER: ADDRESS: 9 '-CITY: + STATE: ZIP-- .L • COMMEN veal Le\r N 4_ d 1' TOTAL• �C- O V PATIENT RECEIVED BY:X ly vi.lrr vra/n Vhifn ! h.•. � (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# CHECK OR nLL IN APPROPRIATE SPACES 7 DATE: 30 lS� PATIENT'SNAME�� ` �-1 O M O F COMPANY# ( 12' ADDRESS AGE DJZyreUAJ CITY •.STATE----- ZIP T:^_ DOB '❑ Sn OM OT ❑ W ❑(ITh OF O S I DRIVERS LICENSE M ? - PHONE NATURE OF DISPATCH_ TYPE OF RANSPORT:! ISPATCH_TYPEOFTRANSPORT:; AMBULANCE?k OTHER STATION 1(A)_2181_3(C1_41D1_5(E)_ BNCIDEfIT LOCATION:' - W.C • `: REPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) pp\ I TO SCENE- JKS.O. CALL RECEIVED : 3.3 3 ❑ P.D. TIME 10-8 PATIENT DES? ATION: --- FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 t '• .� END__,____ TIME 1D•98 r— %DOCTOR? _ PMD/ER START TIME 10.22 s HOW CHOSEN: _ TOTAL STANDBY TIME e"`-L•O NEAREST14 O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK K: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: lO RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ( � _ -- PATIENT CONDITION: DRIVER t,- V.<-- EMT-1A ?I�i _Ll I TECHNICIAN L PARAMEDIC Hx:1DISPATCHE BELE FIE, OO4(V CHIEF COMPLAINT: DRY RUN:�YES ❑ NO REASON FOR DRY RUN Y1`Z �•1�. �-• r1 L� 4qqAUTHORIZATION FOR DRY RUN(EMS USE ONLY) ij PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: _ I INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N a; PRIVATE INS.CO.: BASE RATE: KAISER R; + MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE#:: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP#a + EMERGENCY RUN: MEDI-CAL X: CODE 2/3 OTHER: OXYGEN; (PER TANK) P.O.E.STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY:" -' LV.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "'-NAME: RELATIONSHIP• E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: -' STATF ZIP. C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) 0 "-EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: - STATE- ZIP. 0"214 —COMMENTS: TOTAL• ( -�•�J �� PATIENT RECEIVED BY: X Pv-,viJpr rein(-. Nh(t♦ .�.! t'••a q� ►.ri, ISIGNAlIME) rM 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME �?I(j_ OI Nv S. OM bC'F COMPANYM ADDRESS AGE'SL .S CITY STATES ZIP DOB O Sn O M O T O W .O Th-O F ors; DRIVER'S LICENSE M — PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ -- STATION 1(A)_2(81_3(C1_4(D)_5(EI_ 4_ --I f " / r--4—. INCIDENT LOCATION: ' RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �.�/ n _ 2n�� TO SCENE- 2 n(S.O. CALL RECEIVED �-L� [} � \ t� J ❑ P.D. TIME 10-9 PATIENT DESTINATION: FROM SCENE- 13� FIRE TIME 10-97 / 2-L , kobt Pn �� d-(- ❑ PSAP TIME 10-49' mfOLC Qc cgz(2s ` `��I MILER l I ❑ OTHER/PVT TIME 10-7 �L_ END-� TIME 10.98 c�._j_-�:S�7 DOCTOR -1- PMD/ER START TIME 10-22 �--' HOW CHOSEN: TOTAL 1 r STANDBY TIME ❑ NEAREST .❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT '$OTHER C-C SC,Aj,,) CALL BACK N: AMBULANCE COMPANY: � p PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: CRESPONSE ZONE ❑ YES 4 NO ❑ WAL'CED MIGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER JL-1 AN Z Z EMT-1A r-- [�(I 1 �1 TECHNICIAN . 'FALL- 500P< AMED1 Hx: G(iwSI-tCGVNEAO DISPATCHER: P 0 CHIEF COMPLAINT: DecaeNse'fl LOG DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X fi MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.s.« - PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS K: TOTAL MILES: / X I LI- MEDICARE M: E.O.B. ATT. ROUND TRIP: O YES O NO ,•: ,. 1 O YES .❑ NO NIGHT: (19:00-07:00) �-UL CGRP/PPRP p: EMERGENCY RUN: MEDI-CAL w: CODE 2/3 ,1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' DRUGS: (PER ADMIN.) X I NAME: RELATIONSHIP; E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: •(AUTHORIZED) EMPLOYER: Y OCCUPATION:- OTHER: ADDRESS: �� '• /�d'J a CITY: STATE' ZIP• COMMENTS: n 1 J TOTAL:s.�Do2. .fJ - - -- - �L PATIENT RECEIVED BY:X O [r{-1 (j .� , Provider lvtuir. Vhite er1'i d r.K "N,p .41CYrn Yi:fW Mj+�. t- C+tS Ylvn Dii:i.y (SIGNATURE ) lJ i(, �Y ," t CONTRA COSTA COU AMBULANCE C� _ /J �t PRE-HOSPITAL CARE FORM i UNIT 2/ AUTHORIZATION 11 fA •}� �•-- CHECK OA flLl INAPPROPRIATE UXT6[S/ACID DATE: -1] /,) �PATIENT'SNAM � O M OF COMPANY r ADDRESS __ ! AGE��_ _ CITY - �~ - ..•. DOB + - On OM OT OW O EZIP O F J� ;{ DRIVER'S IICENSE r M - PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:: AMBULANCO2PCCTHER 0 STATION 1(A)_2(B)_3(C)_4(D)_5(E)_r. INCIDENT LOCATION:" ;: RESPONSE CODE: QUESTED BY: TIME—(24 HOUR CLO C /C K) '!3 ,I TO SCENE- O. CALL RECEIVED %� 7 P.D. TIME 10-8 •• rZ l PIATIENT DESTINATION: ' FROM SCENE- ❑ FIRE TIME 10-97 (� PSAP TIME 10-49 O �� Wit! ;y_l'; N`r�r MILEAGE: ❑ OTHER/PVT TIME 107 . .-ZAL t""• END_�_ _ TIME 10.98 CDOCTOR PMD/ER" START': TIME 10-22 ` HOWyCHOSEN: -_... '_I TOTAL STANDBY TIME 13 NEAREST OFAMWY O TRANSFER WAIT TIME ` I O PATIENT c' E3DIRECT 11OTHER CALL BACK r: AMBULANCE COt�PAyY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER. PATIENT CONDITION: __._.. DRIVER Gil, iL:� c _ TECHNICIAN / ��F�1S �'(' PARAMEDIC Hx: -I DISPATCHER: '�( i i � 0 L� CHIEF COMPlyAtNT: ' DRY RUN: ❑ YES O REASON FOR DRY RUN l KfFO-Sc°Rl.� AU OR TION R RY (EMS USE ONLY) 9151- 9r,((,t ..,PATIENT REFUSED SERVICES:(SIGNATURE)`X" + MEDICAL COVERAGE: INDUSTRIAL ❑ YES '❑ NO NO.OF PA TENTS: S.S. .. 1.... � j i. < PRIVATE INS.CO.: BASE RATE: KAISER rt. MULTIPLE PTS.BASE RATE BLUE CROSS r: " 'TOTAL MILES: X MEDICARE r: E.O.B.ATT. ROUND TRIP: O YES O NO L - •--) ❑ YES O NO NIGHT: (19:00-07:00) 1'. CCHP/PPRP r; r -1 EMERGENCY RUN: MEDI-CAL M: - • ' CODE 2/3 OTHER: OXYGEN:; (PER TANK) I P.O.E. STICKER ❑ YES ❑-NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -NEAREST RELATIVE/RESPONSIBLE PARTY: .... _____ I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X _NAME: RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) —CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) T PHONE: WORK PHONE DRY RUN: (AUTHORIZED) ✓�Q �/ _EMPLOYER; OCCUPATIONOTHER; - ADDRESS: THER: _ADDRESS: STATE- ZIP.' _-COM NT : V v 216 d Q. rt TOTAL: c�D- ff 4 —. PATIENT RECEIVED BY: X .1 Pmvidor retailsWhitpi.:,. ;'r� 4itur. r.� t .., (SIGNATURE) ►N� t CONTRA COSTA COUNTY AMBULANCE i PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 CHECK OR FILL INAPPROPRIATE SPACES DATE: !/ } PATIENTS NAME �� T 4M O F COMPANY M A 6`S ADDRESS - �� C( C)��- AGE!,_.L CO CITY.. / TATE ZIP DOB._7_S Z �Sn OM OT 13W ❑ Th OF O-S,._, [)RlVZXCS I 'GENSE tt Z� 17 PRONE�L NATURE OF DISPATCH Imo\Y DC71� V17(�I TYPE OF TRANSPORT: AMBULANC OTHER O _ — STATION 1(A)_2(BI_3(C) INCIDENT LOCATION: RESPONSE CODE: ( ESTED BY: TIME—(24 HOUR CLOCK) r f TO SCENE- O CALL RECEIVED / ( I✓ / �-,-� l^• O�P.S.D. TIME 10-8 PATIENT DESTINATION: /�}� FROM SCENE- 13 FIRE TIME 10-97 —1 O PSAP TIME 10-49 v MILEAGE, ❑ OTHER/PVT TIME 10-7 END____�L(:L..2_ TIME 10-98 �Q y- DOCTOR PM ER START TIME 10-22 HOW CHOSEN: TO STANDBY TIME _ ••I O NEAREST �AMILY ❑ TRANSFERWAIT TIME ❑ PATIENT ❑ DIRECT 13OTHER4 CALL BACK 0: AMBULAN E COMPANY: PT. AM ATORY? PATIENT TA TO AMBULANCE: 5c) ' RESPONSE ZONE �" I O YES NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J- v ' ISO EMT-tA TECHNICIAN C/l �%OPARAMEDIC ..► Hx: ( tl DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN *I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X L COVERAGE: INDU TRIAL ❑ YES NO NO. OF PATIENTS: i �PRtVATE INS.CO.: BASE RATE: LsL� KAIS li: MULTIPLE PTS. BASE RATE i /-BLUE CROSS N �� TOTAL MILES: X so . �y ICAR E.O.B. ATT. ROUND TRIP: OYES ❑ NO Je I i q ' I- " 1 3 O YES ❑ NO NIGHT: (19:00-07:00) `` ~ CCHP/PPRP M: EMERGENCY RU(�h MEDI-CAL N: CODE 2 ! OTHER: OXYGEN: (PER-TANK) �� I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) j E.K.G.: (PER EPISODE) _D•GnJ y i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r` ? UU.�(�DRUGS: (PER ADMIN.) X y�/�• I NAME:(v'� j r,l7 RELATIONSHIP:ULL E.O.A.: (IF NOT REPLACED) ADDRESS: 'r��/f' - ORAL AIRWAY: (IF NOT REPLACED) CITY: STAT ZIP' C-COLLAR: (IF NOT REPLACED) PHONE: OK PHOAiDRY RUN: (AUTHORIZED) EMPLOYER t� ' 'OCUPATIQN: 7 OTHER: .. k 45/7 ADDRESS- I - CITY: - STATE• n ZIPS '`-' � Z(J'GZ� + COMMENTS: i I . C� r TOTAL: 477 PATIENT RECEIVED BY:X -- 0 0 q Provider rota:,.• L/hit.• .."d Pin; ropy .4eturn Ye:low ropy t' INS when bil:inp (SIGNATURE) 01b-1 l d• OI 1�- CONTRA COSTA COUNTY � AMBULANCE � PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION r CHECK OR f,LL IN APPROPRIATE SPACES DATE: PATIENTS NAMEe"pg01 ) L`tit ) i 1 I S- C �� A �O F COMPANY N `V r 9� r_ � ADDRESS L�*'T'fi �`i--I�ri� AGE _ _CITY >✓C t)!.� STATE ZIP DOB '7�rS, O M O T O W D Th O F O S DRIVER'S LICENSE N ___ PHONE�T=� ? NATURE OF DISPATCH 6,. r TYPE OF TRANSPORT: AMBULANCE K OTHER O _ — STATION 1(A)_2(8)_3(C) 4(D)_5(E)_-.. INCIDENT LOCATION: RESPONSE CODE: QEOOUUESTED BY: TIME-(24 HOUR L CK) TO SCENE- S.O.— CALL RECEIVED G 11d N C; ✓,C �J��N G'�C(-QF ❑ P.D. TIME 10.8 ' � PATIENT D STINATION: FROM SCENE- ❑ FIRE TIME 10.97 'n �A 'n^ O PSAP TIME ID-49 ! C '� Y l MILEAGE' ❑ OTHER/PVT TIME 10.7 r- END C�3��-r TIME 10.98 DOCTOR /� 11^-Te PMIG START S) TIME 10.22 HOW CHOSEN: TOTAL _ _ STANDBY TIME, O NEAREST ❑ FAMILY O TRANSFER WAIT TIME Uk-F54TIENT ❑ DIRECT O OTHER ? CALL BACK C. AMBU CE CPMN �rr PT. AMBULATORY? PATIENT TAKENNT�TO AMBULANCE: S o RESPONSE ZO ❑ YES 0--NO ❑ WALKED P--GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER wt ( E {� c,U 0 EMT;1A I y,� ^ TECHNICIAN S.O r1 CSV PARAMEDIC Hx: ! " `CSTO h CSC( /� C ✓��DISPATCHER:�. I �. I C� CHIEF COMPLAINT: � T)-1 DRY RUN: ❑ YES VNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNA URE)X MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: Q� ►'�.' S.S. PRIVATE INS. CO.: BASE RATE: • J�.1SL—�'-) KAISER M: MULTIPLE PTS.BASE RATE -� BLUE CROSS N: TOTAL MILES: X /3•UZa. MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO O YES -O NO NIGHT: (19:00-07:00) �— CCHP/PPRP N: EMERGENCY RUN: 3D'U S VIED(-CAL N; CODE 2(3? (---- OTHER: OXYGEN: (PER TANK) r% P..O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) . E.K.G.: (PER EPISODE) '_2 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X • "J- tom' DRUGS: (PER ADMIN.) X NAME:(• I VI 1 kVic,f_LQ-_hAELATIONSHIP:L0. E.O.A.: (IF NOT REPLACED) ADDR S L L a I C-11 ? rt 1�) W. - ORAL AIRWAY: (IF NOT REPLACED) CITY: I G Sc. h``TCC I t L 1� STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - - - PHONE:(a'&-S WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER' OCCUPATION: OTHER: ADDRESS: D>'-'.'ii l�� _ /0-L►T) /7 CITY: STATE: ZIP: .Q/'�i74 1'Z ' � 4,0 OMMENTS: �^ (C 7• `7> Zc,3 !lp t c-« cP )'I In r i.`61..L (IC(•' &x C P, li'►1 V(F 'T •s i4 h /0-a-i TOTAL:'VV 3 Gzi.l-0 � e; PATIENT RECEIVED BY:X - C_ ` Provider rets-r. Vhite va hin4 rnPh Return Yr'l,u .nr. !• WS uAen hi i:inp (SIGNATURE) INS-) w F ' CLAIM M BOARD OF SUPERVISORS OF CONTRA CO6TA C xwy, CA1MTWIA BOARD ACTION Claim Against the County, or District ) NOTICE 70 July 31, 1984 governed by the Board of Supervisors, ) The �Y ..L u,.., �..�...�:. ..��.... r.x� �� Y'L u Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervises (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Henry J. and Marcella B. Colarich County Counsel 4748 Laura Drive Attorney: Concord, CA 94521 JUL 0 3 1984 Address: Mart+net, CA 94553 Amount: $ 41,79 By delivery to clerk on Date Received: June 29, 1984 By mail, postmarked of June 27, 1984 I. FROM: Clerk of the Board ot Supervisorg County Counsel Attached is a copy of the above-noted claim. Dated: June 29, 1984 J.R. OISSON, Clerk, By Deputy Jolene Edwards II. FROM: County Counsel T0: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim an ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: f Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: ) County Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD By unanimous vote of Supervisors present (XX) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e e n i DuBois ` Dated: 7-31 -84 J. R. OI.SSON, Clerk, By eJ , Deputy Clerk T WANING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this .. notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) Canty Administrator Attached are copies of the above claim. we notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant, n DATED: 7-31 -84 J. R. OLSSON, Clerk, By �; �/. -��> , Deputy Clerk cc: Canty Administrator (2) County Counsel (1) Q Q Q 21 9 CLAIM CLAIM TO': BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions ;:o Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553 (or mail to P.O. Bax 911, Martinez, .CA) . C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end his form. RE: Claim by )Reserved for ClercIs filing stamps ' ) RECEIVED Against the COUNTY OF CONTRA COSTA) ) or DISTRICT) �. R. OLSSON Fill in name) I CLERK BOARD O' SUPERVISORS B .. CO " A COSTO CO ....... :R.. _ The undersigned claimant hereby makes claim against Costa or the above-named District in the sum of $ -VI,7 y. and in support of this claim represents as follows: AZi 1. When did the damage or injury occur? (Give exact date and hour) --------- T--- ------------:------------------------------------------- Where did tie damage or snjury occur? (Include city and county) e �----------------------(- ------------------ injury ---------------------- - ----T--------------- 3. Sow did the damage or injury occur? (Giils, use extra sheets if required) �1ee Fed .041*,100 t't4lCk a,J1,d Moved � �c �i��clQ ��xnPit . ih .e Zed &&,V4 t 7,-4e T l �.`�a P k�i r� 7►'` �•r G✓ a 7 d � • W s7 - S�adt. /.Gtr`<.iJ� t' ,Da�rh.t oar- 0/" 1`/ w 4 h1' ow� 'Z�,.- 4. What particular act or omission the part of county or district officers, servants or employees caused the injury or damage? Le yB/A ,•yr X111 .4 Q/ „t a t /Yo t .(a •� e r�►- 7'� �a Lu & tti A0- �j(!�/,e" .u� . -�- F (over) 4W yeI7�/�<r�,/ 41e,4,,1dfiQve key e/�'C� OFG� ' S. What are the names of county or district officers, servants or employees Zausing the damage or injur ? : a 0.0ov w<< / cc �/� t-6Pcl2 v /.aeo#-ds o F y--ow n d .+ uov ------- ' ------ - - ------------------------------ --------------- 6. Wh-at-d-amage------or---i-njuries do you claim resulted? (Give full extent of injurie or damages claimed. Attach two estimates for auto � damage) 4/o�n S pvr W aj j'(J l r,o d. —i-le OU j'e pd► tiec� a ¢ v � - _ r a u -------------------------- --------------- ------------------------------ 7. How was the amount claimed above computed? (Include the estimated pun of nx prospept've in.pry or damage. ) . -7;r, 0 01 8. Names and addresses of witnesses, doctors and hospitals. —A"/,0 � PSo, Sty l7dy C�!Q v I Z4 a. i I l ." Gd a 7 ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 4A 1;+-f l ************************************ * *********************************** Govt. Code Sec. 910. 2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or b� ''some erson on his behalf. " Name and Address of Attorney � l Claimant's Signature ddr ss Telephone No. Telephone No. ************************************************************************** NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow -or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " Oo22' 1 JUN 2 7 1984 CUUM Martinez. CA 94553 BOARD CF SOPERgISORS OF Oopm room amm y, CM F01MA BOARD ACTION Claim Against the County, or District ) IMICE TO CLAIMANT July 31, 1984 governed by the Board of Supervisors, ) The copy of this document mailed to you is your Touting Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Tommy Elledge Attorney: James F. Gilwee, Esq. Crow, Lytle, Gilwee, Donoghue, -Adler & Weninger Address: 700 E Street Sacramento, California 95814 _ Amount: $100,000.00 By delivery to clerk on Date Received: June 27, 1984 By mail, postmarked on June 25, 1984 I. FROM: Clerk of the Board at upervisors County Counsel Attached is a copy of the above-noted claim. Dated: June 27, 1984 J.R. OESSON, Clerk, By Deputy Jolene Edwards II. FROM: County Counsel : Clerk of the Board of Supervisors (Check only one) (✓�\j This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to amply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim- an ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: Z - By: Deputy County Counsel III. FI2CM: Clerk of the Board TO: ( Cam Comsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD QRaER By unanimous vote of Supervisors present (X4 This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e e n i DuBois Dated: 7-31 -84 J. R. OESSON, Clerk, By -�/ , Deputy Clerk ------------ MRNING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you shanld do so immediately. . V. PT M: Clerk of the Board ZED: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DAA; 7-31 -84 J. R. OtSSON,' Clerk, By � , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000222 OU222 CLAIM (O JAMES F. GILWEE, Esq. C EIVED 1 CROW, LYTLE, GILWEE. DONOGHUE, ADLER & WENINGER 1584 . 2 700 E STREET. J• R. OMON 3 SACRAMENTO. CALIFORNIA 95814 BOAR OF SUPERVISORS TELEPHONE (916) 441-2980 B STA Co. 4 Attorneys for Claimant 5 6 7 8 CLAIM FOR PERSONAL INJURIES 9 (Government Code, Section 910, et seq. ) 10 11 TO: BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 12 651 Pine Martinez, California 94553 13 CITY COUNCIL, CITY OF MARTINEZ 14 525 Henrietta Martinez, California 94553 15 Claim is hereby made under Government Code Section 910 16 by claimant TOMMY ELLEDGE as follows: 17 (1) CLAIMANT'S NAME AND ADDRESS IS: 18 TOMMY ELLEDGE 19 5 Hanns Avenue Vallejo, California 94590 20 (2) SEND NOTICES TO CLAIMANT AT: 21 JAMES F. GILWEE, Esq . 22 CROW, LYTLE, GILWEE, DONOGHUE, ADLER & WENINGER 700 E Street 23 Sacramento, California 95814 24 (3) DATE, PLACE AND OTHER CIRCUMSTANCES OR OCCURRENCES GIVING RISE TO THE CLAIM ASSERTED AS FOLLOWS: 25 On or about May 25, 1984, claimant was proceeding through 26 the intersection of Berrellesa Street and Buckley Street northbound 000223 1 on Beirellesa Street. One JOSE AMARAL, employed by the United 2 Council of Spanish-Speaking Organizations was proceeding westbound 3 on Buckley Street and failed to yield at a yield sign for claimant. 4 At all times herein mentioned, Berrellesa Street and Buckley 5 Street were public streets and highways in the City of Martinez 6 and the County of Contra Costa. 7 At said time and place, said City and County and others 8 had permitted hedges, bushes, and other foilage as well as other 9 obscurements to obscure the visibility of claimant and AMARAL. In 10 addition thereto, said County and said City had permitted a yield 11 sign to exist when there should have been a stop sign or a traffic 12 light. Claimant is informed and believes and thereon alleges 13 JOSE AMARAL failed to yield and a collision occurred between the 14 AMARAL vehicle and the ELLEDGE vehicle. 15 Claimant' s attorney has not had an opportunity to commence 16 any discovery against any of the government entities at the time of 17 dictating this notice. When further legal discovery is commenced, 18 there may be additional theories of liability against these public 19 entities. 20 (A) GENERAL DESCRIPTION OF INJURIES AND DAMAGES INCURRED INSOFAR AS KNOWN BY CLAIMANT: 21 (a) Severe bodily injuries to claimant TOMMY ELLEDGE, 22 including but not limited to injuries to his neck and back; 23 (b) Loss of private property (personal vehicle) ; (c) Loss of earnings. 24 (_5) RESPONSIBLE PARTIES ARE: 25 a) JOSE AMARAL; 26 LAW OFFICES OF _ CROW, LYTLE, GILWEE, - DONOGHUE, ADLER & WENINGER 000224 700 E STREET SACRAMENTO. CA93914 TELEPHONE(916)441-2960 1 b) United Council of Spanish-Speaking Organizations; 2 c) County of Contra Costa; 3 d) City of Martinez . 4 (6) THE AMOUNT CLAIMED BY THE CLAIM PRESENTED AS OF THE DATE OF PRESENTATION IS: 5 TOMMY ELLEDGE One Hundred Thousand Dollars ($100, 000 . 00) 6 Claimant does not intend to limit his damages to this 7 claim should further damages become apparent. 8 DATED: June 18, 1984 CROW, LYTLE, GILWEE, DONOGHUE, 9 ALDER & WENINGER 10 By 11 JAMES F. GILWEE 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 LAW OFFICES OF CROW, LYTLE. GILWEE, -3- DONOGHUE. ADLER fl WENINGER 000225 700 E STREET SACRAMENTO, CA95814 TELEPHONE(916)441-2980 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 VERIFICATION (Standard) CCP 446, 2015.5 17 1 declare that: 18 I am the .....................)?1.4intif-....................................................... in the above entitled action; I have read the foregoing 19 ..CLAIM......FOR...DAMAGES........................................................................................................................................................... 20 and know the contents thereof; the same is true of my own knowledge, except as to those matters which are therein stated 21 upon my information or belief, and as to those matters I believe it to be true. 22 23 1 declare under penalty of perjury that the foregoing is true and correct and that this verification was executed on 24 pX V 11 ; ...... ..�. .... an ......./. ............... at ....................--......................c�.........a�...................................._, California. 25 i .26 TOMMY ELLEDGE Yn ................................................................................................................. tT'PE OR PRINT NAb1D ` SrONATURE 1 000220 ATTORNEYS PRINTING SUPPLY FORM NO. 16-S CLAIM BOARD OF SUPERVISORS OF CONTRA C1WM COOATPY, CALIFaMIA BOARD ACTION Claim Against the County, or District ) p(YglCE Tp CEAIMANp July 31, 1984 governed by the Board of Supervisors, ) The Dopy o� this document mailed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings'. Claimant: Robert W. Keys, Jr. County Counsel Attorney: Ryan L. Werner J U L 0 3 1984 Gordon & Rees Address: 601 Montgomery Street CA 9.4553 San Francisco, CA 94111 Hand carried Martinez, Amount: Unspecified By delivery to clerk on June 27, 1984 Date Received: June 27, 1984 By mail, postmarked on I. FRom: Clerk of the Board ot Supervisors 1 County Counsel Attached is a copy of the above-noted claim. Dated: June 27, 1984 J.R. OLSSON, Clerk, By Deputy Iff Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) K) This claim complies substantially with Sections 910 and 910.2. ✓( \) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: /' By: / + Deputy County Counsel III. FRCM: Clerk of the Board 70: ) C / y Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I 'L7>i�T saa Q � iaQ j IV. BOARD By unanimous vote of Supervisors present ( X ) This claim is rejected in full. ( ) Other: I I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. IR e e n i DuBois Dated: 7-31 -84 J. R. OLSSON, Clerk, By ty Clerk MHUM (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County 'Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this doctmnent, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DATED: 7-31 -84 J. R. 0ESSON, Clerk, By, � , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000227 CLAIM ..,,�,�.. ...: avAUW Vr aurZrKV4.DV cti Ur CONTRA CGIOppacationto: Instructions to ClaimantoorkotdW Board -P.0.60011 n A. Claims relating to causes of action for death or o= injury to� person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.21 Govt. Code) S. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pini Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County.-the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. •*�*�*�t:*:,rft��,rpt:�*��t***�t�t�***�►*�**��ritt�t�tie*s��t�� tt** :* RE: Claim by )Reserved stamps ROBERT W. KEYS, JR. l i?•; , Against the COUNTY OF CONTRA COSTA) or A.C. Transit DISTRICT) K ARS RVI SORS (Fill n name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ s"ee- attached- letter. and in support of this claim represents as follows: --!!! !-!N--- ! !!! M!! 1. When did the damage orn3ury occur? ZGive ex !!act date an fiourj See attached letter. occurude city and eountyS See Item 3, below.. . 3. How did the damage or �n�ury occur? Give �uII details, uee extra . sheets if required) This is a claim for indemnity and contribution. plaintiff John Baker has filed Alameda superior Count Civil Action No. 58389-5 against Keys, Bishop, and others for damages resulting from a bus/bicycle/autcnnbile collision on Solaro Avenue between Colusa and Fresno Avenues, City of Albany, County of Alameda. a. What particular act or omission on .the part of county or district officers, servants or employees causedtthe injury or damage? See attached letter. (over) 000228 S. What are the names of county or district officers, servants or employees causing the damage or injury? Eugene R,espicio; others presently unknom. , K what 3amage or 1n3uries ao you claim resulted? ZG1veu�I extent of injuries of damages claimed. Attach two estimates for auto damage) Claimants assert that to the extent they may be liable for plaintiff's- injuries, the County of Contra Costa is obligated to hold them harmless and assume that liability, or to contribute for their praporticmal share of fault. 7. Bow was the amount claimed above computed? TInclude the estimates amount of any prospective injury or damage. ) Not applicable. See attached letter. �. Naroes and addresses of witnesses, doctors and hospitals. Not applicable. See attached letter. �5.� List the expenditures you made on account of this accident or �n�ury: DATE ITEM AMOUNT Not applicable. See attached letter. Govt. Code Sec. 910.2 provides: 'The claim signed by the claimant SEND NOTICES TO: (Attorney) or b ome person oln his behalf. " Name and Address of Attorney /' Z. 1 C— P. CERHARIYr ZACHER aimant s ignature RYAN L. R See a -aS ched letter for claimant's 601 Montgacrery Street, Fourth Floor Address San Francisco, California 94111 address & telephone mmiber. Telephone No. (415) 986-8041 Telephone No. NOTICE Section 72 of the Penal Code provides: "£very person who, with intent to defraud, presents for allowance. or for payment to any state board or officer, ' or to any county, towno city district, hard or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony." 000229 CUUM BOARD OF sa mTISORS QF caffI A coeur comrY► amnpmmIA BOARD ACTION Claim Against the Canty, or District ) IiiMICE TO (LUMANT July 31, 1984 governed by the Board .of SuoPrvi:axwA. I ThP nnov of this document mailed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below),, to California Government Codes ) given pursuant to Government Cade Section 913 and 915.4. Please note all *Warnings'. Claimant: Herbert and Shirley Mead County Counsel Attorney: Ryan L. Werner JUL 0 3 1984 Gordon & Rees Address: 601 Montgomery Street Martinez, CA 94553 San Francisco, CA 94111 - Amount: Unspecified By delivery to clerk on Date Received: June 29, 1984 By mail, postmarked on June 26, 1984 I. FROM: Clerk o the Board ot Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: June 29, 1984 J.R. OLSSON, Clerk, By �t,.ri,c_ Deputy Jolene Edwards II. FROM: County Counsel M: Clerk of the Board of Supervisors (Check only one) (VI This claim ccmplies substantially with Sections 910 and 910.2. ( �) T1,is claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: • - i r - c- By: Deputy Canty Counsel III. FROM: Clerk of the Board TO: ) County Counsel, (2) Canty Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD By unanimous vote of Supervisors present (XX) This claim is rejected in full. ( ) Other: I cern y that this is a true and correct copy R e e n ie D u B o ins Order entered in its minutes for this date. Dated.. 7-31 -84 J. R. OLSSON, Clerk, By . Deputy Clerk - MMUM (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. .V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action an this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leanto.prngn s late claim was mailed to cl t. DATED: - J. R. OiSSON, Clerk, By _ , Deputy Clerk cc: Canty Administrator (2) Canty Counsel (1) 000230 C MN CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COP*rFMtapplication to: Instructions to ClaimantClerk of"Board P.O.Box 911 M rtinez Califomia94553 A. Claims relating to causes of action for death or or Injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) = B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed. by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. . E. Fraud. See penalty for fraudulent. claims, Penal Code Sec. 72 at end oT this form. t�*�*•��r�+e+e:�***�*��**:****�**�**��**�:�*��**w*:��*�•*�:*war**�*�**��w�� RE: Claim by )Res:::z ' ling stamps Herbert Mead & Shirley Mead )Against the COUNTY OF CONTRA COSTA) See attached letter.or DISTRICT) ORS tv Fi in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ See attached letter. and in support of this claim represents as follows -- -r - --------�. --- - exactdateandhour]--6-- ---- when-did the damage or Injury occur? Giv See attached letter. T 9 ------------�Incl::de city and countyj- '�. Tik'.;'t�re did tac d.:ma a or See Item 3, below. 3. How did the damage or in�ury occur? Give dull details, use extra . sheets if required) This is a claim for indemnity and contribution. Plaintiffs Richard and Betty Johnson have filed Contra Costa Superior Court Action No. 257547 against Herbert Mead, Shirley Mead, the County of Contra Costa and others, for damages resulting frau an autanobilE pedestrian collision at the intersection of Willow Pass Road and San Vincente Drive, City of Concord, County of Contra Costa, in which Cynthia, their-minor daughter was killed. 17What particular act or omission on the -part o?-;- or district officers, servants or employees caused the injury or damage? See attached letter. (over) 000231 t • 3. What are the names of county or district officers, servants or employees causing the damage or injury? Presently unknown. �:--whet�ainag-e-car in3u=ies-coo you claim=esulte��NZG�ve-�u��-extent---- ofmagejries of damages claimed. Attach two estimates for auto Presently unknown. See attached letter. . - 7. How was the amount claimed above computed? Include the estimates amount of any prospective injury or damage.) Not applicable. See attached letter. -------------------------------------------------------------------- �. -iJames and addresses of witnesses, doctors and hospitals. Not applicable. See attached letter. �. List the expenditures you made on account of this accident orn3ury: DATE ITEM AMOUNT Not applicable. See attached letter. Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by pomeperson on his behalf. " Name and Address of Attorney c., h )' P. GER RDT ZACHER aimant gnature RYAN L. NERNER See 4ftached letter for claimants' GORDON & REES Address 601 Nbntgcnnery Street, San Francisco, CA 94111 address & telephone number. Telephone No. (415) 986-8041 Telephone No. p_ Section 72 of the. Penal Code provides: 'Every person who, with intent to defraud, presents for allowance -or for payment to any state board or officer, ' or to. any county, town, city* district, ward or village board or officer', authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " 000232 • tip - LAW OFFICES STUART M.GORDON DONALD W.REES GORDON & BEES TELEX 6"1151GRSF UW P.GERHARDT ZACHER JAMES MOUSHEGIAN FOURTH FLOOR TELECOPIER(415)906.6041 DOUGLAS B,HARVEY JAMES M.HANAVAN JACK B.MCCOWAN JR MITCHELL L.FORSTER' 601 MONTGOMERY STREET JAMES PATRICK CASTLES P.KURT PETERSON SAN FRANCISCO,CALIFORNIA 94111 OF COUNSEL DONALD K.BUSSIERE WILLIAM A.ROBLES (415)986-6041 ARTHUR L.LANTZ JR. NANCY E.HUDGINS WILLIAM C.WILKA CRAIG A.BESTWICK ELIZABETH B.SANDZA June -28, 1984 DIANE R CROWLEY GREGORY W.JARRETT MICHAEL T.LUCEY H.SCOTT SIRLIN S.MITCHELL KAPLAN DANIEL J.HERLING THOMAS C.CROSBY HOLLY HELMUTH KENNETH B.TISHGART THOMAS A.PACKER �- V WILLIAM J.PETERS ALEXANDER M.WEYAND FRECEi IRENE K.GREENBERGJOHN E HUGHES RYAN L.W.PET R MARK S.ER M.WEY SON 'A PROFESSIONAL CORPORATION O'-v11 i a i Clerk of the Board Board of Supervisors J. R. Contra Costa Count CLERK Y Or:R.� c�,•,a. P.O. Box 911 e __ _.... Martinez, California 94553 Re : Claim for Indemnity .and Contribution in Connection with Contra Costa County Superior Court Civil Action No. 257547 : Richard Johnson and Betty Johnson v. Douglas Gregory Mead, et al. To whom it may concern: This office represents Shirley Mead and Herbert Mead in the above-referenced civil action. On behalf of Mr. and Mrs . Mead, we hereby present a claim for indemnity and contribu- tion pursuant to California Government Code Sections 910-910. 2 : 1 . The names of the claimants are' Shirley Mead and Herbert Mead and their address is 1947 Carlotta Drive, Concord, California 94519 . All correspondence directed to the Meads should be sent to P. Gerhardt Zacher, Ryan L. Werner, Gordon & Rees, 601 Montgomery Street, 4th Floor, San Francisco, California 94111 . 2. The injuries of which plaintiffs in the above- referenced civil action complain occurred on September 14 , 1983 at 3 : 10 p.m. Plaintiffs filed suit on March 22, 1984, and claimants Herbert Mead and Shirley Mead were served with process on April 3, 1984 . The Meads appeared in this action on May 30 , 1984 . The County of Contra Costa, the Probation Department of the County of Contra Costa, and the Crossroads Crisis Center have also been named as defendants and made parties 000233 Page Two Clerk of the Board June 28 , 1984 to plaintiffs' suit. Herbert Mead and Shirley Mead make this claim against the County of Contra Costain connection with plaintiffs ' suit. Claimants are informed and believe,. and based upon such information and belief allege, that the injuries and damages complained of by plaintiffs, if any,. were caused by the entity to which this claim is addressed, through its negli- gent and careless operation, control, construction, design, planning, building, maintenance, management, supervision, inspection, alteration, and repair of the location, instru- mentalities, equipment, and personnel which caused the injuries to plaintiffs as alleged in the complaint. 3 . The specific identities of the persons employed or connected with the entity to which this claim is addressed who were responsible for the activities listed above are unknown to these claimants at this time. 4 . The amount of damages sustained by claimants are presently unknown. Claimants are seeking indemnity and contribution. We await your response to this claim. Very truly yours, GORDON & REES By RYAN WERNER 9 000234 CLAIM BOARD OF SUPERVISORS OF COrTMA CO6`rA C x"ff, QUJ7 RNIA BOARD ACTION Claim Against the County, or District ) NdrICE TO CZAIMARr July 31, 1984 governed by the Board of Supervisors, 1 The cow of this document mailed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph Iv, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. please note all wwaro&WCounsel Claimant: State Farm Mutual Automobile Ins. Co./John Squallati 3254-B Pierce Street JUL O 3 1y84 Attorney: P.O. Box 6265 Albany, CA 94706 Martinez, CA 94553 Address: Via Public Works _. Amount: Unspecified By delivery to clerk on June 29, 1984 Date Received: June 29, 1984 By mail, postmarked on - I. FROM: Clerk of the Board ot Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: June 29, 1984 J.R. OLSSON, Clerk, By Deputy o ereMwarcts II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) ( ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are. so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: - /-- By: Deputy County Counsel III. FRCM: Clerk of the Board TO: ) County Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD By unanimous vote of Supervisors present ( X) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. LRO DuBoisDated: 7-31 -84 J. R. OLSSON, Clerk, By �x� ,c,c �-e , Deputy Clerk SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail 'to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. . V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DATED: 7-31 -84 J. R. OLSSON, Clerk, By, , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000235 CLAIM A • L State Farm Mutual Automobile Insurance Company • Albany Hill Service Center 3254-B Pierce Street June 25, 1984 Post Office Box 6265 Albany,California 94706 Phone: (415) 527-9040 CONTRA COSTA COUNTY PUBLIC WORKS 1801 Shell Avenue Martinez, Ca. 94553 RE: Our Claim No. : 05 1256 019 Our Insured : JOHN SQUALLATI Date of Loss : 6/11/84 Your Insured : DAVID E. EATON Address : 651 Pine Martinez, Ca. 94553 Drivers Lic. : E0473609 Gentlemen: We have been informed that you are the insurance carrier for the party designated as your insured in the caption of this letter. Our investigation establishes that your insured was responsible for the damage to our policyholder's vehicle as a result of the accident on the date designated. Please accept this letter as a notice of our subrogation rights, and comminicate with us with regard to your position in the matter. e y trply youpi c � JACKIE JENKINS �� Claims Representative �v CL AST gam - 203 JJ:g cc: 6000 Encl. Return Envelope RECPWVIT-wilD B ;;;:. M, :Puly 000236 HOME OFFICE: BLOOMINGTON. ILLINOIS 61701 County Counsel AMENDED CLAIM JUN 2 7 1984 CLAIM BOA or smmmnsoRs of Qo[ m coSTA owwr, CALImO wm Martinez, CA 94553 BOARD ACTION Claim Against the County, or District ) NMICE TO CLAIMANT July 31, 1984 -.1 ...... .......,�_ " ��pe "i Y6, ) The copy Of th s document milled to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings'. Claimant: Aetna Casualty & Surety Co. (John & Lynn Smith) R.O. Box 8090 Attorney: Walnut Creek, CA 94596 Address: Via County Counsel Amount: $8,991.00 By delivery to clerk on 7 ,n 96. 1 C)84 Date Received: June 26_, .1984 By mail, postmarked on I. FROM: Clerk of the Board ot supervisors county Counsel Attached is a copy of the above-noted claim. Dated: June 26, 1984 J.R. OISSON, Clerk, By Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) ( ) This claim canplies substantially with Sections 910 and 910.2. 10(�) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late ' claim (Section 911.3) . ( ) Other: , Dated: - Z - k- By: - Deputy County Counsel III. FROM: Clerk of the Board M ) County Counsel, (2) County Administrator ( ) Claim was returned as untimely ith notice to claimant (Section 911.3) . IV. BOARD ORdER By unanimous vote of Supervisors present ( X ) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e n i DuBois Dated: 7-31 -84----- J. R. OLSSON, Clerk, By �,�� -tee , Deputy Clerk WING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months fram the date of this .. notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. . V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a.memo thereof has been filed, and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. lz � �cf/�� 0 DATED: 7-31 -84 J. R. OiSSON, Clerk, By , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000237 C um VICTOR,J. WESTAIAN l I _ j CONTRA COSTA COUNTY COUNSEL To ' c z•�C. Z -- ^� (JL— PO Box 69, Co. Admin. Bldg, Martinez CA 94553 DATE SUBJECT-4 / �'VZ'"��" �X �'�'-•"� i !�TFCM J. R. C=c BUt^D Gt' SUFcRVISGRS C nT2A- COgTA CO. Bv. ...... � . . _ •--• .. ....-"....fie u V♦ .. :�� _ . - - .. - ':dam:.+.. •°r 0002.38 F e Personal Financial Security Division a . 201 No.Civic Drive,Suite 225 P.0.Box 8090 Walnut Creek,Ca. 94596 June 29, 1984 County Counsel County Council Contra Costa County JUL U 2 1984 P. 0. Box 59 Martinet, County Administration Building CA 94553 Martinez, CA 94553 RE: INSURED: JONATHAN SMITH DATE OF LOSS: 3/1/82 LOCATION: 56 CAMINO SOBRANTE ORINDA, CA Dear Sir/Madam: On March 29, 1984, I wrote to you putting you on notice of loss incurred to our insured's property. We have concluded this loss and as I indicated to you before, it appears that the County is responsible for damages to our insured's property. We have paid a total sum of $8,891.00. The insured has a $100 deductible. Please make your check payable to Aetna Casualty and Surety Company, subrogee for John and Lynn Smith, in the amount of $8,991.00. This file is being transferred to our Sacramento Office and further correspondence should be directed to them. Their address is as follows: Aetna Casualty and Surety Company P. 0. Box 13696 Sacramento, CA 95853 Thank you in advance for your cooperation. Very truly yours, rD J�k hL"� Debra M. Hall Aetna Casualty and Surety Co. (415) 947-6515 aLll/29 ,Etna Life Insurance Company I ktna Life Insurance and Annuity Company 000239 L-467-B The ktna Casualty and Surety Company County Counsel ,. AMENDED CLAIM JUN 2 7 1984 ' MUM BoAm oP smmnsow OF COWMA amm oo MT#, CUMMMA Martinez, CA 94553 BOARD AMON Claim Against the County, or District ) NOTICE TO QAIMANT July 31, 1984 governed by the Board of Supervisors, ) The copy of th s document mailed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". ' ,Claimant: Patricia Mitchell Attorney: Neil A. Cook Strom, Schrag, Baum & Buller Address: One Kaiser Plaza, Ordway Building Oakland, CA 94612 Amount: $5,000,000.00 By delivery to clerk on Date Received: June 26, 1984 By mail, postmarked on June 25, 1984 - I. Fwm: Clerk of the Board ot supervisors County Camsel Attached is a copy of the above-noted claim. Dated: June 26, 1984 J.R. OISSON, Clerk, By Deputy Jolene Edwards Ii. FRom: County Counsel TO: Clerk of the Board of Supervisors (Check only one) 0 This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: - — By: Deputy County Counsel III. FROM: Clerk of the Board TO: ( Count Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD CLtDIIt By unanimous vote of Supervisors present (X ) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board'sUr-der entered in its minutes for this date. e e n i DuBois Dated: 7-31 -84 J. R. OL.SSON, Clerk, By ,, Deputy Clerk �..v SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. ( DATED: 7-31 -84 J. R. CLSSON, Clerk, By �`bo , Deputy Clerk cc: County Administrator (2) County Counsel (1) 000240 CLAIM i y AMENDED CLAIM AGAINST CONTRA COSTA COUNTY PATRICIA MITCHELL, presents a claim for damages against CONTRA COSTA COUNTY in the sum of. FIVE MILLION ($5,000 ,000.00) DOLLARS. CLAIMANT' S ADDRESS: 2509 Tassajara Avenue El Cerrito, CA. 94530 ATTORNEYS FOR CLAIMANT (AND ADDRESS TO WHICH NOTICES SHOULD BE SENT) : STROM, SCHRAG, BAUM & BULLER Professional Corporation One Kaiser Plaza, Suite 20£5 Oakland, CA. 94612 DATE OF OCCURRENCE: April 3 , 1984 PLACE OF OCCURRENCE: Kaiser Hospital 1330 Cutting Boulevard Richmond, California SAID CLAIM ARISES FROM THE FOLLOWING CIRCUMSTANCES: Medical negligence by failing to adequately care for claimant' s mother PEARLINE JONES while a patient at the CONTRA COSTA COUNTY HEALTH CLINIC proximately causing her death on April 3 , 1984 ITEMS, NATURE AND EXTENT OF DM AGES OR INJURIES: Claimant alleges loss of society care and comfort and funeral and burial expenses as a result of the death of decedent. NAMES OF PUBLIC EMPLOYEES RESPONSIBLE: UNKNOWN DATED: June 22 , 1984 STROM, SCHRAG, BAUM & BULLER Professional Corporation ECR By; NEIL A. COOK a At orneys for Claimant OF LCLE111C R t -C 000241 �. AMENDED CLAIM CLAIM BOARD CF SUPERVISORS OF CORMA COSTA COMM, all FCFUIA BOARD ACTION Claim Against the Canty, or District ) INCE TO CLAIMANT July 31, 1984 governed by the Board of Supervisors, ) The appy of this document mailed to you is your Routing Endorsements, and Board ) notice of the action 4.*Ken uri Y%oc= "%A .,& uy vie Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Vincent Pree COUiIt 901 Court Street Y Counsel Attorney: Martinez, CA 94553 JUL 18 1984 Address: Martinez, CA 94553_ Amount: $75.00 By delivery to clerk on Date Received: July 17, 1984 By mail, postmarked on July 12, 1984 I. FROM: Clerk of the Board ot Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: July 17, 1984 J.R. OISSON, Clerk, By Deputy o enear s II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) ( ) This claim camplies substantially with Sections 910 and 910.2. ( This claim FAIIS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: - - By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) Canty Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDII2 By unanimous vote of Supervisors present (XX) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. R e e n i DuBois Dated: 7-31 -8.4 J. R. OLSSON, Clerk, ByQ��_,�� , Deputy Clerk WARNING (Goa. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. DATED: 7-31 -84 J. R. OLSSON, Clerk, By, �oou aX1�o , Deputy Clerk cc: Canty Administrator (2) Canty Counsel (1) 000242 CLAIM CLAIM TO; • ' BOARD OF SUPERVISORS OF CONTRA COq. ur � �q(bn C I application to: Instructions to Claimant A. Claims relating to causes of action for death or for�ninjury-o�'g3 person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. ;Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end 3Y—this form. RE: Cla' y \ )Reser ' g stamps _ .�� ; EIVED Against the COUNTY OF CONTRA COSTA) CLERK or } ' � ,� ! DISTRICT) F i i n ame The undersigned claimant hereby makes claim again s C y of Contra Costa or the above-named District in the sum of $ and in support of this claim represents follow ----------------T-------------------5�qk-W L 1. Whendidthe dama ox . ury Gig xact�, (: C�SICULc( tJti c�:�/r d'd r Nd Be CA JU ILLS c. LZ ti CS t�' Fvr�-7 'S 1,�� _ Civ__!nlei_iv��L f�Z�-1 1. -Where did' the damage or i 'ur _ occur? (Include city couand nt ) � Y -------------------------------------------------- ---t- ------------- 3. How did the damage or injury occur? (Give full details, use extra sheets if requires UJ ' u 000243 ------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? c� (.SOU 5. What are the names of county or district officers, s.ervants or employees causing the damage or injury? U� ------------------------------------------------------------------------- 6. What damage or injuries do you claim resulted? (Give full extent of injur T or damages c aimed. !�Attach two, estima esQr auto damage) �111�,,. el CCS L-U(>v _ D�C� �(,�� - t�f-L-- -='-�------------------------ 7. _ - How was the amount claimed ab ve computed? (Inclue the estimated amount of any prospective injury or damage. ' (c S L -co L P LAC-L_ �, p1t,0 LL5 6�_ ------------------------------------------------------------------------- - ------- ------------ 8. Names and addresses of witnesses, doctors and hospitals. P ------------'�---------------------------------------- -------- ---------- - 9. List the expenditures you made on account of this accident-or injury: DATE ITEM AMOUNT ************************************************************************** Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney Claimant' s Signature Address Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment -to any state board or officer, onto any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a fe'iony. " 000244 APPLICATION TO FILE LATE CLAIM BOARD OF SUPEFVISOR.S OF COMM COSTA OOUI r Y, C U IF'ORNIA BOARD ACTION Application to File Late ) NOTE TO APPLICANT July 31, 1984 Claim Against the County, ) Uhe copy of this document mailed to you is your Routing Endorsements, ,and ) notice of the action taken on your application by Board Action. (All Section 1 the Board of Supervisors (Paracraph III, below) , references are to California ) given pursuant to Government Code Sections 911.8 Government Code.) ) and 915.4. Please note the "Warning" below. Claimant: James Anthony Leyendecker c/o James Leyendecker County Counsel Attorney: 2221 Lafayette Drive 4 Antioch, CA 94509 198 Address: CA 94553 Ma�inez, Amount: $100,000.00 By delivery to Clerk on =- Date Received: June 28, 1984 By mail, postmarked on June 26, 1984 I. FRO*'- Clerk of -the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Application to File Late Claim. DATED: June 28, 1984 J. R. OLSSON, Clerk, By ,�,�c.,�,L , Deputy o one ar s II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this App lication to File Late Claim (Section 911.6) . (X) The Board should deny this Application to File a Late Cl ctio 911.6) . DATED: Z5 4—/ JOHN B. CLAUSEN, County Counsel, By , Deputy III. BOARD ORDER By unanimous vote of Supervise present (Check one only) ( ) This Application is granted (Section 911.6) . ( X X) This Application to File Late Claim is denied (Section 911.6) . I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED- 7-31 -84 J. R. OLSSON, Clerk, �' , Deputy eeni DuBois DATO1ING (Gov't.C. §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation re- quirement) . See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your applica- tion for leave to present a late claim was denied. You may seek the advice of any attorney of your choice in connec- tion with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1 County Counsel, 2 County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a mem thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATM): 7-31 -84 .I. R. OLSSON, Clerk, By , Deputy eeni -DuSuis V. FROM: 1 County Counsel, 2 County Administrator '!n: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By 000245 APPLICATION TO FILE LATE CLAIM ...-r.r.. ..w. R. c-c. - .. _. . -.,,---'�r�.x-n^.�-m—r-e^mt+az-r:�x-.;r+..�r-+r-. ..-cert_ ..a �r.rrrr .-rzv+ar-....•.-�. _.. _. .. ' d ! JAMES ANTHONY LEYENDECKER R E C E.N E:J C/o JAMES LEYENDECKER 2 2221 Lafayette Drive gum off A4 Antioch, CA 94509 �.R. OLSSON 3 CLEPK BOARD OF SUPERVISORS (415) 778-0136 c0 RA COSTA CO 3y r"iav 4 5 IN PROPRIA PERSONA I 6 I 7 8 CONTRA COSTA COUNTY AND CALIFORNIA DEPARTMENT OF CORRECTIONS 9 In the Matter of the 10 Claim of : ' JAMMES ANTHONY LEYENDECKER, No. 11 Claimant, APPLICATION FOR LEAVE TO PRESENT LATE CLAIM 12 vs. (Government Code §911 .4) 13 CONTRA COSTA COUNTY, CALIFOR14IA DEPARTMENT OF CORRECTIONS, DOES I 14 through X, inclusive, Defendants. 15 / 16 TO: CONTRA COSTA COUNTY AND CALIFORNIA DEPARTMENT OF CORRECTIONS: 17 1 . Application is hereby made for leave to present a late I 18 claim under Section 911 .4 of the Government Code. The Claim is 19 founded on a cause of action for personal injury which occured on 20 or about the first two weeks in February 1984 , and for which a claim 21 was not timely presented. For additonal circumstances relating to 22 the cause of action, reference is made to the proposed claim attacher 23 hereto as Exhibit A and made a part hereof. 24 2 . The reason for the .delay in presenting this claim is the 25 mistake, inadvertence , surprise, and excusable neglect of the claim- 26 ant as more particularly shown in the declaration of JAMES ANTHONY _1_ GO0246 i f 1 j I LEYENDECKER, attached hereto. CONTRA COSTA COUNTY and CALIFORNIA I I 2 DEPARTMENT OF CORRECTIONS were not prejudiced by the failure to timely file the claim as shown by the declaration of JAMES ANTHONY 3 � 4 LEYENDECKER, attached hereto as Exhibit B and made a part hereof. 5 3. This application is presented within a reasonable time I 6 after the accrual of the cause of action as shown by the declaration ; 7 of JAMES ANTHONY LEYENDECKER, attached hereto as Exhibit B and made I 8 a part hereof. 9 WHEREFORE, it is respectfully requested that this application 10 be granted and that the attached claim be received and acted upon in 11 accordance with Sections 912.4-912. 8 of the Government Code. 12Dated: I � 13 14 A: ESES ANTHON LEYENDECKER. 15 Claimant 16 f 17 18 19 i 20 21 22 23 24 25 i 26 -2 00024'7 1 JAMES ANTHONY LEYENDECKER C/o JAMES LEYENDECKER 2 2221 Lafayette Drive 3 Antioch, CA 94509 4 (415) 778-0136 5 IN PROPRIA PERSONA 6 7 8 CONTRA COSTA COUNTY AND CALIFORNIA DEPARTMENT OF CORRECTIONS 9 In the Matter of the 10 Claim of JAMES ANTHONY LEYENDECKER, No. 11 Claimant, DECLARATION OF JAMES ANTHONY LEYENDECKER 12 vs. 13 CONTRA COSTA COUNTY, CALIFORNIA DE- PARTMENT OF CORRECTIONS, DOES I 14 through X, inclusive, 15 Defendants. 16 17 I , JAMES ANTHONY LEYENDECKER, declare: 18 1 . I am the claimant and injured party in this matter. 19 2. In July 1983 , I underwent surgery including a bone graft 20 on my right wrist. During that surgery, several pins were placed 21 in my wrist, and I was told by my surgeon that the pins had to be 22 removed in September 1983 . 23 3. In August 1983 , I was arrested and incarcerated in the 24 CONTRA COSTA COUNTY jail in Martinez , California where I remained 25 until October 24 , 1983 when I was transferred to the CALIFORNIA 26 DEPARTMENT OF CORRECTIONS at Vacaville. -1- 000248 ' I i 1 4 . During my detention at the CONTRA COSTA COUNTY jail, I 2 received no medical attention whatsoever for the removal of the 3 pins, despite my repeated requests. The pins began to puncture my 4 skin and work outward. Infection set in, for which I also received 5 no treatment, despite my requests . . 6 5 . Upon my arrival at Vacaville , I was told by the doctor 7 who gave me my routine physical, that I would be given an appoint- 8 ment with an orthopedist. Two such appointments were made. Althoug 9 I submitted request slips and asked the CALIFORNIA DEPARTMENT OF 10 CORRECTIONS personnel on numerous occasions to let me out of my 11 cell to keep the appointments, I was never permitted to see the 12 orthopedist. The infection continued, and another pin began to 13 puncture the skin. 14 6 . Upon my release from Vacaville in Janaury 1984 , I im- 15 mediately contacted the surgeon who had operated on me prior to my 16 arrest, and arranged to have the necessary procedures to remove the 17 remaining pins. 18 7 . Early in February, my surgeon told me that the condition 19 of my wrist had markedly deteriorated due to the lack of treatment 20 during my incarceration. 21 8. It wasn' t until approximately two weeks ago that an at- 22 torney, who had obtained my medical records in another matter, told 23 me that I might have a claim against CONTRA COSTA COUNTY and CALI- 24 FORNIA DEPARTMENT OF CORRECTIONS for personal injury; and that there 25 was a 100 day deadline for filing a claim. Thinking that he meant 26 100 days from the date I talked with him, .-and he told me I could -2- �1'� � 1 have a valid claim, I made an appointment to see another attorney 2 about pursuing that claim. That was on May 24 , 1984 , only a few 3 days past the filing deadline (although the exact date for filing 4 is uncertain because I am not completely sure what date in February 5 my doctor told me my injuries were aggravated due to lack of proper 6 medical attention) . The attorney I saw on May 24th advised me to 7 prepare and file my claim as soon as possible, which I am now 8 doing. 9 I declare under the penalty of perjury that the above is 10 true and correct. 11 Dated: 12 �AY,E7s— �JANTHONY LEYENDECKER 13 14 15 16 17 18 19 20 21 22 23 24 25 26 -3- 000250 RECEIVED JUIN 2k 1984 TO: COUNTY OF CONTRA COSTA J. R. OLSSON CLERK BOARD OF SUPERVISORS ONTRA--COSTA CO. Martinez , CA 94553 By.. 36t•••A�ZL&LIM`-De James A. Leyendecker hereby makes claim against the County of Contra Costa, a public entity, for the sum of $100 ,000 and makes the following statements in support of the claim: 1 . Claimant ' s post office address is : James Anthonv Levendecker c/o James Leyendecker 2221 Lafayette Drive Antioch, CA 94509 2 . Notices concerning this claim should be sent to the claimant at the above address. 3 . The date and place of injury giving rise to this claim was during the period of August 3 , 1984 through October 24 , 1983 at the Contra Costa County jail in Martinez , California. 4 . During the time period in question, claimant was denied medical care for a pre-existing, post-surgery condition which was known to Contra Costa County and its employees from the time of claimant 's arrival at the Contra Costa County Jail . 5 . The names of the employees involved are unknown to the claimant. 6 . Injuries are: destruction of a bone graft in claimant' s right wrist, due to a severe infection resulting from lack of medical attention. Claimant is informed and believes that a second graft is not possible. In addition, claimant suffered extreme pain, subsequent disability, and mental and emotional distress. 7 . The basis for computation of the above claim amount is as follows: Medical expenses incurred to date: Unknown Estimated future medical expenses: Unknown General damages TOTAL $100 , 000. 00 DATED: JAf4ES ANTHON LEYENDECKER 00 0 2 511 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA . Adopted this Order on July 31, 1984 by the following vote: AYES: Supervisors Powers, Fanden, Schroder, McPeak, Torlakson NOES: None ABSENT: None ABSTAIN: None SUBJECT: Legal Defense IT IS BY THE BOARD ORDERED that the County provide legal defense for Larry Ard, Chief Deputy, Sheriff-Coroner Department, in connection with U. S. District Court, Northern District of California, Case C82-4117 RHS, Ernest Montano vs Dr. Lundburg et al, reserving all rights of the County in accordance with the provisions of California Government Code Sections 825 and 995. cc: Larry Ard 1 hereby certify that this Is a true and correct copy n" County Counsel an action taken and enterec!or the minutes of t!: County Administrator Board of Supervisors on the data shown. ATTESTED: 3! /984/ J.R. OLSSO , COUNTY CLERK and ex officio Clcrk of the Board By 442"� 000252