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MINUTES - 07311984 - 1.7
TO: BOARD OF SUPERVISORS OF CONTRA CO* r99WRYapplication to: Instructions to ClaimantClerk of the Board .O.Box 911 Martinez,Califomia 94553 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, 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 his form. RE: Claim by )Res A'%1T'fftircr ing stamps CADILLAC AMBULANCE SERVICE- INC., 4601 Nevin Avenue ) Ric and- CA 94805 JUL 3o, 1984 Against the COUNTY OF CONTRA COSTA) J. R. OLSSON . CLE BOARD Of SUPERVISORS or DISTRICT) B NTRA T Co. Fill in name ) puty The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $8/ .171.28 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour] AUGUST 1, 1983 through December 27, 1983 --- SEE ATTACHED �. W�iere did the damage or injury occur? (Include city and county) Contra Costa County --- SEE ATTACHED ----------------------------------------------- -- — --- ------------- 3. How did the damage or injury occur? (Give dull details, 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 �s�Raxata�axal_cu gac ==-F.EATZALHEA-------------------------------- - -- 4. What particular act or omission on the part of county or district 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) FM � NAME DATE OF SERVICE AMOUNT DRY RUN 08/01/83 $ 50.00 SPARDIN, Marie 08/01/83 33.45 BROWN, Delbra 08/01/83 166.00 CONTRARES, Peter 08/01/83 228.50 DRY RUN 08/01/83 50.00 KEENAN, Karen 08/01/83 233.50 DRY RUN 08/01/8.3 50.00 DRY RUN 08'/01/83 50.00 DRY RUN 08/01/83 50.00 FOREMAN, Bruce Zell 08/01/83 176.50 DANGERFIELD, .Fred 08/01/83 229.50 GARDNER, Philip 08/01/83 213.00 DRY RUN 08/01/83 50.00 DRY RUN 08/02/83 50.00 DRY RUN 08/02/83 5.0.00 GERARD, Debra 08/02/83 50.00 BUCHMUELLER, David 08/02/83 234.50 DRY. RUN 08/02/83 50.00 DRY RUN 08/02/83 50.00 DRY RUN 08/02/83 50.00 BENNETT, Joe L. 08/02/83 62.00 WITT, Gary 08/02/83 365.00 WRIGHT, Frederick 08/03/83 254.50 DRY RUN 08/03/83 50.00 REED, Becky 08/03/83 288.00 DRY RUN 08/03/83 50.00 PYES, James 08/03/83 50.00 BROWN, Michael 08/03/83 229.50' ERKEN, Hakan 08/03/83 248.00 DRY RUN 08/04/83 50.00 NOEL, .Sadie 08/04/83 74.00 -1- r NAME DATE OF SERVICE AMOUNT DRY RUN 08/04/83 $ 50.00 DRY RUN 08/04/83 50.00 GIBSON, Terry 08/04%83 50.00 DRY RUN 08/04/83 50.00 DRY RUN 08/04/83 50.00 BROWN, Bobbie (Bobby?) 08/04/83 206:00 BRASHER, Gil 08/04/83 100.00 CURRY, Preston . 08/04/83 25.00 RIDGE, Bea 08/04/83 159.50 AMARAL, Angela 08/04/83 146.50 JACKSON, Wilma 08/04%83 33.00 WALLACE, Tony 08/04/83 49.00 MORRIS, Randall 08/05/83 45.90 DRY RUN 08/05/83 50.00 MORRIS, Randall 08/05/83 77.90 DRY RUN 08/05/83 50.00 DRY RUN . 08/05/83 50.00 DRY RUN 08/05/83 50.00 ALFRED, TAMMY A. 08/05/83 151.50 ALLEN, Andre 08/05/83 166.00 FOATNER, David 08/05/83 76.00 MCLEOD' Sabrina 08/05/83 196.00 DRY RUN 08/05/83 50.00 FOLLINS, Nannie 08/06/83 216.50 MALLARD, Walter 08/06/83 49.00 SARTOR, Annelide 08/06/83 84.00 DRY RUN 08/06/83 50.00 KING, Danny 08/06/83 250.50 DRY RUN 08/06/83 50.00 DESMOND, Helen 08/06/83 38.60 DRY RUN 08/06/83 50.00 DRY RUN 08/06/83 .50.00 -2- NAME DATE OF SERVICE AMOUNT . PEDROTTI, WILLIAM 08/07/83 $ 216.50- . DRY 16.50. DRY RUN 08/07/83 50.00 HAMAN, Henry 08/07/83 220.50 DRY RUN 08/07/83 50.00 DRY RUN 08/07/83 50.00 DRY RUN 08/07/83 .50.00 CROCKETT FIRE DEPARTMENT 08/07/83 540.00 JEFFERSON, Melvin 08/07/83 88.00 DRY RUN 08/07/83 50.00 SAUNDERS, John 08/07/83 50.00 BROWN, Gregory Tyrons, Sr. 08/08/83 .383.00 HOPKINS, Roosevelt 08/08/83 43.00 HUTCHISON, Zelda 08/08/83 399.50 MARTIN, Rosalind 08/08/83 271.00 BOWEN, Alice M. 08/08/83 242.00 DRY RUN 08/08/83 50.00 HALE, Odell 08/08/83 196.50 DRY RUN 08/08/83 50.00 DRY RUN 08/08/83 50.00 DRY RUN 08/09/83 50.00 DRY RUN 08/09/83 50.00 DRY RUN 08/09/83 50.00 DRY RUN 08/09/83 50.00 DRY RUN 08/09/83 50.00 WILLIA14SON,, Michelle L. 08/09/83 214.76 LEGGETT, Rosalee 08/09/83 377.50 DRY RUN 08/09/83 50.00 DRY RUN 08/09/83 50.00 DALE, William 08/09/83 301.00 DRY RUN 08/09/83 50.00 DE EAIRIE, Lorraine 08/10/83 209.00 DRY RUN 08/10/83 50.00 WOHLRAB, John 08/10/83 284.50 -3- NAME DATE OF SERVICE AMOUNT WHITE, Eugene 08/10/83 $ 199.50 DRY RUN 08/10/83 50.00 DRY RUN 08/10/83 50.00 DRY RUN 08/10/.83 50.00 DRY RUN 08/10/83 50.00 DRY RUN 08/10/83. 50.00 DRY RUN 08/10/83 50.00 WILEY, Classie May 08/10/83 223.00 RASMUSSEN, Gloria 08/11/83 78.00 DRY RUN 08/11/83 50.00 WATERS, A.G. 08/11/83 67.00 DRY RUN 08/11/83 50.00 EDWARDS, Geneive 08/11/83 25.00 KORSGAARD, Joby 08/11/83 234.00 NEUMAN, Roy .08/11/83 159.50 DUMAS, Earl D. 08/11/83 50.00 VALDES (Vides?) , Dora 08/11/83 237.50 DRY RUN 08/11/83 50.00 DRY RUN 08/11/83 50.00 BURKE, Sheila .08/11/83 37.14 RICHARD, Jean 08/12/83 141.01 DRY RUN 08/12/83 50.00 DRY RUN 08/12/83 50.00 LAMBERT, George 08/12/83 214.25 TRUSHEPM, Ronald 08/12/83 184.00 WALKER, Timothy 08/12/83 243.00 DRY RUN 08/12/83 50.00 BRILEY, Jessie 08/12/83 54.00 DRY RUN 08/12/83 50.00 -4= NAME DATE OF SERVICE AMOUNT DRY RUN . 08/13/83 $ 50.00 ELDRED, Lisa Kay (Mayes, Amy Lee) 08/13/83 235.00 CURTIS, James 08/13/83 189.50 CHAMBERS,. Ruth T. 08/13/83 39.00 DRY RUN 08/13/83 50.00 DRY RUN 08/13/83 50.00 DRY RUN 08/13/83 50.00 DRY RUN 08/13/83 50.00 DRY RUN 08/13/83 50.00 WATERS, Darrell 08/13/83 196.00 DRY RUN 08/14/83 50.00 DRY RUN 08/14/83 50.00 MAYO, Peggy 08/14/83 240.50 CHAMBERS, Ruth 08/14/83 50.00 DRY RUN 08/14/83 .50.00 VILLENUEVA, Brenda 08/14/83 52.40 DRY RUN 08/14/83 50.00 GILBERT, Darla 08/14/83 242.50 SMALLWOOD, Jeanie 08/14/83 50.00 DRY RUN 08/15/83 50.00 LOHR, Amee 08/15/83 50.00 DRY RUN 08/15/83 50.00 DEMARS, Eddie 08/15/83 223.00 MEDEIROS,. Patricia Ann 08/15/83 234.50 turcios, Louis S. 08/15/83 71.60 DASGUDTA, Robin 08/16/83 216.50 MARTINEZ, John 08/16/83 316.50 WALLACE, Joe 08/16/83 202.50 SMITH, Mark 08/16/83 337.50 dry run 08/16/83 50.00 HESS, STEVEN R. 08/16/83 241.50 DRY RUN 08/16/83 50.00 FANARO, Ralph Donato 08/16/83 273.00 -5- NAME DATE OF SERVICE AMOUNT MILES, Adell 08/16/83 $ 59.00 DRY RUN 08/16/83 50.00 HOLMES, Mary 08/16/83 299.50 LAWSON, Robert 08/16/83 50.00 DANIELS, James 08/16/83 246.50 BLANCHFIELD, Daniel 08/17/83 334.50 ENGELSMAN, Ronald 08/17/83. 235.00 ROBERT, Sharon 08/17/83 50.00 LAMSON, Aileen 08/17/83 393.00 DRY RUN 08/17/83 50.00 DOMBROWSKI, Stan 08/17/83 277.50 WHITE, Annie A. 08/17/83 127.29 DRY RUN 08/17/83 50.00 DENNIS, Charlotte 08/1/783 202.50 THOMPSON, Kenneth 08/18/83 231.50 DRY RUN 08/18/83 50.00 SANFORD, Timothy 08/18/83 50.00 DRY RUN 08/18/83 50.00 HUSSEY, Robert 08/18/83 183.00 DRY RUN 08/18/83 50.00 .EMERICK, Floyd 08/19/83 50.00 PALMER, Sandra 08/19/83 160.32 SHERMAN, Arthur 08/19/83 50.00 DRY RUN 08/19/83 50.00 JENKINS, Thomas W. 08/19/83 211.50 OMAH, Carey 08/19/83 212.50 DRY RUN 08/19/83 50.00 POHL, Timothy Eldon 08/19/83 284.50 RICKLEFFS, James 08/19/83 202.50 LEAVITT, Helen, 08/20/83 136.00 DRY RUN08/20/83 50.00 DRY RUN 08/20/83 50.00 WRIGHT, Prola 08/20/83 193.00 DRY RUN 08/20/83 50.00 -6- NAME DATE .OF SERVICE AMOUNT BOLAR, Mildred 08/20/83 $ 32.00 DRY RUN 08/20/83 50.00 DRY RUN 08/20/83 50.00 SMITH, Oscar 08/20/83 50.00 DRY RUN 08/20/83 50.00 DRY RUN. 08/20/83 50.00 WALSH, .Linda 08/20/83 229.00 DRY RUN 08/20/83 50.00 ROMER, Andy 08/20/83 219.00 DRY RUN 08/20/83 50.00 PIPKINS, Mike 08/20/83 202:..50 CASTIRI, Bob 08/21/83 133.80 SNEED., Deborah 08/21/83 121.16 DRY RUN 08/21/83 50.00 JACKSON, Rickie 08/21/83 206.00 S,CHWERIN, Ruth 08/21/83 101.60 DRY RUN 08/21/83 50.00 LAMONT, Orlando 08/21/83 189.00 COOPER, Charles 08/21/83 . 235.50 DRY RUN 08/21/83 50.00 STREETER, Pilar M. 08/21/83 186.00 HUDSON, Mack 08/21/83 336.50 DRY RUN 08/21/83 50.00 DRY RUN 08/21/83 50.00 WARNER, Violet 08/21/83 214.00 DRY RUN 08/21/83 . 50.00 WILLINGHAM, Mary 08/22/83 317.50 . DENNIS, Cueva 08/22/83 136.00 DRY RUN 08/22/83 50.00 DRY RUN 08/22/83 50.00 GULLEN, Charles 08/22/83 199.50 JONES, .Casey 08/22/83 257.50 HOWARD, Dwayne 08/22/83 229.50 MONTPTIT, Victor 08/22/83 249.00. -7- NAME DATE OF SERVICE AMOUNT DRY RUN 08/22/83 $ 50.00 DRY RUN 08/22/83 50.00 DRY RUN 08/22/83 50.00 HEMINGWAY, Edward 08/23/83 50.00 DRY RUN 08/23/83 50.00 DRY RUN 08/23/83 50.00 VILLANUEVA, Brenda 08/23/83 72. 70 HILL, Welton 08/23/83 358.00 THORNTON, Roderick 08/24/83 223.00 PETERSON, Jane 08/24/83 193.00 BAGNETTE, Stefanie 08/24/83 50.00 MURRAY, Patty 08/24/83 193.00 ENGLISH, Roger 08/24/83. 223.00 DRY RUN 08/24/83 50.00 HINES, Moses 08/24/83 50.00 . KREWSON, Lisa 08/24/83 231.50 DRY RUN 08/24/83 50.00 JONES, Nancy .08/25/83 50.00 MULLER, Kimberly 08/25/83 317.00 DRY RUN 08/25/83 50.00 KLINE, Julie 08/25/83 217.00 MEYER, Janice 08/25/83 236.50 DRY RUN 08/25/83 50.00 HENSLEY, Mary 08/25/83 196.00 ECKELS, Leroy 08/25/83 179.00 THOMPSON, Kenneth 08/25/83 213.00 DRY RUN 08/26/83 50.00 DRY RUN 08/26/83 50.00 KERSEY, Richard 08/26/83 249.50 DRY RUN 08/26/83 50.00 DRY RUN 08/26/83 50.00 HERRON, Reilo 08/26/83 237.50 BROWN, Robert 08/26/83_ 176.00 BROWN, Michael 08/26/83 . 229.50 -8- NAME DATE OF SERVICE AMOUNT GRISBY, David 08/26/83 $ 24.80 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 NOLAN, James 08/27/83 206.00 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 FRANKLIN, Calvin Jr. 08/27/83 50.00 DRY RUN 08%27/83 50.00 DRY RUN 08/27/83 50.00 DRY RUN 08/27/83 50.00 KENDRICK, D. Jonathan 08/28/83 302.00 WALKER, Scott 08/28/83 374.50 DRY RUN 08/28/83 50.00 CROSSMAN, Darlene 08/28/83 211.00 ESPIRITU, Erlinda 08/28/83 122.50 ' VANECK, Terry 08/28/83 148.00 ALLISON, Monti 08/28/83 284.50 STEPHENSON, Johnny 08/28/83 184.75 DRY RUN 08/28/83 50.00 DRY RUN 08/28/83 50.00 DENNICK, David 08/28/83 283.00 SPIERS, Lisa G. 08/28/83 255.50 DRY RUN 08/28/83 50.00 EMERSON, Linda 08/28/83 299.50 OKADA, Yumiko 08/29/83 119.50 DRY RUN 08/29/83 50.00 HUNT, Lem 08/29/83 211.5.0 JACKSON, Reed 08/29/83 304.50 PAYNE, , Ed 08/29/83 136.00 TYLER, Richard 08/29/83 50.00 PAYNE, Ed 08/29/83 136.00 DRY RUN 08/29/83 50.00 -9- NAME DATE OF SERVICE AMOUNT DRY RUN 08/29/83 $ 50.00 MACLAY, Mildred 08/29/83 354.00 JACKSON, Reed 08/29/83 332.50 DRY RUN 08/29/83 50.00 DRY RUN 08/30/83 50.00 FREITAS, Debra 08/30/83 242.50 , DRY RUN 08/30/83 50.00 OLDWINE, Inez . 08/30/83 50.00 DRY RUN 08/30/83 50.00 JOHNSON, Catherine 08/30/83 310.50 FAGALAR, Gordon C. 08/30/83 194.50 DRY RUN 08/31/83 50.00 DRY RUN 08/31/83 50.00 HARRISON, Arnold R. 08/31/83 211.50 DRY RUN 08/31/83 50.00 DRY RUN 08/31/83 50..00 DRY RUN 08/31/83 50.00 MCCLAY, Atelean S. 08/31/83 50.00 DRY RUN 08/31/83 50.00 DRY RUN 08/31/83 50.00 REINHOLD, Kurt H. 08/31/83 261.00 MARISSAIL, Grace 09/01/83 331.50 DRY RUN 09/01/83 50.00 HOLMES, Dawn 09/01/83 50.00 HENSLEY, Mary. 09/01/83 166.00 LEWIS, Maurice 09/01/83 172.50 DRY RUN 09/01/83 50.00. MONROE, Patricia Jo 09/02/83 241.5.0 GORDON, Ramsey 09/02/83 308.50 COMMISKEY, Elda 09/02/83 67.00 DRY RUN 09/01/83. 50.00 ROBERTSON, Alex 09/02/83 199.50 -10- NAME DATE OF SERVICE AMOUNT BENNIE, Guy L. 09/02/83 $ 193.00 DRY RUN 09/02/83 50.,00 GOSS, Domico 09/02/83 295.50 DRY RUN 09/02/83 50.00 DRY RUN . 09/02/83 50.00 DRY RUN 09/02/83 50.00 CASTILLO, Samuel 09/02/83 60.00 HAMILTON, Ron 09/02/83 294.50 LOGAN, Carol 09/02/83 248.00 NICHOLSON, Belinda :09/02/83 229.50 DAVIS, Tomie 09/03/83 30.00 S.HEPARD,- Steve 09/03/83 411.00 MORRIS, Carlos D. 09/03/83 273.00 DRY RUN 09/03/83- 50.00 HOOK, Jeff 09/03/83 219.00 DRY RUN 09/03/83 50.00- MARTIN, 0.00MARTIN, Philip 09/03/83 30.00 PALMER, Sandra 09/03/83 97.88 DRY RUN 09/03/83 50.00 DRY RUN 09/03/83 50.00 DRY RUN 09/03/83 50.00 SLUDER, Thomas 09/03/83 193.00 MARTINEZ, Bill 09/03/83 193.00 DRY RUN 09/03/83 50.00 DRY RUN 09/03/83 50.00 - STEFFY, Mark 09/03./83 263.00 ,RICHIE, Alice 09/03/83 45.00 DRY RUN 09/03/83 50.00 MAYO, Peggy 09/03/83 192.50 DOE, John 09/04/83 254.50 SEVERSON, Scott M. 09/04/83 202.02 BLACKBURN, Bibi 09/04/83 192.02 DRY RUN 09/04/83 50.00 DRY RUN 09/04/83 50.00 =11- NAME DATE OF. SERVICE AMOUNT DRY RUN 09/04/83 $ 50.00 MASON, Albert 09/04/83 .199.50 DRY RUN 09/04/83 50.00 NAGANUMA, Jay 09/04/83 103.30 PFAUTCH, Marge 09/05/83 180.40 DRY RUN 09/05/83 50.00 DRY RUN 09/05/83 50.00 SUGAR,. Leona 09/05/83 29.00 DRY RUN 09/05/83 50.00 DRY RUN 09/05/83 50.00 DRY RUN 09/05/83 50.00 DRY RUN 09/05/83 50.00 SCOTT, Anne Maria 09/05/83 . 233.50 SPIERS, Annalissa 09/05/83 255.50 SMITH, Linda 09/05/83 231.00 GREER, Losson 09/05/8.3 42.00 DRY RUN 09/06/83 50.00 THAYER, Helen 09/06/83 100.00 BROOKS, Helen 09/06/83 68.90 DRY RUN 09/06/83 50.00 DRY RUN 09/06/83 50.00 DRY RUN 09/06/83 50.00 DRY RUN 09/06/83 50.00 MCCALL, Esther 09/06/83 29.00 DEWEY, Emmett 09/06/83 298.00 SILVA, Linda 09/06/83 321.50 DRY RUN 09/06/83 50.'00 TURNER, Christopher 09/07/83 244.50 RUNNESTRANO, Betty 09/07/83 347.50 DRY RUN 09/07/83 50.00 DRY RUN 09/07/83 50.00 DRY RUN 09/07/83 50.00 MILLER, VANGIE 0.9/07/83 189.50 r -12- NAME DATE OF SERVICE AMOUNT DRY RUN 09/08/83 $ 50.00 DRY RUN 09/08/83 50.00 DRY RUN 09/08/83 50.00 MARQUEZ, Jonas 09/08/83 174.,64 DRY RUN 09/08/83 50.00 POLLARD, Arthur 0.. 09/08/83 27.00 DRY RUN 09/08/83 50.00 RAPD, Gary 09/08/83 238.00 GLASSBROOK, Frank 09/09/83 194.50 DRY RUN 09/09/83 50.00 DRY RUN 09/09/83 50.00 COTTON, Cathy 09/09/83 202.50 FOUST, Jasper 09/09/83 50.00 DRY RUN 09/10/83 50.00 RUBALEABA, Benito 09/10/83 199.50 DRY RUN 09/10/83 50.00 DRY RUN 09/10/83 50.00 KENNEDY, Angela 09/10/83 275.00 DRY RUN 09/10/83 50.00 DRY RUN 09/10/83 50.00 DRY RUN 09/10/83 50.00 MABRY, Gene 09/10/83 279..00 DRY RUN 09/10/83. 50.00 SINGER, Nicholas 09/10/83 166.00 WALDRON, Darryl R. , Jr. 09/10/83 231.50 DRY RUN 09/10/83 50.00 TATE, Robin 09/10/83 159.50 SAATHOFF, John 09/10/83 199.50 dry run 09/10/83 50.00 DRY RUN 09/10/83 50.00 DRY RUN 09/10/83 50.00 MYERS, Glen . 09/10/83 43.30 POTAP, Kenneth 09/10/83 274.00 ROB (?) , Terri 09/11/83 189.50 -13- M NAME DATE OF SERVICE AMOUNT DRY RUN 09/11/83 $ 50.00 DOE, Jane 09/11/83 293.00 CHURCH, Mary . 09/11/83 41.00 DRY RUN 09/11/83 50.00 DRY RUN 09/11/83 50.00 KANE, Daniel 09/11/83 329.00 DRY RUN 09/11/83 50.00 DRY RUN 09/11%83 50.00 DRY RUN 09/11/83 50.00 COATS, Geri 09/11/83 50.00 DRY RUN 09/11/83 50.00 DRY RUN 09/11/83 50.00 DRY RUN 09/11/83 50.00 ZAMUDIO, Arturo 09/11/83 334.50 FOGUE, Charles 09/12/83 308.50 DELLACORT, Dennis 09/12/83 288.00 MAUPIN, Less 09/12/83 23.90 BRIDGEWATER, Ethel 09/12/83 65.00 BARNELL, Clifford N. 09/12/83 198.50 RENFRO, David 09/12/83 166.00 GILMORE, James 09/12/83 219.00 DRY RUN 09/12/83 50.00 MCHELHINEY, Nellie 09/12/83 186.50 SCHANETTE, Charles 09/12/83 166.00 WALTERS, Vicki 09/12/83 286.00 CLARK, Stella 09/12/83 214.00 STREETER, Pilar . 09/12/83 231.00 RILEY, James 09/12/83 62.78 FOREST, Clarence 09/12/83 183.00 DOGALIK, Dorothy Carol 09/12/83 258.50 BATLER, Gary 09/12/83 375.50 COMBS, Issaiah 09/12/83 431.00 DRY RUN 09/12/83 50.00 -14- NAME DATE OF SERVICE AMOUNT PHILLIPS, , Michael 09/13/83 $ 254.50 BELLICAN, Robert 09./13/83 17.80 ALEXANDER, Grace 09/13/83 229.00 DRY RUN 09/13/83 50.00 ELLIOTT, John 09/13/83 297.50 ALLAN, Dixie 09/13/83 254.50 . DRY RUN 09/13/83 50.00 DRY RUN 69/13/83 50.00 DRY RUN 09/13/83 50.00 DRY RUN 09/13/83 50.00 MCNEELY, Alton 09/13/83 290.50 DRY RUN 09/13/83 50.00 OJEDA, Cora Anne. 09/13/83 351.50 POTAP, Kenneth 09/14/83 261.00 MITCHELL, Velda (AKA: Porter) 09/14/83 237.50 DRY RUN 09/14/83 50.00 DRY RUN 09/14/83 50.00 ' DRY RUN 09/14/83 50.00 YOUNG, Karen 09/14/83 166.00 DRY RUN 09/14/83 50.00 WALKER, Bobby Ray 09/14./83 233.50 DRY RUN 09/14/83 50.00 SHALLENBERGER, Lois Ann 09/14/83 283.00 WINSOR, Scott (Patrick?) 09/14/83 277.50 DRY RUN 09/14/83 50.00 STEWART, Russell 09/14/83 197.38 SCRIBNER, Ken 09/14/83 197.38 DRY RUN 09/15/83 50.00 DRY RUN 09/15/83 50.00 DRY RUN 09/15/83 50.00 MARKABLE, Joe 09/15/83 229.50 RODRIGUEZ, Robert 09/15/83 228.00 DRY RUN 09/16/83 50.00 KELLY, Willie Mae 09/16/83 50.00 -15- y Y: l NAME DATE OF SERVICE AMOUNT FOLTZ, Ernest 09/16/83 $ 218.00 DRY RUN 09/16/83 50.00 DUNN, Keenan 09/16/83 255.00 DRY RUN 09/16/83 50.00 DRY RUN 09/16/83 50.00 BROWNING, Timothy 09/16/83 176.00 DRY RUN 09/16/83 50.00 DRY RUN 09/16/83 50.00 TERREL, Donald L. 09/17/83 183.00 BLALOCK, Charles 09/17/83 44.60 ROSE, Victoria 09/17/83 442.50 DRY RUN 09/17/83 50.00 DRY RUN 09/17/83 50.00 DRY RUN 09/17/83 50.00 WEBB, Robert 09/17/83 52.00 DRY RUN 09/17/83. 50.00 VERVALIN, James 09/17/83 199.00 DRY RUN 09/18/83 50.00 DRY RUN 09/18/83 50.00 .CUMMINS, Helen A. 09/18/83 174.40 LIVINGSTON, Gregory 09/18/83 159.50 NILES, Drusilla 09/18/83 288.00 MARSHALL, Sharon 09/18/83 206.00 GRIFFIN, Robert 09/18/83 229.50 FUJIE, Hono 09/18/83 150.00 HATHAWAY, Marvin 09/19/83 513.00 DRY RUN 09/19/83 50.00 DRY RUN 09/19/83 50.00 DRY RUN 09/19/83 50.00 DRY RUN 09/19/83 50.00 DRY RUN 09/19/83 50.00 EDWARD S, Arthur 09/19/83 194.50 TIMMONS, TAMMY 09/19/83 159.50 -16- NAME DATE OF SERVICE AMOUNT DRY RUN 09/19/83 $ 50.00 DRY RUN 09/19/83 50.00 DRY RUN 09/19/83 50.00 DRY RUN 09/20/83 50'.00 DRY RUN 09/20/83 50.00 BEAR, Laura 09/20/83 131.00 LEVINE, Deborah 09/20/83 164.64 CERDA, Christina `09/20/83 193.00 DRY RUN 09/20/83 50.00 FORD, Joan 09/20/83 407.50 SMITH, Nora 09/20/83 236.00 YOUNG, Robert 09/21/83 287.00 DRY RUN 09/21/83 50.00 SYESS; Marcus 09/21/83 189.50 DRY RUN 09/21/83 50.00 WATSON, Milam 09/21/83 42.00 DRY RUN 09/21/83 50.00 GRIFFIN, Tommy 09/21/83 29.00 COLE, Johnny 09/21/83 186.50 NOLAN, James 09/21/83 .196.00 ESTER, John 09/21/83 190.00 STEWART, George 09/21/83 295.50 DRY RUN 09/22/83 50.00 . DRY RUN 09/22/83 50.00 DOWELL, James 09/22/83 159.50 DRY RUN 09/22/83 50.00 DHEA, Manlanji 09/22/83 297.00 DE BARROS, Phillip 09/22/83 242.50 DRY RUN 09/23/83 50.00 CHAVEZ, Patricia 09/23/83 103.00 .BURGESS, Helen 09/23/83 28.00 POTAP, Kenneth 09/23/83 159.50 DRY RUN . 09/23/83 50.00 GUILLEN, Emilia 09/23/83 66.00 -17- NAME. DATE OF SERVICE AMOUNT SPIERS, David 09/23/83 $ 134.35 DRY RUN 09/24/83 50.00 DRY RUN 09/24/83 50.00 LOPEZ, Jimmy 09/24/83 456.00 GALLO., Steven 09/24/83 246.00 DRY RUN 09/24/83 50.00 . SCROGGINS, Alice 09/24/83 181.00 PARROS, Hilda 09/24/83 410.50 DRY RUN 09/24/83 50.00 THOMPSON, Robin L. 09/24/83 50.00 DRY RUN 09/24/83 50.00 ATNIP, Sterlan 09/24/83 267.50 DRY RUN 09/24/83 50.00 DRY RUN 09%24/83 50.00 BARRETT, Sheila 09/24/83 206.00 POTAP, Kenneth 09/24/83 209.00 COOKSEY, Peggy 09/24/83 189.50 DRY RUN 09/24/83 50.00 DRY RUN 09/24/83 50.00 DRY RUN 09/24/83 50.00 DRY RUN 09/24/83 50.00 DRY RUN 09/25/83 50.00 RODRIGUES, Rosa 09/25/83 50.00 DRY RUN 09/25/83 50.00 DRY RUN 09/25/83 50.00 DRY RUN 09/25/83 50.00 DRY RUN 09/25/83 50.00 STOLES, Garnes 09/25/83 50.00 DRY RUN 09/26/83 50.00 DANKOWSKI, Henry P. 09/26/83 339.00 GLASSBROOK, Frank 09/26/83 88.00 TEAL, Robert 09/26/83 188.00 JACKSON, Joe 09/26/83 199.50 DRY RUN 09/26/83 50.00 MORENO, Ignacio 09/26/83 239.50 DRY RUN 09/26/83 50.00. -18- NAME DATE OF SERVICE AMOUNT DRY RUN 09/26/83 $ 50.00 . VIGIL, Jesus 09/26/83 50.00 DRY RUN 09/26/83 50.00 BAKER, Judy 09/26/83 75.00 DRY RUN 09/26/83 50.00 BRITT, Jeff 09/27/83 33-00 CRAWFORD, Ruth 09/27/83 96.00 HICKS, Joseph Jr. 09/27/83 153.00 CUNNINGHAM, Ruby 09/27/83 62.00 DRY RUN 09/27/83 50.00 DRY RUN 09/27/83 50.00 SHANKS, Jack A. 09/27/83 239.50 SIMMS, Leona 09/27/83 50.00 JACKSON, Lee C. 09/28/83 114.76 WARD, Sherry 10/04/83 267.50 HARRELL, Helen 10/06/83 41.00 SHALLENGERGER, Lois. A. 10/06/83 261.00 DRY RUN 10/07/83 50.00 JONES, Francine 10/09/83 166.00 MONTIEREY, Toby 10/09/83 38.00 CARTER, Harold 10/09/83 113.00. NASSER-FAILI, Diane 10/10/83 61.30 WINSOR, Patrick 10/14/83 159.50 SONCINI, Dorothy 10/14/83 223.00 BARNES, Charles 10/15/83 183.00 BOUGHTON (?) , Roy 10./17/83 183.00 WESLEY, Jeanette 10/18/83 193.00 SMITHERMAN, Mark 10/20/83 193.00 HARREU, Alisha 10/26/83 341.50 PARSON, Thomas 10/27/83 191.50 MARTINEZ, Opal 10/28/83 24.00 DRY RUN 10/29/83 50.00 LUCKETT, Robert 11/03/83 183.00 MCD.ONALD, Timothy M. 11/08/83 59.90 -19- . NAME DATE OF SERVICE AMOUNT POKIPALA, Daniel 11/09/83 $ 270.00 WATSON, Lula M. 11/11/83 207.50 PIERCE, Tyree 11/16/83 240.00 MAY, Rhonda 11/18/83 224.50 ALPERIN, Iyan 11/19/83 263.50 KIEFERT, Ralph . 11/23/83 261.00 GARBARINO, Ruth 11/25/83 122.30 STEIN, Robert 11/26/83 231.00 CHAPMAN, Mildred 11/28/83 29.00 DOE, John 11/28/83 183.00 MCCLOUGH, William 11/29/83 276.50 LOGAN, Starlyn 11/30/83 51.00 THORNTON, Roderick 12/07/83 264.50 CAIN, Melvin 12/08/83 153.00 . GRAY, Edward D. 12/08/83. 162.00 VIGIL, Jesus 12/09/83 206.00 HARRISON, Thomas 12/21/83 183.00 RISCH, Tony 12/22/83 29.35 LYONS, Syble 12/27/83 119.05 -20- CONTRA COSTA COUNTY ( AMBULANCE PRE HOSPITAL CARE FORM i ; uNiT AUTHORIZATION # CHECK OR EILL IN APPROPRIATE SPACES DATE. PCI IENT'S NAME � �7 � `1 ❑ M ❑ F COMPANY a ADDRESS --- .. - -- - AGE ._. . . I CITY ..__ .._. -_— STATE __ . _. .- ZIP _. DOB ❑ Sn ❑ M ❑ T ❑ W ❑ TT�h ❑ F ❑ S DI,IVER'S LICENSE to PHONE NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER❑ A INCIDENT LOCATION RESPONSE CODE REQUESTED BY TIME - (24 HOUR CLOCK) 1 TO SCENE - `J�PS O. ..._. . CALL RECEIVED 1 _, � /,� _t1�cYJ ---.._. . . •J-- ❑ PD ------ TIME 10-8 PATIENT DESTINATION FROM SCENE - ❑ FIRE ___ —_— TIME 10-97 :~— _—_______.. ❑ PSAP TIME 10-49 —_— �( MILEAGE: ❑ OTHERiPVT TIME 10-7 I + END --_._..--- --- ---- -- - TIME 10-98 DOCTOR _. PMD/ER START—__. —_.--_ TIME 10-22 HOW CHOSEN TOTAL —_—_—_ _-_—_—. STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK #: AMBULANCE COMPANY. PT AMBULATORY? PATIENT TAKEN TO AMBULANCE RESPONSE ZONE ❑ YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION DRIVER �l`rl�l�iA EMT-1A .__ _ .. TECHNICIAN . `[1L1"J_/ ���_ PARAMEDIC Hx ----__---- -.—___._—. ------- . DISPATCHER: i CHIEF COMPLAINT: .__--.___ ___..__._ ___.._—._— DRY RUN Q YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN{EMS USE ONLY).. PATIENT REFUSED SERVICES (SIGNATURE) X,-,-- MEDICAL ._.-_MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS. SS # -- ----- - -- -- - --- / 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) CCHP/PPRP#: _ EMERGENCY RUN. MEDI-CAL#:_ —____—_._ 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 ADMINX DRUGS: (PER ADMIN.)_-.--_-._._._.. X NAME: _______— _...._.. RELATIONSHIP _._.- _. _. E O.A.. (IF NOT REPLACED) ADDRESS: — .__.._. .._.._ ORAL AIRWAY (IF NOT REPLACED) CITY:____ __— _______. STATE . -_ZIP:ZIP:_______.. C-COLLAR (IF NOT REPLACED) PHONE: __ WORK PHONE ___...____._..__.. DRY RUN: (AUTHORIZED) EMPLOYER. _. OCCUPATION____.__.._. _ ___. OTHER ADDRESS—____.. - CITY: STATE.-___ZIP: COMMENTS .. — ------ ------ — • IfllAl ---- --_ .-. PA11LNT III Cf IVf.I1 fly X 1 14 CONTRA COSTA COUNTY ' AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION� CHECK OR FILL INAPPROPRIATE SPACES .. DATE: PATIENTS NAME ! r ❑ M ❑ F COMPANY N ...-+r� ADDRESS L �'-��?n! AGE _ I l DOB�CITY_ _ STATE ZIP OT,OW OTA .OF I O$'� DRIVER'S LICENSE M __ PHONE TURE OF DISPATCH J R i TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ rSTATION 1(A)_2(B)_3(C)_4(D)_5(EL.. . I 1111 INCIDENT LOCATION: AV 0" RESPONSE CODE: REE ESTED BY: TIME-(24 HOUR CLOCK) I ) (� ,� ^ TO SCENE- 2 as .O. CALL RECEIVED Y--P 1 "1 .7 O P.D. TIME/0 8 1 :.3 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 Zvi, r o �j c f' �%' .� ❑ PSAP TIME 10-49(A:.) ✓ - �� MILEAGE: O OTHERIPVT TIME 10.7 END TIME 10.98 DOCTOR cif\TV �i PM /ER START 4 TIME 10.22 ;------ HOW HOW CHOSEN: TOTAL D STANDBY TIME,, ,:_,="^I ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME PATIENT 11 DIRECT 13 OTHER �? CALL BACK R: AMBULANC MPANY: eEMS BULATORY? PATIENT TAKEIj�fO AMBULANCE: v RESPONSE ZONE❑ NO ❑ WALKED LGUERNEY ❑ OTHER (�.�1 PATIENT CONDITION: DRIVERl .f�� [V-�/)�`?ARAMEDIC r`! I TECHNICIAN 11 Hx: �Q�� S DISPATCHER: v s _ I I " CHIEF COMPLAINT: js�l7 DRY RUN: OYES NO REASON FOR DRY RUN AUTHORIZATION PKAIDRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL 13YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: .[. - KAISER M: MULTIPLE PTS.BASE RATE X / ^ —� BLUE CROSS C TOTAL MILES: _GG:s Y 1_zl��Se�— / MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO. NIGHT: (19:00•07:00) 1 � CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2�3 V OTHER: OXYGEN: (PEI TANK) ,6.0.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ti E.K.G.: (PER EPISODE) qq ) NEAREST RELATIVE/RESPON�IBLE�PARTY: I.V.: (PER ADMIN.) p, DRUGS: (PER ADMIN.) X Bi NAM ! j iA I�91 ATIONSHI E.O.A.: (IF NOT REPLACED) ADDRESS: ��-� ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PFtONE: WORK PHONE: DRY RUN: (AUTHORIZED) 6CCUPATIO ' = OTHER ADDRESS: CITY: 7�1` IJ STATE' ZIP* COMMENTS: _ TATAI • PATIENT RECEIVED BY:X ( Provider retain. Aite vrd Pin< Topp Retur" Ye'lm npr t• _M.< <dve bil'inp (SIGNATURE) O�-1 CONTRA CO.T:=UNTY ,L-),\ AMBULANCE I Q� PRE-HOSPITAL CARE FORM I 1 UNIT AUTHORIZATIONNJL=� 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ?1�-���I v n 1 �C 1. fi l l ❑ M 16 COMPANY 0 (�� 2 (��BC� ADDRESS _ �J A I by I`-iJ AGE �`' ` ' L CITY �'�IC.�� — ba ICY STATE ZIP �1`i 0 0 1 DMLX=l l' �Q�S�0 Tom❑W O Th O F O$ DRIVER'S LICENSE.A ____ PHONE -2 3 S- �D5-NAi TYPE OF TRANSPORT: AMBULANCE OTHER❑ l — ATION 1 2(8)_3(C)_4(D)_6(E)_ INCIDENT LOCATION: RESPONSE CODE: D BY: TIME- (24 HOUR CLOCK) _ TO SCENE- �` CALL RECEIVED of r ❑ P.U. TIME 10-8 JL5 -LL V PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 r 7 �' ❑ PSAP TIME 10-49 I` � 14 MILEAGE: �7 ❑ OTHER/PVT TIME 10.7 END 3,5 TIME 10.98 DOCTOR J< r v ':::z PMD t START �-� TIME 10-22 HOW CHOSEN: TOTAL 7- STANDBY TIME _❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME PATIEN ❑ DIRECT ❑ OTHER <.. � CALL BACK N: AMBULANCE COMPANY: 1 ®�MBULATORY? PATIENT TAKE ANCE: RESPONSE ZONE S ❑ NO ❑ WAL'CEC(. GUERNEY OTHER PATIENT CONDITION: 3 SvDRIVER ✓�� a'7J �' MT-IAS TECHNICIAN -)33— PARAMEDIC Hz: UQ l;"� I�h, 1,Ly i lrA O �' P'IV<<tDISPATCHER: CHIEF COMPLAINT: pn-` Nt Sc LLIT Cr DRY RUN: ❑ YES REASON FOR DRY RUN t�u <<L< UTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 1 PATIENT REFUSED SERVICES: (SIGN Ir ! ; I TRI M CAL COVERA cINDUSL)p YES NO.)0F PATIENTS: D S. S��- am- - a N� RIVATE INS. CO.: A 11 ' BASE RATE: KAISER x: I r. " MULTIPLE PTS. BASE RATE BLUE CROSS It: I '� J c ` TOTAL MILES: �7 X - �1 MEDICARE R: ';E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r ❑ YES ❑ NO NIGHT: (19:00-07:00) l �HPlPPH p: J - EMERGENCY RUN: f MEDT-CA �_) ?.3 CODk 2/3 -� - 1 61-4THER: OXYGEN: 7(PER TANK) P.O.E. STICKER ❑ YES 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.P: b 142 tj k A T 1 i L _ RELATIONSHIP:rlj O E.O.A.: (IF NOT REPLACED) - `-- ADDRESS: l 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: I��� �-U'lt O /�+Uf�iTL.J& _ - OT s'=AIs AEls me,(3z-cA t- TOTAL:Ivl'•0/0 SSH upJ bl�, 4. io MU-CAL- PATIENT RECEIVED BY:X C r, „, (SIGNATURE) DIS-1 Provider nta:c Vhitc ;. -opo 5r+i¢t� Y¢:;:o' —:111 !• n(^ uhra D!i inQ CONTRA COSTA COUNTY }'. AMBULANCE (j PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATIOLI A JI — CHECK OR FILL INAPPROPRIATE SPACES DATE: 44 . PATIENT'SNAMk 7- r 1•''&i km ❑ F COMPANY • 1-3 I ADDRESS 1E��1�� -h\\ c' C \- AGE- CITY GE P� 'w 'i STATED ZI nyJ J CITY C��( �� ( �.-- r .,7 DOBLa�L.L_�I�D Sn O;t D W O Th ,O F O S"-� DRIVER'S LICENSE a _ _ PHONE v• f Imo_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEK OTHER❑ _ -- - STATION 1(A)._2(8)_3(C)_4(D)_5(E)_ j,, INCIDE T LOCATION: t, RESPONSE CODE: QUESTED BY: TIME— (24 HOUR CLACK�j - Y TO SCENE- /1 S.O. CALL RECEIVED G" 7 V� J ❑ P.D. TIME 10-8 ;: •~ ' i I PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 0��/ ❑ PSAP TIME 1D-49,�• MILEAGE: l ❑ OTHER/PVT TIME 10-7 ENDTIME 10-98. ;• �� . Z DOCTOR14`r11�•h PMD(EF� START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME • NEAREST O FAMILY O TRANSFER WAIT TIME D PATIENT ❑ DIRECT O OTHER I CALL BACK N: AMBULANCE COMPANYr ef�---•1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �O RESPONSE ZONE_ Q YES O� NO O WAL'<ED R�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER _ �� ISO EMT-1A TECHNICIAN - ~ PARAMEDIC- ti DISPATCHER: - L/r CHIEF COMPLAINT: �( i 4 s' ?t �/P 'c 2 P-k-)Cl DRY RUN: O YES VNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7' PATIENT REFUSED SERVICES: (SIGNATURE) X_ ' L MEDICAL COVERAGE: I DUSTRIAL 13 YES El NO NO. OF PATIENTS: —� S.S. «_S 1(� - �-1iri PRIVATE INS. CO.: BASE RATE: _ I KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS M: _ TOTAL MILES: X 6-' s d eU) MEDICARE a: J J .7 / Jy E.O.B. ATT. ROUND TRIP: O YES ❑ NO t O YES r O NO NIGHT: (19:00-07:00) ' CCHP/PPNP a: EMERGENCY RUN: , -� � t4 MEDI-CAL .C��� �l,yq;;n CODE 2A ��I}JER OXYGEN: (PERIfANK) a P.O.E.-STICKER 0jYES ONO NEONATAL: (INCUBATOR) r .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:Cnfl CL�Cx1 X11 (IN`. RELATIONSHIP__Ss_t,Ll(. E.O.A.: (IF NOT REPLACED) - ADDRESS:a_}I-VI R<i-!-) L. XYu ORAL AIRWAY: (IF NOT REPLACED) CITY:Plt�k STATES:--) .-ZIP: C-COLLAR: (IF NOT REPLACED) PHONE:-432, .L 5r WORK PHONE: DRY RUN: 4AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: - CITY: STATE: ZIP: COMMENTQ ,�� ��•�iy•j(r CONTRERAS PET3 - C7609555764930 TOTAL: - 20eP3P47M PATIENT RECEIVED BY: X - , Pmuidcr ntoi Vhity •rd o'r.5 ��P� 9oturn Yo'Srh np� n.^ rrkrn Iif':.•,, ($IGT RE) DIS-t (J CONTRA COSTA COUNTY AMBULANCE �� •Z� I PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N Ctwl CN[CK 011 PILL IN A►PROPRIA TF 3PAC[J DATE: ' PATIENTS NAME ❑ M OF COMPANY M �J IA ADDRESS ) AGE Z > l CITY - STATE ZIP DOB '❑ Sn MOT /Ot-W� OjThh OF O S DRIVER'S LICENSE A _ - - PHONE NATURE OF 0 SPATCH k - TYPE OFTRANSPORT: AMBULANCE/T OTHER STATION 1(A).._2(B)_3lC) 4(D)_5(E)_. INCIDENT LOCATION: 1 RESPONSE CODE: EQUESTEO BY: TIME— (24 HOUR CLOCK) C Y `� TO SCENE- 0) .0.P.D. TIME RECEIVED : y / �Y l'/ PATIENT DESTINATION: FROM SC EN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 fA ` k_)`' MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-96 `7 6OCTOR PMO/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME •_ O NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK R: AMBUL NCE C (v1PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE D YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER t�a ca PATIENT CONDITION: z� '����T e DRIVER / �/� a/n6M SAD �jt� g-i- IVF� TECHNICIAN SI I L SPARAMEDIC Hx: DISPATCH CHIEF COMPLAINT: DRY RUN- YES ❑ NO REASON FA DRY RUN GrK AUTHORI FOR DRY RUN(EMS USE ONLY) 0'r.'�G K�µ�- j f�Y PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: ) 1 I ✓ S.S. M PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS c TOTAL MILES: X MEDICARE M:' E.O.B.ATT. INIGHT: UND TRIP: O YES ❑ NO O YES O NO (19:00-07:00) GCHP/PPRP N: ERGENCY RUN: MEDI-CAL N: CODE OTHER: YG . (PER TANK) P.O.E. STICKER O YES O NO ONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I\ vl 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:------"- DDRESS: 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: PATIENT RECEIVED BY: X ti•..i ani -. + .. ,.. .. (SIn NAT11gF) CONTRA COSTA COUNTY AMBULANCE �3`/_7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME__ N_f� ��-� ❑ M IK/ F COMPANY M ADDRESS „?� S_S' `TScC> .N 5 - AGE 7� ! . ;� ! ! ; •.3 I CITY �� h!_.STATE C, - ZIP__. DOB&-41v3 ❑ Sn $(M ❑ T ❑ W ❑ Th O F ❑ S DRIVER'S LICENSE a _ PHONE NATURE OF DISPATCH /SVx7.1Z Fit TYPE OF TRANSPORT: AMBULANCE7 OTHER❑ _—._---.. ._ STATION 1(A).X2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) , TO SCENE- ❑ S.O. CALL RECEIVED1C-�--7�-- / f• ��7 f�• �. J 1 ❑ P.U. TIME 10-8 1 /� PATIENT DESTINATION S � �l./ �l FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 ,AILEAGE00 OTHER/PVT TIME 10-7 END �/9 TIME 10-98 DOCTOR - PMD/ER START .�� f />7 �>✓ TIME 10-22 HOW CHOSEN TOTAL i C. STANDBY TIME ❑ NEAREST ❑ FAMILY &TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ' CALL BACK#: AMBULANCE OMPANY: PT AMBULATORYo7 PATIENT TAKEN TO AMBULANCE: {� Q RESPONSE ZONE YES ❑ NO ❑ WAL`:ED X GUERNEY ❑ OTHER ' I ✓ PATIENT CONDITION: DRIVERA1161Ghlt/L TP ! EMT-tA TECHNICIAN �✓�G T 'r PARAMEDIC Hx' [?1L/� ♦ C._Nfl�__Z/>' %i2U/3t��wS DISPATCHER: _ 4-14-1,, 1 ' 1 CHIEF COMPLAINT: iC 72 /✓S 'Q�— 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. a - /Mco PRIVATE INS. CO BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a TOTAL MILES: X �• ��✓p�- MEDICARE#:-- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ' ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP a:_— EMERGENCY RUN: EDI-CAL 7 6,Vn CODE 2/3 1 1 C'1�++fft• � i11T1/� A '��Z.c? '�/ OXYGEN (PER TANK) P.O.E. STICKER ❑ YES fitNO 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 AREPLACED) CITY ..�—_.____ .. .._.. .:_ STATE_`ZIP:—_-- C-COLLAR: (IF NOT REPLACED) PHONE. _ WORK PHONE: DRY RUN: (AUTriORIZFID) EMPLOYER: OCCUPATION: OTHER: [ I) . ADDRESS: CITY. STATE: ZIP:— COMMENTS: IP:COMMENTS: 195-31. E L /Ni A, / 07'S`/YS CNij - �J Q•'7 TOTAL:' PATIENT RECEIVED BY: X - _ (SIGNAT REI DIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# 3 CN[CK OR FILL IN APPROPRIATE SPA CES DATE: - PATIENT S NAME I OM OF COMPANY# ADDRESS -�✓��T �'�<n►^-1 P AGES �1 CITY c STATE ZIP DOB ❑ Sn � OT OW O Th ❑ F 13S DRIVER'S LICENSE# _ t PHONE _ NATURE OF DISPATCH U h 1--- TYPE OF TRANSPORT: AMBU HER — STATION 1(A)_2(8)_3(C)._4(D)_5(E)- 4:1z C y 7 INCIDENT LOCATION: �„FTS, 57_AT_ 01,1 RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOJC) ��-- L TO SCENE- 18 S.O. CALL RECEIVED / 7 Q 1 Q CA✓-yr �.CJ+G' i 1 :', -�L�� ❑ P.D. TIME 10-8 /1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 111 i END TIME 10.98 'DOCTOR''; PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST-:' ❑ FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHERCALL BACK#: AMBULANCE Compff: AN c a PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES. ❑ NO ❑ WALKED O GUERNEY ❑ OTHER q PATIENT CONDITION: DRIVER r - e " EMT-1A ! TECHNICIAN U 'bARAMEDIC V Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REA N FOR DRY RUN I O -Z Z nK->_r C j=-I-) (/y - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) O S �� VA . ( ' PATIENT REFUSED SERVICES:(SIGNATURE)X X99 .. . ('} MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: C(` S.S. # r PRIVATE INS.CO.: BASE RATE: KAISER 0, MULTIPLE PTS.BASE RATE BLUE CROSS 0: " ' TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#:] ' EMERGENCY RUN: MEDT-CAL 0: 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) �l -'EMPLOYER: OCCUPATION: OTHER: ADDRESS: ' CITY: - STATE: ZIP: "COMMENTS: TOTAL. 9_cc/.-- - PATIENT RECEIVED BY X J 1 CONTRA COSTA COUNTY AMBULANCE Q� PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N e CHECK OR FILL IN APPROPRIATE SPACES DATE: J PATIENT'S NAME _� L l ❑ M ❑ F COMPANY 0 ADDRESS ` ' -�' 1. C�t I/1//; [-Lf / l� AGE STATE ZIP 44(1 DOB ❑ Sn )DM ❑ T ❑ W ❑ O F C3 DRIVER'S LICENSE a ___._�__ PHONE_ ._��'-`� NATURE OF DISPATCH 14 f_ TYPE OF TRANSPORT: AMBULANCE D OTHER❑. _ __ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: . RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOK) (/(Atj\�;` � TO SCENE- S.O. CALL RECEI ❑ VED ` L. f j P.D. TIME 10-8 I: " PATIENT DESTINATION: _ FROM SCEN ❑ FIRE TIME 10-97 n r ❑ PSAP TIME 10-49 j 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 ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANY: _ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �v TECHNICIAN PARAMEDIC�--1 (. Hx: _ DISPATCHER: — CHIEF ISPATCHER: —CHIEF COMPLAINT i ` I I DRY RUN: 13 YES ❑ NO REASON FOR DRY RUN —.__—__ THORI ION F N EZ0=5-722 E LYJ ,7 PATIENT REFUSED SERVICES: (SIGNATURE) X 1= �,lf �� —: MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ., S.S. R PRIVATE INS. CO.: BASE RATE: r KAISER#: _ MULTIPLE PTS. BASE RATE — --^i -� BLUE CROSS M:_ TOTAL MILES: Ix MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r(B[� ❑ YES ❑ NO NIGHT: (19:00-07:00) LJ� CCHP/PPRP 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) 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) �Il•uFi EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL: 9L1 Oj PATIENT RECEIVED BY:X Provider rets". White /rd Pin; rope 5eturn ye,im rape t• VfSuhen DiT"i.47 (SIGNATURE) CONTRA COSTA COUNTY 1 _ AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: 57 PATIENTS NAME ❑ M ❑ F COMPANY 0 /. -' g2 7- ADDRESS AGE— CITY GE CITY STATE ZIP--- DOB—__ ❑ Sn J�V ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE 0 _ _ _.__-_- PHONE_,__-_--- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ __ _—_ __ STATION 1(A)-_.2(B)_3(C)_4(D)_5(E)_ INCIDENT L CATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) I y 7 o j� CJS TO SCENE- RO. — CALL RECEIVED (4 ❑ P.D. TIME 10-8 / L. . / PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 -41— ❑ PSAP TIME 10-49 , I� I MILEAGE: ❑ OTHER/PVT TIME 10-7 4- END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— 1 ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COMPANY: 7i1 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: l% RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER `�r -EMT.-I'A ' TECHNICIAN cr3 Nu tiAI !t{� PARAMEDIC - Hx: — DISPATCHER: a 1 i '11 L1 CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO • EASON FOR DRY RUN T ZATIO FOR DRY R N EMS,nUSE ONLY �J PATIENT REFUSED SERVICES: (SIGNATURE) X -� G e Ao.f- IZ� 77 _ y MEDICAL COVERAGE: INDUSTRIAL ❑ Y ❑ NO NO. OF PATIENTS: I ,B Ss. a r PRIVATE INS. CO.: BASE RATE: KAISER R; MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X I MEDICARE x: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP R: EMERGENCY RUN: MEDT-CAL M: 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) O 1 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - ___._.. TOTAL:_ �___._ PATIENT RECEIVED BY. X.___---.---_-_-. �i� rn�i nirl CONTRA COSTA COUNTY AMBULANCE , PRE-HOSPITAL CARE FORM I 'I UNIT AUTHORIZATION M 7 4-3 CHECK OR iICL IN APPROPRIATE SPACES DATE: / U PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE CITY STATE ZIP — DOB—__ ❑ Sn ❑ T ❑ W`❑ Th ❑ F ❑ S DRIVER'S LICENSE M __— ___-.---_ PHONE--_-_ .—____—._ NATURE OF DISPATCH_se �` �� • TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _—_- ___—__.. STATION 1(A)._2(B)_3(C)_4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME — (24 HOUR CLOCK) TO SCENE O. CALL RECEIVED r' le I �Q Z13_ `i r) ❑ P.U.— TIME 10-8 r PATIENT D STINATIOFROM SCENE ❑ FIRE -- TIME 10-97 :T_ �j ❑ PSAP TIME 10-49 :T_ MILEAG �OTHER/PVT TIME 10-7 END TIME 1098 DOCTOR PMD/ER START D TIME 1D-2� HOW CHOSEN: TOTAL i 7 y 3 ANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT 13DIRECT ❑ OTHER CALL BACK a: AMBULANCE CTPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER _\ ' PATIENT CONDITION: DRIVER_ 1 Z0 "f 1 EMT-1 TECHNICIAN .�k'4 1 `- MEDIC Hx DISPATCHER: s / c' I CHIEF COMPLAINT: DRY RUN:YYES ❑ 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: I i S.S. 11 1 PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO j ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP k: 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.) ( 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) mA PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ---- — TOTAL:------- — —..--•-_--.—. - — —.--_-.-.- -. _ PATIENT RECEIVED BY X -- ----._-- p...,,.i l.•r rte•..'.. (SIGNATIIIIF) •..• CON tRA COSTA COUNTY ,j;' AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IN APPR PRIA7E SPACES DATE: PATIENT'S NAME Z LL �?�=L)lvl- M ❑ F COMPANY M 5 C0171, ADDRESS 7S 12� P� 7L, -Te`r racc� AGE 3 ? l /CITY-CCIAYC.-7 (=ACLS STATE MN ZIP a- DOBG' ( ❑ Sn JX M= P. u O O F DRIVER'S LICENSE A __ PHONE NATURE OF DISPATCH LAC r TYPE OF TRANSPORT: AMBULANCE O OTHER❑ STATION 1(A)-218)_31C1_41D)_6(E)_, INCIDENT LOCATION: Nl T_2- RESPONSE CODE: 1 REQUESTED BY: TIME- (24 HOUR C�,O�CK) TO SCENE X S.O. 'N CALL RECEIVED a v ,97 _ 2 ❑ P.D. ME•10-8Q L... J PATIENT DESTINATION: FROM SCENE^ ❑ FIRE TIM60.97 ❑ PSAP TIME 10-49• MILEAGE: ❑ OTHER/PVT TIME 10.7 END -- TIME 10.98 A DOCTOR P.� PMD/0 START TIME 10.22 :=s-- HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT:TIME CALL BACK M: AMBULANCE COMPANY ❑ PATIENT ❑ DIRECT ❑ OTHER C •t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: '601 V RESPONSE ZONEZ YES ❑ NO ❑ WALKED 11 GUERNEY ❑ OTHER PATIENT CONDITION: -DRIVER ICA 7,4 2-10 EMT=1A TECHNICIAN OST It R 2—0 PARAMEDIC 1 L Hx: �'� t�� DISPATCHER: CHIEF COMPLAINT: E4LL. DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 0"S AUTHORIZATION FOR DRY RUN(EMS USE ONLY) y ' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES )�NO NO. OF PATIENTS: C� I S.S. M -74) IVATE tNSO': C(/I ICS Sc_c 7hr� �o Cvn.a r BASE RATE: - �'`/. KAISE� MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X. i (( MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ 1 �)(/`� ❑ YES ❑ NO NIGHT: (19:00-07:00) � - 05 I ✓`, EMERGENCY �I gypT._ ?CCHP/PPRP#: MEDI-CAL CODE(D/3 I L OTHER: OXYGEN: (PER TANK) P.Q.E. STICKER ❑ YES )ff 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: I-n re AA k RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 5 STATE-_ZIP: C-COLLAR:' (IF NOT REPLACED)* - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) - EMPLOYER: V OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: t-43 cl Lf �- W O t_n ()(i i s%Q r- TOTAL: 50 . PATIENT RECEIVED BY:X ora-! Provider nta?r. White .rd F4*.i eopr ,4etum Ye:Ivu �npy t7 SIS when bikPW.NATURE)ing f r C k CONTRA COSTA COUNTYI AMBULANCE e PRE-HOSPITAL CARE FORM I I E: t UNIT p AUTHORIZATION# ffu CHECK OR FILL INAPPROPRIATE SPACES DATE: u_ /^ , (Q C/ PATIENT'S NAM//E Mire,y�� 1 r L AM OF COMPANY# (J ADDRESS /0 a AGE CITY'-# R I c/r>t. STATE CA- ZIP 9 y°RYU l DOB�?'��7-y� ❑ S yu M O T ❑W ❑ Th O F O S Mk.$3, Qp ,/ DRIVER'S LICENSE# — PHONE -47L� NATURE OF DISPATC► ('70 P fd L/CTjp. TYPE OF TRANSPORT: AMBULANCE 19,OTHER❑ STATION 1(A)._2(B)_3(C)_4(D)_5(E)___.• INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR TO SCENE- S.O. CALL RECEIVED � ❑ P.U. TIME 16.8 PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10-97 : U •' I ❑ PSAP TIME 10-49 aE�-? y J _ MILEAGE: ❑ OTHER/PVT TIME 10-7 f• END 1*22 TIME 10-98 DOCTOR L-131G 1L f C�-M START- 0� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY. O TRANSFER WAIT TIME 0(PATIENT O DIRECT ❑ OTHER J CALL BACK#: AMBULANCE 9OMPANY: } C'. PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL'<ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER/ f "� /lE T�IA ^� V, S,pk' T CHNICIAN GQj4 L [.ArV 6 0 A M �7 �x fRyc k 45 (/?-,'V 085ECT fo cFA'GtDISPATCHER: CHIEF COMPLAINT: 14 &AP nAIA, DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) J PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES KNO NO. OF PATIENTS: /� ��•� PRIVATE INS. CO.: BASE RATE: ��-� j' KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: 3 X l, SU 7 y -••• MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO i ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: CODE 2 r/3 OTI ER: 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 _ FIF�p DRUGS: (PER ADMIN.) X NAME:PAVLE I f( OANGE� RELATIONSHIPALI EE.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) i� CITY: STATE-_.ZIP: C-COLLAR: (IF NOT REPLACED) - - - �'��� PHONE:,-' 5 /0 WORK PHONE: DRY RUN: (AUTHORIZED) I EMPLOYER: __ OCCUPATION: OTHER: - -- ADDRESS: CITY: STATE: ZIP:- -COMMENTS: IP:-COMMENTS: - J�\ TOTAL: _ PATIENT RECEIVED BY:X / •L`C (SIGNATURE) Provider retain White rrd r•ir: nip} .4etu>* YF'1uu mp. t• ENS when biZ'inQ CONTRA COSTA COUNTY - AMBULANCE ;; �,Z"7 PRE-HOSPITAL CARE FORM 1 I •� 1 UTHORIZATION N CHECK OR FILL IN APPROPRIA It,SPACES - h, fa.. PATIENTS NAME eM ❑ F COMPANY 4 ��'ADDRESS M O iti, }}�, �� AGE CITY��((ll! •v STATES..(.i._�_ ZIP D08���( O Sn M O T.O W O OF DRIVER'S,LICE SE Mrd_ K —�-- PHONE NATURE OF DI•SPATCH U40G dd — S'll•Al AAA TYPE OF TRANSPORT:. AMBULANCEHER _ STATION 1(A)_2(B)_3(C)_4(D)_5(E) ' A ' 1 ! 4 I INCIDENT LOCATION: RESPONSE COD R QUESTED BY: TIME—(24 HOUR LOCK) C , (� TO SCENE`:L 0. CALL RECEIVED L cJ 3 ❑ P.D. TIME 10-8 "j Z' PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME LL ,.r t N J JYY1 PSAP ': �TIME_10-4?IADj MILEAGE: ❑ OTHER/PVT�;.•! TIME 10-7 END -►kov TIME 10.98 ! DOCTOR ,e PMED START ' S _TIME 10.22 •� HOW,.�CHOSEN: 1313TOTAL -n 1 STANDBY IME �' NEAREST FAMILY TRANSFER _ I WAIT TIMEA� j •' ' IENT ❑ DIRECT 13 OTHER CALL BACK M: AMBO IC AANY:'' !i''•' • PT. AMBULA ORY? PATIENT TAKEN TO AMBULANCE; RESPONSE ZON 13 YES 1(0 ❑ WALKED GUERNEY OTHER':L-&'e'1- PATIENT CONDITION: DRIVER b )30 EMT+1A' f TECHNICIAN �"� 39o.PARAMEDIC"' -` ' DISPATCHER: � •• r CHIEF COMPLAINT: DRY RUN: ❑ YES R NO REASON FOR DRY RUN i (r ? AUTHORIZATION FOR DRY HUN(EMS USE ON�r). ( � 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS: fqt S.S. M' 3- 33 3C)34 /� PRIVATE INS. CO.:1�an ;) urs T BASE RATE: KAISER M; MULTIPLE PTS.BASE RATE n'1 T f"l BLUE CROSS M: TOTAL MILES: X '� f MEDICARE M: E.O.B.ATT. ROUND TRIP:— ❑ YES • ❑ No' , f O YES ❑ NO NIGHT: (19:00•07:00) ��IR J CCHP/PPHP M: EMERGENCY RU ' iM� C 1 +� �yiI�JQ � MEDI-CALM: CODE 2/ rs ,.,�. ..: OTHER: OXYGENS (PE LANK) I P.O.E. STICKER ❑ YES ❑ NO 1 NEONATAL: (INCUBATOR)Tk`?I aw' ', 7. DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) " NEAREST RELATIVE/RESPONSIBLE PARTY: "" I.V.: (PER ADMIN.) DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP* E.O.A'(IF NOT-REPLACED)•'"'-AA`Im�" "IBM& ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) • '•' CITY: STATE_ ZIP. C-COLLAR: (IF NOT REPLACED)}•"". PHONE: O R K PHONE: 3 -67 0 DRY RUN: (AUTH09IZED) r 1 fly V tr :I. . . 1 "i . �.�-,..,• y.. ; EMPLOYER-Da"' 3 ��` LOUCUPAI'IONc OTHER'" ADDRESS: 1530 r7 kW, D i P $I V�c� • ,c: 5•G0 I I CITY:w► n - -STATEi.g&_ZIP-L.' - - '•'a"""'^"".i _ COMMENTS: - -- - / i:. A. TOTAL: PATIENT-RECEIVED Bel "-'C_ Provider air Vhite and Pink copy Aetw" Ye:2w copy t.• DKS I�Aen blt:{n0 •� •�jtc�81(iNATURE) ,wi'r� PMh15-t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ' UNIT AUTHORIZATION N CHECK OR FILL IN APPRO Rune SPACES DATE: PATIENTS NAME ` M ❑ F COMPANY N' ���' r ADDRESS AGE12 _ CITY STATE ZIP— DOB--_ ❑ Sn kM OT ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE --_-----.__-- NATURE OF DISPATCH /N F17/ CAL TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ ... STATION 1lA) 2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: 3PD. OUESTED BY: TIME — (24 HOUR CLOCK) r Y /� / / r�f� /C •I TO SCENE - S.O. CALL RECEIVED . :1 !+ TIME 10.8 �'- PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �./ ❑ PSAP TIME 10-49 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 r END TIME 10-98 DOCTOR - PMD/ER START TIME 10.22 1 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 7 1. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_! l:A 'NAM ' ' EMT-1A TECHNICIAN I/i C_� w��L Nl r ZOIC Hx: DISPATCHER: )l -" ' ! CHIEF COMPLAINT: DRY RUN YE ❑ NO REASON FOR DRY RUN T'. 61 r✓rA �- �� AUTHORIZATION FOR/DRY RUN (EMS US 0*Y) PATIENT REFUSED SERVICES: (SIGNATURE)X 4�tv ,q , c,& 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 N: 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 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) _13 EMPLOYER: OCCUPATION: OTHER: ADDRESS: ' CITY: STATE: ZIP: COMMENTS: TOTAL. —.— —_ PATIENT RECEIVED EKY X (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATI N M CHECK ON FILL IN APP rE aPAcra DATE: PATIENT'S NAME OM OF COMPANY N ADDRESS" ( j z AGE~ l , "V CITY STATE ZIP DOB - ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH 447/7—_kr egn her- TYPE erTYPE OF TRANSPORT: AMBULANCE 15 OTHER 0 — STATION 1(A)._2(B),31C)_4(D)_5(E)_ INCIDENT LOCATION:r - RESPONSE CODE: R�EOU�ED BY: TIME— (24 HOUR CLOCK) TO SCENE- S`O CALL RECEIVED I L4610 �,qn o ,t%) ❑ P.D. TIME 10-8 a!` PATIENT DESTINATION: --! FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 S DOCTOR't` " I PMD/ER START TIME 10-22 :J� HOW CHOSEN: TOTAL STANDBY TIME X11 ;__❑ NEAREST,,; ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: A . PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A ?v Z ! T ` �© �''TG CJ rAAAME ECHNIC;AN DIC OD Hz: DISPATCHER- 6 J Llgq CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN b AUTHOR? TION 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 N: 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/RPHP 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) --EMPLOYER:- OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X.__..__ _ i.- (9K1NAlkinF) 1 . CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION M 2P 3 - Xf1Q %'( CHECK OR FILL IN APPROPRIATE SPACES DATE:-_ y - Z Y 1 t PATIENTS NAME 7 ❑ M OF COMPANY M ADDRESS o K JC b( /7 AGE , C R ? CITY " STATES— ZIP DOB '❑ Sn ❑ ❑ W O Th OF OS DRIVER'S LICENSE N _ PHONE — _ NATURE OF DISPATCH fm 4 4_ . / i TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION 1(A)_2(B)_31C1,4(D)_5(E),_ j I INCIDENT LOCATION:, RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOCK) 3 TO SCENE .0. CALL RECEIVED r•c� ,L r� I�Zb T; C�lroN 1t -�-la O P.U. TIME IOB /-� PATIENT DESTINATION: FROM SCENE, ❑ FIRE TIME 10-97 r Q ❑ PSAP TIME 10-49 T MILEAGE: ❑ OTHER/PVT TIME 10-7 END y- TIME 10-98 - DOCTOR ' PMD/ER START d r<i 4 TIME 10-22 _ HOW CHOSEN: - TOTAL STANDBY TIME ❑ NEAREST, O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: L•rr � r Z _ PT AMBULA•rORY? PATIENT TAKEN TO AMBULANCE: 5'f0 RESPONSE ZONE ❑.YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: ) DRIVER rig. It ciri' 1 EMT-l' /Z 1 TECHNICIAN R Llj.-a :5 PARAMEDIC Hx: DISPATCHER: �EL- t'jC' CHIEF COMPLAINT: DRY RUN:t YES ❑ NO REASON FOR DRY RUN-10 2.1- r, tZaCStt><t 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 C MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M:' EMERGENCY RUN: MEDI-CALM: CODE 2/3 IOTHER: 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: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) cr EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _. TOTAL:— Vr` __________._ PATIENT RECEIVED BYX __ i CONTRA COSTA COUNTY AMBULANCE .I C7-2- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N . ... . . . , � CHECK OR FILL IN APPROPRIATE S ACES DATE: ago1 I Art PATIENT'S NAME ❑ COMPANY M ADDRESS - h A 2f M ) CIT 7 L � � CCil 1 a E •. U •� 0TSTATSn ■ yew wIP hl 13 FCO S DRIVER'S LICENSE K _._______._..____..._.�_.� PHONE 313L- NATURE OF DISPATCH � 1 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CK ' TO SCENE- i CALL RECEIVED. R �I ❑ P.U. TIME 10-8 ' '.` PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �(1 ! ❑ PSAPTIME-10-49 - MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98�� • � DOOTOR _ PMD/ER START TIME 10-22 HOW CHOSE TOTAL I STANDBYTIMEi _� ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT 11 OTHER CALL BACK M: AMBULANCE CO A +1 f PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i 5l0 RESPONSE.ZON ❑ YES ❑ NO ❑ WAL`:ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER ,��E T-1A •' r1 AMTECHNICIAN 2 RAMEDIC I Hx: f _ _4,IVAVISPATCHER: CHIEF COMPLAINT: RY RUN, YES ❑ NO REASON FOR DRY RUN AU OR ATION F DRY RU EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X - MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: J�S' 14, S.S. # PRIVATE INS. CO.:— ' BASE RATE: - KAISER#: MULTIPLE PTS. BASE RATE I' ' x(`:' `�� ' . '-�-1 BLUE CROSS#: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YeOR) '.r.0 t ❑ YES ❑ NO NIGHT: (19:00-07:0 .' CCHP/PPRP q: 'EMERGENCY RUN: I,'._C;'; MEDI-CAL p: CODE 2/3 OTHER: OXYGEN: (PER TA 31'� :•JP.O.E. STICKER ❑ YES NO NEONATAL: (INCUvDATES BILLED: STANDBY: (OVERE.K.G.: (PER EPISONEAREST RELATIVE/RESPON IBLE PARTY: I.V.: (PER ADMIN.) XDRUGS: (PER ADM . X I NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT RE LACED) CITY: _ STATE--ZIP: C-COLLAR: (IF NOT REP ED) ^� PHONE: WORK PHONE: DRY RUN:-(AUTHORIZE -- - EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP _ . r COMMENTS: TOTAL: i PATIENT RECEIVED BY:X' (SIGNATURE) • . r - Provider retain Phite cnd Pink copy Return Ye'Zov copy t+ VfS when bi1Zinp CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# Z CHECK OR FILL IN APPROPRIATE SPACES DATE: r PATIENT'S NAME-BAlA M O F COMPANY IV ADDRESS y/ t o SS z c Q. AGE 1 _ CITY STATE ZIP c?el7o 3 DOB, O Sn ❑ M�WT ❑W ❑Th ❑n F ❑S DRIVER'S LICENSE# _ - ...—. ----- - --- PHONE 1 �yCv NATURE OF DISPATCH .5F TYPE OF TRANSPORT: AMBULANCE V OTHER O __ _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLO�C) .. /C -� l I TO SCENE- S.O. CALL RECEIVED � 175� �� n� IN , � � ❑ P.D. TIME 10 8 ' �S PATIENT DESTINATION: FROM SCENE-,L_ ❑ FIRE TIME 10.97 ❑ PSAP TIME ID-49 S: a ( Y' MILEAGE: / ❑ OTHER/PVT TIME 10.7 _\ END TIME 10.98 DOCTOR — 'U`JZR. PMD/ft START ,�'z TIME 10.22 - -- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER l �`= � CALL BACK#: AMBULANCE COMPA PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 RESPONSE ZONE YES O NO ❑ WAL!,ED GUERNEY ❑ OTHER �( PATIENT CONDITION: DRIVER_QL n EMT-1A 1 > TECHNICIAN '�-Gu �07� PARAMEDIC Hx: v�� 2�1J"ter RE_LF.Et_L 004 - DISPATCHER: CHIEF COMPLAINT: 5 f/ un F _ DRY RUN: ❑ YES ;WNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ } MEDICAL COV RAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. Q3 - &Q 9 G 50 _. ., PRIVATE INS. CO.: ;.fid 14 L- BASE RATE: KAISER#: _ MULTIPLE PTS. BASE RATE G, ..-T,J TJ• BLUE CROSS k TOTAL MILES: X - MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ONO ❑ YES ONO NIGHT: (19:00-07:00) J CCHP/PPHP#: EMERGENCY RUN: cj -1 MEDI-CAL k: CODE 2/3 _ ��•�%. OTHER: OXYGEN: (PER TANK) c" ' P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) I( E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X nn.. DRUGS: (PER ADMIN.) X NAME:C 1Z-L5 �L- RELATIONSHIP:.'—I E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONOZLI DRY RUN: (AUTHORIZED) EMPLOYER:/AAAGr3 L--1t)T OCCUPATION: OTHERi' ADDRESS !�5 7 _3 0 U CITY: 19 A WANT CP 4 f� STATE: ZIP: COMMENTS: TOTAL: "5 Sc_ RECEIVED BY:X S AURE as-1 Provider nru:r. white vrd M'r.% ropp hotur+i ye'1�,�� ..npp t C1v� when bi1'ing V/ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N IC CHECK OR FILL IN APPROPRIATE SPACES DATE:_--l )- ( - PATIENT'S NAME,___.___ � � S��J. -- ) Cl M ❑ F COMPANY a ._ I �. ADDRESS ---- - --- -- - _- AGE --- 1 (�►. CITY_ STATE. __ ZIP____.__-_.. ._ _ DOB ❑ Sn ❑ M T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE p _.____ . PHONE NATURE OF DISPATCH/� ) TYPE OF TRANSPORT AMBULANCE ❑ OTHER❑ INCIDENT LOCATION RESPONSE CODE EOUF.STED BY: TIME - (24 HOUR CLOCK) C F TO SCENE - 5 0 CALL RECEIVED 1t_�- 1l L ❑ PD _ _ ______. TIME 10-8 c ' ,c` 1 PATIENT DESTINA ION. FROM SCEN Cl FIRE ____ -.._ TIME 10-97 ❑ PSAP TIME 10-49 ------ 4- MILEAGE: 4- 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 ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANC GO PANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �1(^J RESPONSE ZONE ❑ YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION DRIVER'_ __ TECHNICIAN _.�i _"_ �:� ^`•�r-"PARAMEDIC Hx: ----- - --. ----- DISPATCHE ,.._ l_t f_�-�-- �' - f - - - ( CHIEF COMPLAINT: __1`�__L` ___�__�_�..��_._�______..-. DRY RUN YES ❑ NO REASON FOR DRY RUN—A AUTHORI WFOR DRY RUN(EMS USE UNLY) PATIENT REFUSED SERVICES (SIGNATURE) X-________.__---_.__-.___-_._ MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: .-______ .___--___- S.S a� - - - -- --- --- PRIVATE INS. CO.:___ --_--_-__- -_ BASE RATE: KAISER x'' — MULTIPLE PTS. BASE RATE BLUE CROSS#:__-- - -- ----------. TOTAL MILES: - -- - - ------ X -- MEDICARE a: _-_ -- __..— E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19.00-07.00) 1 CCHP/PPRP#: -_ _ EMERGENCY RUN: MEDT-CAL a:— __ CODE 2/3 OTHER: _ _.. OXYGEN: (PER TANK) P O.E. STICKER ❑ YES ❑ O NEONATAL: (INCUBATOR) - DATES BILLED: STANDBY: (OVER 15 MIN.) E.K G.: (PER EPISODE) NEAREST RELATIVERESPON--_ IBLE PARTY: I V.: (PER ADMIN) X DRUGS: (PER ADMIN.)_-. -_ _X -_-_- NAME:-_-__-_-__-_. _-- _.� -.-___- RELATIONSHIP:_ ___ ._.. E 0,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'-------_. COMMENTS: --- ------ ------- ----- ------"- -- --.- -- ---- -- - .. TOTALrZ� -- - -- I'Al IE NT fit CIFIVI D BY X I ret , (';I(.NA.I ORE) I / CONTRA COSTA COUNTY AMBULANCE 3 ! ' s t•.' 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M -- `"- CHECK OR Flll IN APPROPRIATE SPACES DATE: Q PATIENTS NAME ❑ M ❑ F COMPANY k ADDRESS AGE CITY STATE ZIP DOB—.—_ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M PHONENATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _ STATION 1(A)_2(B)._3(C)_4(D)_5(E)_ INCIDENT LOCATION: •, I'-j RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) \ \` \ I I Z r TO SCENE- CJ S.O CALL RECEIVED It E J ❑ P.U. TIME 10-8 - 1 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 J HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER I /' CALL BACK q: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: _:r RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER' !A / `-I < << I S '^ EMT-1A ) TECHNICIAN 1 ' PARAMEDIC Hx: DISPATCHER: ) L- - (.. 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: S.S. M PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE T BLUE CROSS M: TOTAL MILES:-- X MEDICARE I►: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO y� ❑ YES ❑ NO NIGHT: (19:00-07:00) _ CCHP/PPRP N: 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.) 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: 1 CITY: — STATE: ZIP: COMMENTS: TOTAL:.12 ____-- PATIENT.RECEIVED BY: X (SIGNA TUBE Provider nkii r, whit, r( h(•• tp 5,•f:,.- ,.u.. ;,•I„.: 1,i i•rr ) ��• 1 l CONTRA COSTA COUNTY AMBULANCE �, 7. PRE—HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# 3 0 3� CHECK OR FILL INAPPROPRIATE SPACES GATE: .______C PATIEN S NAME_.---__-- _-. _--- - -- E3M ❑ F COMPANY a /�1 ,.-- - ADDRESS - -- - -- AGE _ I "I 1 Ir CITY..—__ STATE-_.--- ZIP___-_.____- DOB------ _-_. ❑ Sn OM OT ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE # __--_ _ . . PHONE . _-...._ A,j` OF DISPATCHS�1 L C 1 TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION RESPONSE CODE. EOUF.SiED BY TIME - (24 HOUR LOCK) TO SCENE - O. __.____._. CALL RECEIVED ---- -- ❑ PU - —. TIME 108 PATIENT DESTINATION: FROM SCEN - ❑ FIRE __._-__ TIME 10-97 -_ ❑ PSAPTIME 10 49 - MILEAGE: ❑ OTHERiPVT TIME 10-7 END TIME 10-98 DOCTOR _ _.- _ PMD/ER START _—__ TIME 10-22 J r HOW CHOSEN. TOTAL _- _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER _—____ WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER �� CALL BACK#: AMBULAN E OMPA—NY - PT AMBULATORY> PATIENT TAKEN TO AMBULANCE: �y�;' RESPONSE ZONE- r ❑ YES ❑ NO ❑ WAL',ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER___& ii_� ii TECHNICIAN PARAMEDIC Lf 1 11 Hx: �I�� `,`� ���_ i�� I ( 'L �_ DISPATCHER: CHIEF COMPLAINT: I_I I' s DRY RUN: YES ❑ NO REASON FOR DRY RU AUTHORIZATION FOR DRY RUN (EMS USE UNLY)_ 115 �5 ��✓ r-j PATIENT REFUSED SERVICES (SIGNATURE) X.--.- MEDICAL .__._MEDICAL COVERAGE. INDUSTRIAL Cl YES 1�1NO NO. OF PATIENTS S S. # —� —-- - -------- - PRIVATE 1N67-6 .: BASE RATE: KAISER #: _- MULTIPLE PTS. BASE RATE --- BLUE CROSS#- —__`_— TOTAL MILES:__ -___-- X MEDICARE #. --- __E.0 B. ATT. ROUND TRIP: O YES Cl NO ❑ YES ❑ NO NIGHT: (1900- 07.00) CCHP/PPRP#: —____--______ _______—__ EMERGENCY RUN: _ ( MEDI-CAL#: _ ___--___ __ CODE 2 13 OTHER: _ _. OXYGEN: (PER TANK) P O.E STICKER YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:- _- _ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATI /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: --. _-- _--- __---- -- -- ---- - - ---- ---- -- - TOTALv PAI LENT RECEivrn BY X 1.,,.,L:,•: r•.•r., .1: •, r . (SIGNATURE) I 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 ;;R, INAPPROPRIATE CHECK OFIIL SPACES DATE: I PATIENTS NAME me n n e _ Q'��� - DQ D F COMPANY k ADDRES AGE V CITY STATE ZIP_ _ b-_ OOB-7-aS_�'/` ❑ Sn ❑ M T ❑ W ❑ Th F ❑ S I DRIVER'S LICENSE N _ l O.._. PHONE_ 3.5_,.`l Q! ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑rIle INCICOENT LOCATION: RESPONSE CODE: PEOVESTED BY. TIME- (24 HOUR�}LO/C,K) _ it TO SCENE- 2 O. _ CALL RECEIVED t�1,\1 A E 10-8 PATIENT DESTINATION: (}� FROM SCENE- ❑ FIRE _ _ TIME 10-97 3L O ❑ PSAP TIME 10-49 n O"' ?, `f• MILEAGE: n ❑ OTHER/PVT TIME 10-7 END_� SL—. TIME 10-98 "DOCTOR _ PM /ER START_). TIME 10-22 HOW CHOSEN TOTAL - STANDBY STANDBY TIME DEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �— <❑ PATIENT ❑ DIRECT ❑ OTHER 30CALL BACK N: AMBULANC C P NY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE µ. ❑ YES O ❑ WAL"ED�UERNEY ❑ OTHER --- PATIENT CONDITION. DRIVER �40 WTI _ TECHNICIAN EDIC Hz DISPATCHER (� ly J5 S CHIEF CO PLAINT: _fll2j _ DRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION F R DRY RUN (EMS USE ONLY). -_ l PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: _LL4DUSTRIAL ❑ YES)'NO NO. OF PATIENTS: S.S."_ � �� AC PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: 4 TOTAL MILES: �� X ✓ ��� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ICAR MI: / ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP x a t ��0. l.`�� / EMERGENCY RUN: MEDT-CAL N:Q 7Z-,2 015 3 s��,fJ� 3 CODE 2/3 OTHER: OXYGEN: IPER TANK) c1-1 07 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: fie _ - - - TOTAL PATIENT RLCFIVI D W X ---- - ---- --- -.. .-- -- �- -- - -- IS A+�I AFI • CONTRA COSTA COUNTY AMBULANCE y i PRE-HOSPITAL CARE FORM I UNIT Io� AUTHORIZATION N :% 1- ~ ..- LJ s CHECK OR FILL 1N APPROPoIIArE SPACES I DATE: t `-'' to M ❑ F COMPANY M 'i'AT(ENTS/NAME /� ' 1 ADDR SAM �l OJ M )C ST AGE A-' L) CIN ^'7 STATE _ I ZIP DOB ❑ Sn O M /R3 T OW O Th ❑ F ❑ S DRIVER'S ILICENSE 0 PHONE �_t�, NATURE OF DISPATCH JI'S 0 TYPE OF TRANSPORT:, AMBULANCE OTHER STATION t(AI_2(81_3(CI_4(D)_5(E1l� '.) INCIDENT LOCATION:i RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR%OgK)�� I TO SCENE- ❑ S.O. - CALL RECEIVED ❑ P.D. TIME ID y • .t` PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1�3? 1 (3PSAP TIME 10-49 c3� - "�� ) MILEAGE: OTHER/PVT TIME 10-7 L LrZ I t.. END 3 TIME 10-98 RDOCTORr +' PMD/ER START [)q_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME , ►�,O NEAREST•? O FAMILY �TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHERS CALL BACK M: AMBULANCE COMPACTS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I, RESPONSE ZONE_ YES ❑ NO' l- ❑ WALKED &GUERNEY ❑ OTHER r ) PATIENT CONDITIONS DRIVER t-) EMT-tA TECHNICIAN (r—��T� PARAMEDIC 1 Hx: DISPATCHER: CHIEF COMPLAIN T:�T� (��- AA' DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 ;IA_"!_t;} PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 4 S.S.4 — — — PRIVATE INS. CO.: BASE RATE: �t ' KAISER N: MULTIPLE PTS.BASE RATE OSS M: •" TOTAL MILES: X �_ pj EDICAR .^(d`'D `?a E.O.B. ATT. ROUND TRIP: OYES ❑ NO ��) f ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: 1 1 EMERGENCY RUN: MEDT- '_c:i) COO 91 &uuT:ztv_t!�� - CODE 2/3 n OTHER: OXYGEN: (PER TANK) !/ ( P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: 1 '�' 11 STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —'NEAREST RELATIVE/RESPONSIBLE PARTY: - - I.V.: (PER ADMIN.) X r ) DRUGS: (PER ADMIN.) X —• NAME:%4`.j�''J `-' -lam REL.ATIONSHIP41AA2 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: .�L TOTAL: 3 U PATIENT RECEIVED BY. Prot+idor retain Vhito vrd Pink no . koturn re:i✓u mo (SIGNATURE) LMS-1 PY iy t Ewt; uh�n Di lana CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N �+►� CHECK OR FILL IN APPROPRIATE SPACES �7 -"" � � DATE; PATIENT S NAME_1�-1��t"F�/ ❑ F COMPANY N �"O� ADDRESS t4 C . �(' 7 / C7 Ire AGE �� �1P CITY l,3 C STATE -� ZIP - DOB�9 s O sn Om OIT W"" 17 Th, O F DRIVER'S LICENSE M =sIZp PHONE }=��[1 NATURE OF DISPATCH ' �••..~•J TYPE OF TRANS ORT: AMBULANCE OTHER❑ _ STATION 1(A)_2(8)_31C1_41D)_51E)_I++�-- "INCIDENT LICATI�t! RESPONSE CODE: OUESTED BY: TIME—(24 HOUROCK �( 7 , TO SCENE ^,S.O. CALL RECEIVED Caw, + P.D. am PATIENT QESTINATION: FROM SCENE- rl ❑ FIRE TIME 10-97 ( )5`l (� ❑ PSAP /TIME_10.-4R cc c--N C ��14 �� MILEAGE: ( .,L ❑ OTHER/PVT TIME 10.7 END TIME 10.88 DOCTOR ,1 L- TC'_ PMD/ER START TIME 10-22 HOW CHOSEN: TOT ���(� STANDBY ME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME J ❑ PATIENT ❑ DIRECT .OTHER 4 PF_oPw119_T CALL BACK p: :AMBULANC COMPANY' �~+ ' PT MBULATORY? PA IENT TAKEN TO AMBULANCE: -- '_ (50 [RESPONSE ZONE YES ❑ NO �WAL'<ED ❑ GUERNEY ❑ OTHER T - t t'r.• PATIENT CONDITION: � � DRIVER (9 130 „EMT-1A j TECHNICIAN PARAMEDIC ~•�•�•� C�c)L ) Hz:�y�'. �L-t 5C DISPATCHER: CHIEF COMPLAINT: SJ =SU a WC DRY RUN: ❑ YES XKO REASON FOR DRY RUN " AUTHORIZATION FOR DRY RUN(EMS USE•ON�1 PATIENT REFUSED SERVICES: (SIGNATURE) X vvvn � MEDICAL�OV RAGE: INDUSTRIAL ❑ YES XNO NO.OF PATIENTS: S.S.M ,4 u! PRIVATE INS.CO.: BASE RATE: KAISER#: n •MULTIPLE PTS.BASE RATE t�,j •. � /�.' BLUE CROSS 1t: TOTAL MILES' x MEDICARE It: E.O.B.ATT. ROUND TRIP: ❑ YES ONO ;11 CAI; R.114 4 ❑ YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPHP p:- --- EMERGENCY RUN: „� MEDT-CAL N: CODE 2/'3 v��1a1(11')}� �'}(:] OTHER: OXYGEN:' (PER TANK) t fJ�1:Qia a`f"'c c'"f1X•"-'� r�.. P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ! (. 0 4 r DATES BILLED: STANDBY: (OVER 15 MIN.) . .- . E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) 7 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: +4'' , CITY: 'STATE. ZIP .. - - - - ._ ..•;,ter: COMMENTS: TOTAL: 011 `- •.9 ""`.'�! " V V( 1 PATIENT-RECEIVED BY!X \ Provider xtair. White v:d Pink cope Ratwrn fe:ivu ropy t+ M Ownn bit-ing (SIGNATURE) - i� i CONTRA COSTA COUNTY' �` AMBULANCE PRE-HOSPITAL CARE FORM I UNIT L� AUTHORIZATION M Y 3— Z Con CHECK OR FILL IN APPROPRIATE SPACES DATE: 3 PATIENTS NAME Z O M ❑ F COMPANY M ADDRESS _ AGE CITY TATE ZIP DOB -❑ Sn O M O T OW ❑ Th O F ❑ S ' DRIVER'S LICENSE 0 _ PHONE NATURE OF DISPATCH X"() - TYPEOFTRANSPORT: AMBULANCE:L5 OTHERO STATION I(A)_2(B),3(C)_4(D)_5(E)X INCIDENT LO ATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)- . �C����il WK�-"�, TO SCENE-31e Rr S.O. CALL RECEIVEDy 7 3 Y y°i 1 ❑ P.U. TIME 10-8 Ll 7 3 — PATIENT DESTI ATION: FROM SCENE - ❑ FIRE _— TIME 10-97 i 0 O PSAP TIME 10-49 � t/ry C?( M MILEAGE: ❑ OTHER/PVT TIME 10-7 �P I END TIME 10-98 .DOCTOR PMD/ER START TIME 10-22 U 2 `1� HOW CHOSEN: I TOTAL / \ STANDBY TIME P ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT, ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER S 61 PATIENT CONDITION:; ) DRIVER EMT-1A _ TECHNICIAN ` C PARAMEDIC Y Hx: Q?? A�f " 6'jl L)611 fi12f t511 iCC11C, DISPATCHER: - / FE � CHIEF COMPLAINT: DRY RUN: RYES ❑ NO REASON FOR DRY RUN e c ` . � Y AUTHORIZATION FOR DRY RUN (EMS USE ONLY) l 5� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N 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: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: n MEDI-CALM: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RE SPONSIBLE 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: '(A UTHORIZED) EMPLOYER: OCCUPATION OTHER: ADDRESS: CITY: STATE: ZIP:— COMM ENTS: IP:COMMENTS:' TOTAL: PATIENT RECEIVED BY' X . .;. (SIONA'1)RE► CONTRA COSTA COUNTY � AMBULANCE �7 c PRE-HOSPITAL CARE FORM I UNIT Z' AUTHORIZATION IY 1 ` b CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME 1 ❑ M O F COMPANY k 'Z c3`t i n l A v �3`� r ADDRESS �� DOAGE P CITY G STATECA( ZIP_ _ __ B3���L O Sn ❑ M O T �W O Th O F d S DRIVER'S LICENSE N ����"`_v y`_�_-- PHONE 5 t 7- �1 L NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE09 OTHER❑ __ _ .. STATION 11A)_2(B)_3(C)_4(D)_5(E)_ s INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) y 2-0 ���7 1 j 7� TO SCENE - XS 0. -- CALL RECEIVED I I A'/'- ❑'P U. TIME 10-8 :_L- PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 O PSAPTIME 10-49 I MILEAGE: ❑ OTHER/PVT TIME 10-7 I �i O ' END�. .�� TIME 10-98 DOCTOR PMD/6) STARTL--iL SI�ff- _ TIME 10-22 HOW CHOSEN: TOTALSTANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY: ^ S T AMBULATORY? &TIENT TAKEN TO AMBULANCE: RESPONSE ZONE_j I• YES ❑ NO WALKED ❑ GUERNEY O OTHER — PATIENT CONDITION: DRIVER W I EMT-1A CTECHNICIA G�`U PARAMEDIC Hx: S GL` DISPATCHER: CHIEF OMPLAINT: G DRY RUN: ❑ YES NO REASON FOR DRY RUN G AUTHORIZATION FOR DRY RUN(EMS USE ONLY) .r PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES �NO NO. OF PATIENTS: // . S.S. N PRIVATE INS. CO.: BASE RATE: . SER 11 ( Z'"f 5v MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: X ' MEDICARE 11: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL M: a-A Q CODE 2"13 / 1 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER ❑ YES ANO NEONATAL: (INCUBATOR) `,l ✓) 5 DATES BILLED: STANDBY: (OVER 15 MIN.) E K.G.: (PER EPISODE) NEAREST F�trLATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �J G DRUGS: (PER ADMIN.) X NAME: ! n , "C'\ RELATIONSHIPf Lie-1 E.O.A.: (IF NOT REPLACED) ! ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) �T CITY: -t.0-G STATE ZIP: C COLLAR: (IF NOT REPLACED) (" PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) J { EMPLOYER: ki p OCCUPATION: OTHER: ADDRESS: �' r.c •`� CITY: STATE: ZIP: `r'" t COMMENTS: - - -- - TOTAL - -- _- — PATIENT RECEIVEDHY X.J y (.LCC f'nrvidir tyta!r Vin r. n., (SIGpj►*UNF) tn�-f r. CONTRA COSTA COUNTY ' AMBULANCE G c� PRE-HOSPITAL CARE FORM I UNITn AUTHOR12ATION#7r� _ CHECK ON FILL IH APPROPRIATE SPACES DATE: /'/ 3 - PATIENT'S -PATIENTS NAME 0 r\, / " //L/ ❑ M ❑ F COMPANY k 1 I ADDRESS AGE CITY STATE ZIP DOB— O Sn OM ❑ T 4W ❑ Th ❑ F OS DRIVER'S LICENSE# — — _ PHONE —__ NATURE OF DISPATCH/lb L TJ ✓ to ( 17 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) /I TO SCENE- z ks O. CALL RECEIVED ' J U. TIME ta _! L_ N�y ❑ P. b I—L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1 ❑ PSAP TIME 10-49 U MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 I / HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPA A. , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 00 RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LA_/v aGIgMI'/ ' i , ` ' EMT-1A TECHNICIAN V N w t t /A M f P�,(� I � r' Hx: ___ ' - DISPATCHER I `~ CHIEF COMPLAINT: ( 1 / (� DRY RUN: ❑ YE�❑ NO REASON FOR DRY RUN N A :V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I 1PATIENT REFUSED SERVICES: (SIGNATURE) X. • MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. K PRIVATE INS. CO.: BASE RATE: I KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS X: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-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/RE PONSIBLE 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) -.vt) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _. TOTAL`SD^_ PATIENT RECEIVED BY: X_ „I r, ,; (SIGNA PURE) CONTRA COSTA COUNTY AMBULANCE log PRE-HOSPITAL CARE FORM I 1,NIT AUTHORIZATION IF CHECK On ILL IN APPROPRIATE SPACES DATE: ._ 7 i (� h PATIENT'S NAME_.. .. �::._c-1f11�._. � �� (•� �. ❑ M Cl F COMPANY q y ADDRESS ----- ---------- --- — - -- ----------- AGE CITY---_-.--- ------ STATE-----------. ZIP DOB ------ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑.F ❑ S DRIVER'S LICENSE p _._.. PHONE ..__ NATURE OF DISPATCH __.1111� �.-�"� TYPE OF TRANSPORT AMBULANCE 'OTHER❑ I GIDENT LOCATION RESPONSE CODE. UOUFS1'ED BY: TIME - (24 HOUR CLOCK) TO SCENE - S O. . .._ . . . CALL RECEIVED �z'�cs_ �._.1J�J �P.L) - - -- TIME 10-8 �• 1 PATIENT [6ESTINATION FROM SCENE - ❑ FIRL _-_- ..._. . TIME 10-97 ��- -.__-- ❑ PSAP TIME 10-49 i Q•• --------.-- - ___ ___-_.._ MILEAGE: ❑ OTHER/PVT TIME 10-7 :-- END.____-._________. ____._.-_._— TIME 10-98 DOCTOR PMD/ER START--. _._- ____—_ TIME�10-22 HOW CHOSEN: TOTAL STA�BY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER ___-__ WAIT T. IME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: -----------_.-LAS PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: J( ,) RESPONSE ZONE --. ❑ YES ❑ NO ❑ WAL',ED GUERNEY ❑ OTHER PATIENT CONDITION DRIVER...__.----- 4: _ .__Z TECHNICIAN_.._II 4 PARAMEDIC._L_--. Hx DISPATCHER- CHIEF ISPATCHER CHIEF COMPLAINT f( _ .___. DRY RUN: YES El NO REASON FOR DRY RUN 1 / ___. _ ____...___, AUT,110RIZ TION FOR DRY RUN�EMS USE I PATIENT REFUSED SERVICES (SIGNATURE) 1 MEDICAL COVERAGE: INDUSTRIAL Cl YES NO NO. OF PATIENTS: SS +� — -------- - ------ --- PRIVATE INS CO.:-___ ---___ -_-_� BASE RATE: KAISER p: .------ _—_ -_ MULTIPLE PTS.BASE RATE BLUE CROSS is __- TOTAL MILES: X -- MEDICARE a _____—__-__-_-_—_ _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (1900-07.00) j CCHP;PPHPq: .--------_.---------------- - _--- ---...- EMERGENCY RUN ----_ -- -. ------ / MEDT-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 RELATIVEiRFSPONSIBLE PARTY: I V.: (PER ADMIN.) ._.___ -_ X DRUGS: (PER ADMIN.).____ X NAME: _..__._._._..____.. RELATIONSHIP____-_ E O.A.. (IF NOT REPLACED) ADDRESS: .._... __.._.`.__..._ _..___._. - ......__.. ORAL AIRWAY: IIF NOT REPLACED) CITY ... . _ ...._.. STATE. ZIP:........__. C-COLLAR: (IF NOT REPLACED) --� PHONE WORK PHONE. . . DHY RUN: (AUTHORIZED) - - EMPLOYER. OCCUPATION.---- _...__..._ OTHER: ' ADDRESS:. ----= -- - --- CITY. — --- STATE:--- ZIP:----- ------- -- - --- ----- COMMENTS---- ._—_. ....------ -. - ---- - ------- - - - - - --- ---.— --- __ _. TOTAL.S'V. ....... - ---- - .... P-^I I( NI RECEIVED RY X fT••rl.CrI, n..-:, w (SIGNATORE) ` CON IRA COSTA COUNTY AMBUL NCE _ PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION a CHECK OR FILL INAPPROPRIATE SPACES DATE: S_.,]. PATIENT'SNAME_bIL/�'),1 OL L-C�Icc.t ._. M 13 COMPANYa_ - ADDRESS �'�.L- ... V""� / 1 AGE ZZ_ 0 0 I L C.G l �--= I • ._-_ _ STATE��-�- ZIP 1_�' __ DOAA�__ ❑ Sn ❑ {„1 ❑ T W ❑ Th ❑ F ❑ $ DRIVER'S LICENSE a ._ ___.._ /.' ~ ._ PHONE _- _ . __.___ NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE❑ OTHER❑ __.. .__.._ INCIDENT LOCATION: RESPONSE CODE: RE pUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE S.O. CALL RECEIVED '7 -- 0 P.U. TIME 10 8 s PATIENT DESTINATION: FROM ST—.-- ENE — ❑ FIRE TIME 10.97 - --"� — —.-- ❑ PSAP TIME 10-49 _____- MILEAGE: yC� ❑ OTHER/PVT TIME 10-7 >' 2 END ` !_' TIME 10-98 DOCTOR _ J�, ✓_ __ PMD ER START y2i_4? TIME 1022 HOW CHOSEN TOTAL - _ o - STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER i� WAIT TIME PATIENT ❑ DIRECT ❑ OTHER (_' CALL BACK a: AMBULANCE COMPANY: Cr/u1-.S PT AMBULATORY' PATIENT TAKEN TO AMBULANCE' RESPONSE ZONE ❑ FS Cl NO 40 AL"ED 1-1GUERNEY ❑ OTHER _ �_ to/C e PATIENT CONDITION. DRIVER_. -__ 14.r+ 15-40EMT-1A_ TECHNICIAN a- L.�i l��4n�1�3Q PARAMEDIC ✓ Hr - ---- ------ -------- DISPATCHER: �.� I w D � CHF C AINT -_._�. L��-,(,JI�U DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENfT REFUSED SERVICES: (SIGNATURE) X MEDICAL CO ERAGE. INDIA TRIAL ❑ YES t1g)NO NO. OF PATIENTS: PRIVATE INS. CO.: _ _ _ BASE RATE: KAISER x: _ MULTIPLE PTS. BASE RATE T BLUE CROSS a:- TOTAL MILES: X J �J MEDICARE a:__ ` ' E.O.B. ATT. ROUND TRIP: O YES ❑ NO r - ❑ YES ❑ NO NIGHT: (19:00-07:00) leJ CCHP/PPRP a:L' _�� EMERGENCY RUN: MEDT-CAL t+:_JVL)--,C-G(,ICODE 2/3 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 - )� f DRUGS: (PER ADMIN.)_ X NAME:!-1 +� _leS__ w__. !_�-. RELATIONSHIPIk 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:-- Q --- ----- - -- TOTAL:. PATIENT RECEIVED BY: X trnnidor rr ,:ic (SIGNATURE) whi,. 7!r. .•-f;i n: Y:'.":L' .nr FII.' uhrn tit i••j OMS-1 CONTRA COSTA COUNTY �'� t'i AMBULANCE �Q--�� 11 PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION ORA t 1peg aI !may - CHECK OF FILL INAPPROPRIATE SPACES DATE:lJ ` PATIENT'S NAME���._�"LL—��C���Q a M ❑ F COMPANY# n LQ 7 ADDRESS`_ I AGE -A-SA - CITY�1S�iL�Sf1C1L1__. STATKG,_ - ZiFq_qa A DOBqll� 13 S O M GtT O W O Th O F O S DRIVER'S LICENSE# __ PHONa..]-1__aL?ag,_ NATURE OF DISPATCH�iS� TYPE OF TRANSPORT: AMBULANCEg OTHER❑ STATION 1(A),2(B)_3(C 4(D)_51E1_.,^-- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,,I � TO SCENE- VS.O. CALL RECEIVED -23 :JG,n,.�L- L.( ` �- !� ----- c� ❑ P.D. TIME 10-8 PATIENT DESTINATION:' FROM SCENE - ❑ FIRE TIME 10-97 L� �v ❑ PSAP TIME 10-49 l•�l l"� L�Z��((__ MILEAGE: 11OTHER/PVT TIME 10-7 �^ END bo,l TIME 10-98, DOCTOR l('R` � S ER START , fl l ..a TIME 10-22 1 HOW CHOSEN: TOTAL f_qSTANDBY TIME :�:_ ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME --- -. ❑ PATIENT ❑ DIRECT 'OTHER CALL BACK#: AMBULANCE COMPANY: r- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE I(YES ❑ NO 'KWAL!<ED Cl GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 0 EMT-1 TECHNICIAN 0c))4— .�](� PARAMEDIC T DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES 9 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: el s.s. # , Sg aq PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE ., r BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO r ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C EMERGENCY RUN: 1.. �J•�LX MEDI-CAL#: CODE 2/3 y�-- OTHER: _ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I E.K.G.: (PER EPISODE) 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: CITY: � STATE' �y ZIP: -" COMMENTS:L��ee. 4n-���L�` lYS 1ZLIT�Y TOTAL: PATIENT RECEIVED BY:X Provider rata-*,. Whitr ir.d Pic:. ropp .;¢turn YY:iou Topp t LHS when DiI i7i (SIGNAT pS-1 Y1� CONTRA COSTA COUNTY AMBULANCE S- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N la ..,... CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME ri ❑ M ❑ F COMPANY N I ADDRESS AGE CITY— STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑�lW� gThh❑ F ❑ S � DRIVER'S LICENSE N PHONE NATURE OF DISPATCH `L J TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _� STATION 1(AI_2(B)_3(CI_4(D)_5(E)_ ` INCIDENT LOCATION: S f I RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) C�) (Q_ ' TO SCENE ❑ S.O. CALL RECEIVED L :� Q 9 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10.97 i , l _,..�- ❑ PSAP TIME 10-49 L) , YMILEAG ❑ OTHER/PVT TIME 147 END TIME 1498 DOCTOR PMD/ER START TIME 1422 HOW CHOSEN TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N AMBULANCE C MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER ''� // ' PATIENT CONDITION: DRIVER_hL�_l_ A),_ 1 ^` _� EMT-1A I TECHNICIAN t•�.)h _ LC_Ljo<lik« PARAMEDIC Hx: DISPATCHER: / CHIEF COMPLAINT,: cr �� } I I D DRY RUN:);�YES ❑ NO REASON FOR DRY RUN ' I `I ^_ AUTHORIZATION FOR DRY RUN(EMS USE-ONLY) PATIENT RE USED SERVICES: (SIGNATURE) X— MEDICAL GOVERAG INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: / ( S.S. k 7 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 ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP k: EMERGENCY RUN: i MEDI-CAL N: CODE 2/3 OTHER: -- OXYGEN: (PER TANK) P.O.E. STICKER ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RES ONSIBLE 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.— __. PATIENT RECEIVED BY: X —_—...•• Pnovidor "tu r• Vhf!., n1 !'i.. I. 5, (SIGNAL URE) oth +' CONTRA COSTA COUNTY AMBULANCE / 9 L PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 :•rte P- i y- �'' C49^`•^Q ' IN APPROMIATf fPACE3 k3- DATE; ' 'PATIENT'S NAME ti .S�I)/C% O M ��QF COMPANY M Z�d U ? 7�- ADORESS '� �ju0 �UOrfV�l� �D py AOELl ,—�/ CITY (C(#/v10 Ld STATE CA ZIPS DOB1��� .L O Sn OM OT OW P(Th OF OS DRIVER'S LICENSE 0 PHONE / v NATURE OF DISPATCH AAF 01 C A t. TYPE OF TRANSPORT:,AMBULANCE OTHER❑ — STATION 1(A) (B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) G r TO SCENE- 3 KS.O. CALL RECEIVED � : J . RUU3S 1'rt'-r or./OO P.O. TIME 10 8 1ZQcy ❑ FIRE TIME 10-97 Q r 1 PATIENT DESTINATION: FROM SCENE -3 I � O PSAP TIME 10-49 -�L :_I T MILEAGE: 0 OTHER/PVT TIME 10.7 l) _ END (mob TIME 10-98 �� 57 DOCTOR ' ' ft�TNi�K PMD START Sfft TIME 1022 HOW CHOSEN: _� TOTAL y STANDBY TIME aT-:':,I�(NEAREST_ ,: O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER 3 CALL BACK 0: AMBULANCECO fyQPj(VY: PT. AMBO TORY? PATIENT TAKEN TO AMBULANCE: C,'O RESPONSE ZONE L �- ❑ YES ( NO O WALKED GUERNEY O OTHER • PATIENT CONDITION:- DRIVER t L �rJ`� EMT-1A :►936.. ! TECHNICIAN�2�/HLT RN 6 1 C �G Hx: CfI—RRl_!� %�yPFRtEN!/oi.. DISPATCHER: I Q t /Jc�- (v o 9(, (� CHIEF COMPLAINT: S/AzA f or 6APA'I Q DRY RUN: ❑ YES. CKNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES A NO NO. OF PATIENTS: S.S.0 I PRIVATE INS.CO.: BASE RATE: "' 2JO'c4 ' KAISER X: MULTIPLE PTS. BASE RATE BLUE CROSS 0' _ TOTAL MILES: —j X Q)• ; �a� �� 0�� E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CHP/00H4 N:' I 1 EMERGENCY RUN: MEDT-CAL M: CODE 2/3 ' OTHER: " OXYGEN: (PER TANK) �� 67 P.O.E.STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) _ %•r� ll ✓ ��/ E.K.G.: (PER EPISODE) _NEAREST RELATIVE/RESPONSIBLE PARTY I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X `NAME: 1-05Y14- /1.oFr! - RELATIONSHIP: uN E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-- ZIP: C-COLLAR: (IF NOT REPLACED) - o PHONE:C 3 1 2 WORK PHONE: DRY RUN: (AUTHORIZED) `EMPLOYER: OCCUPATION: OTHER: ' / ADDRESS: <�� r r r� .� j/.•C! (r-"CITY: STATE: ZIP: V COMMENTS: /lid r c Pri4 o Ity'4/CAel l ` TOTAL: ' PATIENT RECEIVED BY: X Pmvidsr wtgi, whit, ,ted Yin; ,•.,Py hit�rn W'" •npy t lxc ,•har. !il'ivd Cr�•i �— CONTRA COSTA COUNTY AMBULANCE % PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME _ L ❑ M ❑ F COMPANY a// 1 I Z60 2_� ADDRESS AGE u AJ CITY STATE ZIP _ DOB_____ ❑ Sn ❑ M ❑ T ❑ W ❑ Th `O F 0 S DRIVER'S LICENSE # _.-._ -- _ PHONE__ �..__.___ NATURE OF DISPATCHS... 1in _ TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: 'c' I RESPONSE CODE: R UESTED BY: TIME— (24 HOUR CLOCK) Z TO SCENE - S.O. ___ CALL RECEIVED / —t •J _ __ P.U._ TIME 10-8 ' PATIENT DESTINATION. FROM SCENE -7❑ FIRE — TIME 10-97 ❑ PSAP TIME 70-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 DOCTOR PMD/ER START—C— TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER / CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE ❑ YES ❑ NO ❑ WACIED ❑ GUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER_ -- �_ �� EM - f TECHNICIAN_ 7 FDIC (I Cr Hx: � DISPATCHER: CHIEF COMPLAINT: IT DRY RULJ SES ❑ NO REASON FOR DRY RUN l(Sc/N Z E L S AUTHORIZATION FOR DRY RUN (EMS USE ONLY) /II PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICALCOVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 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 ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: 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: 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: I CITY: STATE: ZIP: COMMENTS: _ ---- TOTAL: PATIENT RECEIVED BY: X. !`rtntdnr ro!.:ic Ih,i .I - •• (SIGNATURE) .. 1 CONTRA COSTA COUNTY AMBULANCE c PRE-HOSPITAL CARE FORM 1 UNIT 2 2 AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: O V /l/v PATIENTS NAME ❑ M ❑ F COMPANY N /c) lL I c��tl ADDRESS AGE - . CITY STATE ZIP DOB _ O Sn ❑ M ❑ T OW JgTh ❑ F OS DRIVER'S LICENSE$ _ ___ _ PHONE________-.___ NATURE OF DISPATCH �dJ. �.4/i✓ ' TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- RS.O. __ CALL RECEIVED ❑ P.D._ TIME 10-8 �_ : - �•' 'PATIENT DESTINATION: FROM SCENE-O ❑ FIRE TIME 10-97 -• ❑ PSAP TIME 10-49 9`/ MILEAGE: ❑ OTHER/PVT TIME 10-7 ' I END TIME 10-98 DOCTOR PMD/ER STAR TIME 10-22 (, HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: . r . PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: to RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'(ED ❑ GUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER100 r1T-lA I TECHNICIAN /��d� �Z� PARAMEDIC ^/- Hx: DISPATCHER: CHIEF COMPLAINT: A/& ,,4,"l� A4)DRY RUN: YES ❑ NO REASON FOR DRY RUN /✓U A/r�:Nt C/.� U AUTHORIZATION FOR DRY RUN(EMS USE ONLY) IL L �^� I PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS.CO.: BASE RATE: I 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/PPRP A; EMERGENCY RUN: MEDI-CAL K: CODE 2/3 OTHER: OXYGEN: (PER TANK) 1 ' 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: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �— EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: LL TOTAL:,J�_.-_._ � 'A PATIENT RECEIVED BY: X Provider retcic Aire .-Yid Tin: (SIGNATURE) CONTRA COSTA COUNTY AMB LANCE r �� y i PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPA DATE: PATENTS NAME r alIA ❑ F COMPANY N / y ADDRESS AGE~ CITY - ' STATE—__ ZIP DOB ❑ Sn ❑ M ❑ T ❑ W Z`1 Tr❑ F E3 S DRIVER'S LICENSE N _ _ PHONE NATURE OF DISPATCH - TYPEOFTRANSPORT: AMBULANCE OTHER 0 STATION 1(A)_2(8)_3(C► 4(0)_5(E)_ / INCIDENT LOCATION:( RESPONSE CODE: REO ESTED BY: TIME- (24 HOUR CLOCK) r n' ) TO SCENE- NfS.O. CALL RECEIVED �Cd \ Qy{e! l"iG�P W� L�1 'L O P.D. TIME 10-8 PA TtNA1TOFl _ FROM SCENE ❑ FIRE TIME 10-97 O PSAP TIME 10-49 ry ► cam R p MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 OCTQq t PMD/ER STAR TIME 10 22 4L-4- 24- _v , CHOSEN: _ TOTAL STANDBY TIME c7i (3 NEAREST :, ❑ FAMILY ❑ TRANSFER r WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK It: AMBULANCE COMPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE:' 'RESPONSE ZONE ��¢¢ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ISsO ► "' TECHNICIAN ��� S� �5�� PARAMEDIC Hx: DISPATCHER: Z n(7 ;/ CHIEF COMPLAINT: zli ry DRY RUN: laYES ❑ NO REASON FOR DRY RUN s I 1 ' 1 AUT RIZATION FOR .DRY FV USE ONLY) `f ! PATIENT REFUSED ERVICES: (SIGNATURE) X -�t.�-�+e — qMEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF ATIENTS: S.S.N PRIVATE INS. CO.: _ BASE RATE: I KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES 13 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 ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPO ISLE 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::mac•` > PATIENT RECEIVED BY-X (SIGNA It IRF) CONTRA COSTA COUNTY AMBULANCE G � PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY 0 04 �1 ADDRESS AGE . I f CITY STATE ZIP_ DOB ❑ Sn OM ❑ T ❑ W K-Th ❑ F ❑ S �•r DRIVER'S LICENSE M1 _ PHONENATURE OF DISPATCH !!C/9T=er"/l YL11 l TYPE OF TRANSPORT: AMBULANCE❑ OTHE __ __.—_"___ ... F INCIDENT LOCATION: of RESPONSE CODE. REQUESTED BY: TIME— (24 HOUR CLOCK) ) TO SCENE- 2 — CALL RECEIVED •• ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 1049 MILEAGE: L ❑ OTHER/PVT TIME 10-7 _T END TIME 10-98 r DOCTOR. PMO/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME r, ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT O OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �lO RESPONSE ZONE ❑ YES ❑ NO O WAL`,ED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER C)C)2 EMT-lA� 1 I i _ TECHNICIAN N�/�E;� -L00 PARAMEDIC Hx: _� z Z _ 42 ��—� DISPATCHER: 4- C CHIEF COMPLAINT: �LQ1__ ��yh`L DRY RUI�i ; ❑ NO REASON FOR DRY UN i1^� 11 L/ AUTHORIZATION FOR DRY RUN (EMS USE PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. R PRIVATE INS. CO.: BASE RATE: r KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) .N CCHP/PPRP#: EMERGENCY RUN: I MEDI-CAL It: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVElRESPO SIBLE PARTY: I.V.: (PER ADMIN.) X f' DRUGS: (PER ADMIN.) X I 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: I ADDRESS: CITY: STATE: ZIP: ` COMMENTS: ! TOTAL: PATIENT RECEIVED BY X {� ni!r- r� L9; .., .. •, (SIGNATI){+E) CONTRA COSTA COUNTY AMBULANCE C 31 �r� PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# b / CHECK OR fill IN APPROPRIATE SPACES DATE: n PATIENTS NAME ❑ M ❑ F COMPANY# ADDRESS ' 7DIg- Yuo— - AGE1 C K'U AJ CITY STATE ZIP DOB __ ❑ Sn ❑ M O T ❑ W Th ❑ FF 11 S/ DRIVER'S.LICENSE# _T_ --_ PHONE________-__.__ NATURE OF DISPATCH-�1u�C{ C TYPE OF TRANSPORT: AMBULANCE 31OTHERO \ INCIDENT LOCATION: RESPONSE CODE: REQ STED BY: TIME- (24 HOUR CLOCK) 1-3 2 TO SCENE- � S.O. CALL RECEIVED 1L : � -J ❑ P.U. TIME 10-8 ,yL_ 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: ITOTAL 7o ISTANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE FMYA�NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: O RESPONSE ZONE � TT- ❑ YES ❑ NO ❑ WAL"ED ❑ GUERNEY ❑ OTHER —F_ PATIENT CONDITION: DRIVER—-I��u��.(0�►--��� EM7-1A TECHNICIAN rR C 1� t 2-15 ARAMEDIC Hx: n, DISPATCHER: 00 J CHIEF COMPLAINT: WV DRY RUN: gWES ❑ NO REASON FOR DRY RUN ��-a C Fly AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r-te 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#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND'TRIP: ❑ YES ❑ NO n ❑ YES ❑ NO NIGHT: (19:00-07:00) / 1 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) - CITY: STATE--ZIP: C-COLLAR: .(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) a EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: — —. - - -- TOTAL�'SZ� �' J --- - -- ------------_.---- --. PATIENT RECEIVFD BY X -- ,•. CON 1 RA C.(1:;1 A COUN tY AMBULANCE / PRE-HOSPITAL CAFE FORM I UNIT AUTHORIZATION M 1 CHECK OR FILL INAPPROPRIATE SPACES DATE: rATIFNT'S NAME I � / S O�M ❑ F COMPANY# ` ADDFjG�4 - � .h.._._ ^/h AGES_ /-;)-6 9 �l - CITYc__._ STATE.__.-.__ -- ZIPDOB. //_/Sl ❑ Sn ❑ M ❑ T' ❑ W Th OF O $ , DRIVER'S LICENSE # _.__.. . -_. _. PHONE � .-. (O NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC .5 OTHER❑ -_.__._- INCIDE T LOCATIO�— RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C�gCK) pcc, r7 1 / � ,y� TO SCENE - S.O. — CALL RECEIVED I 1 ^ ., S .___-�. _ --- �-(-/7'?7_q' __ ----- - ------- ❑ P.U. TIME 10.8 :e- I PATI NT DESTINATION: FROM SCENE -Z ❑ FIRE - TIME 10-97 ��, : io �,' ❑ PSAP 71 TIME 10 49 r - _ > ; 1 - --+J--/� MILEAG ❑ OTHER/PVT TIME 10-7 n/ END ��] TIME 10.98 •� ' DOCTOR `el STA PMD EF START TIME 10.22 HOW CHOSEN TOTAL;.._ __J'_ STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 11 PATIENT ❑ DIRECT ❑ OTHER -f CALL BACK#: AMI!!r COMPANY: PT AMBULATORY? [PATJENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE ES ❑ NO .WAL :ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER _!_ 100EMT-1A ' I ��-���� _ Cr. TECHNICIAN 1j� u1`Il1[ PARAMEDIC 1 Hx: L_-/.`�/T J UJ` .__4 �'J.. __�L '=_ DISPATCHER: 0`i' CHIEF COMPLAINT -__�___._. ._ .. - DRY RUN: ❑ YES-g NO REASON FOR DRY RUN / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) '�`7 • PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. (� NDUT IAL ❑ YES�NO NO. OF PATIENTS: S S �--- - PRIVATE INS. CO.: P___._._ �. __ _ BASE RATE: KAISER R: -= MULTIPLE PTS. BASE RATE BLUE CROSS# — __ ._ TOTAL MILES: y X e MEDICARE'#: _-___ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO h ❑ YES ❑ NO NIGHT: (19.00-07:00) L CCHP/PPRP#:____—_—.... - _ EMERGENCY RUN: i MEDI-CAL t1: _--- CODE 2/3 a OTHER: ___J-- 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 ElE_7t'l'JlJ_ DRUGS: (PER ADMIN.) X NAME: r,41rCl(71AELATIONSH1416_ E.0 A.: (IF NOT REPLACED) ADDRESS:.--_- r 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' - PATIENT REdEIVED BY: X frr.vidcr r�tJr. ;?flr v:' �dc f'� �" kr^ t.:.'i•:� (SIGNATURE) d1S-1 U) S� c, ' V / CON I RA COS I A COUN TY � AMBULANCE �+ L PRE-HOSPITAL CARE FORM I �� \. UNIT AUTHORIZATION M 3 Z CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME L_ � i \l 4 �'M `O F COMPANY N ADDRESS L (1/� _ ._ STATEZIP ` AGE J� 13 Sn O M O T O IW Pt:h,.,O. F 7..e..'._-�..- ' i .CITUOB DRIVER'S LICENSE to _____ —.____—_ PHONE— NATURE OF DISPATCH • ' ""I TYPE OF TRANSPORT: AMBULANCE❑ OTHER I _ _ I --- STATION 1(A)_2(B)_31C)_4(D)_5(E)___I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- 3 R'S.O. CALL RECEIVED ❑ P.D. TIME 10-8 - •: V'� PATIENT DESTINATION: FROM SCENE - FIRE TIME 10-97 L1�( ❑ PSAP TIME 10-49 V l MILEAGE: O 0THER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME -- O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER , CALLBACK IN: AMBULANCE COMP�IN 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ 51c) RESPONSE ZONE W ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER n _.1 PATIENT CONDITION: 4=— DI?RAT G r U _`O EMT-IA i)( IAN e-S I • ^--1 _ PARAMEDIC Hx: !� 'v 1HER:CHIEF COMPLAINT: L C°� YES ONO REASON FOR DRY RUN y�rAllv ZATION FOR DRY RUN(EMS USE ONLY) -PATIENT REFUSED SERVICES: (S G ATU MEDICAL COVERAGE: INDUST Al_IYES N NO. OF PATIENTS: S.S. p PRIVATE INS. CO.: BASE RATE: % KAISER p: MULTIPLE PTS. BASE RATE BLUE CROSS><: TOTAL MILES: X CI MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES O NO r�- nn O YES ❑ NO NIGHT: (19:00-07:00) 't 1 C CCHP/PPRP N: EMERGENCY RUN: fiMEDI- _ CODE 2/3 OTHER: V OXYGEN: (PER TANK) .E-STtCKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) , DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) .57•� �� 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) 15-49 w EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL: ��'✓� -- PATIENT RECEIVED BY:X ._, G•- Pnwidrr' nta:� Vhitr v i P(n' -,,r, Yr'iuu rnp. t EW7 whin bif'inp (SIGNATURE) DI/-I i CONTRA COSTA COUNTY AMBULANCE F3- Z // PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 (a(O 8/ 13 CHECK ON flLl IN APPROPNG fE SPACES DATE: / PATIENTS NAME Gj _ �/v.�- M ❑ F COMPANY p ADDRESS —.? AGE If t /n/ 1 O STATE ZIP Do CIT . ❑ Sn ❑ M ❑ T ❑ W X*Th ❑ F ❑ S DRIVER'S LICENSE M --_ ____ PHONE J 3q-._^_VV NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATIO RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O.---_ CALL RECEIVED 1 7 t ❑ P.U. TIME 10-8 PATIENT DESTINA ION: n FROM SCENE - ❑ FIRE TIME 10.97 NO3 _ _ ❑ PSAP TIME 10-49 Il MILEAGE: ❑ OTHER/PVT TIME 10-7 END_:___.�a� TIME 10-98 ] DOCTOR PMD START TIME 1G-22 HOW CHOSEN: ��,,// TOTA_L 2 ' STANDBY TIME ?, ' NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER r CALL BACK N: AMBWCOMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE__1 -- 26YES ❑ NO ❑ WAL!CED-12WGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-IA TECHNICIAIJ 7 L�.- a PARAMEDIC-- :aD� Hx: CVA . V •`I 6f 1,��- DISPATCHER: _1� n17� CHIEF nCQMPLAINt ) �2��L 1 DRY RUN: ❑ YES NO REASON FOR DRY RUN M AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAG S RIAL ❑ YES J NO NO. OF PATIENTS: S.S.M —� 1 RIVATE INMUC3U e /J 11-1 on�l�L- 06-5 BASE RATE: KAISER C MULTIPLE PTS. BASE RATE _ B >r: TOTAL MILES: 1 X G =''J /,:..;7y MEDIC_A E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) HPlPPHP p EMERGENCY RUN: MEDT-CAL k: CODE 2/3 OTHER: OXYGEN: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 r., DRUGS: (PER ADMIN.)_ X NAME: VP47-.�Z_ RELATIONSHIPS 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) EMPLOYER: � OCCUPATION: OTHER:, _ ADDRESS: J J CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: — - TOTAL PATIENT RECEIVED BY-X fSlrNA"InFI CONTRA COSTA COUNTY AmnULANCE Q > PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: 8 2 _ PATIENT'S NAME �C �--- ---------- ❑ Aq `R) F COMPANY# cj ADDRESS:ar So AGE- / CITY �,�-11J._C�.1---- STATEZIP`(' yU�__ DOB3_'�� ❑ Sn O M ❑ T ❑ W $(Th ❑ F 0 S DRIVER'S LICENSE PHONE�33.-q NATURE OF DISPATCH GrE r1 l _;,L>AKn • Hca. TYPE OF TRANSPORT: AMBULANCE OTHER❑ .- INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR C OCK) R(f) �1 TO SCENE �.0. _ CALL RECEIVED _ ❑ P.0 _ TIME 10-8 ( ~ PATIENT DESTINATION: FROM SCENE - ❑ FIRE _ TIME 10-97 1 n -- _ ❑ PSAP TIME 10.49 '\ 1 s `lJ --__ - MILEAGE: ❑ OTHER/PVT TIME 10-7 r � ( �. END �?y`a�7 TIME 10 98 DOCTORR 1 �P_ /ER START,6& TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK It: AMBULANCE COMPANY: 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE �!n RESPONSE ZONE 9YES ❑ NO Pf'��VAL',ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: 'DRIVER -s-.R_Al EMT-1A , `` 11 TECHNICIAN ), S PARAMEDIC 1/ (. Hx: V_ DISPATCHER: _�_LLI-� �L OO 4 1 CHIEF COMPLAINT: -..._Sly r�.0� _ DRY RUN: ❑ YES '�1,N0 REASON FOR DRY RUN _ --------- _. ---- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X ' MEDIC Aj-/CO/V�RAGE I�jUSTRIAL ❑ YESKNO NO. OF PATIENTS: J PRIVATE INS. CO. - BASE RATE: d0 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/PPRP#:_ _.__ _ EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER_ __-_._-_ OXYGEN: (PER TANK) , I1 f P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) r ' DATES BILLED: ---- __- STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r o`T`11 DRUGS: (PER ADMIN.) X NAME RELATIONSHIPLL_/�._I .- E O.A.: (IF NOT REPLACED) ADDRESS9�C�Y_ � � _ .. _. ORAL AIRWAY: (IF NOT REPLACED) CITY: T-) C ` STATE .._._- ZIP:__. .. C-COLLAR' (IF NOT REPLACED) PH0NE' � WORK PHONE._. _ DRY RUN: (AUTHORIZED) EMPLOYER: ___- __ OCCUPATION: _._ OTHER: " ADDRESS: CITY: ( STATE:--ZIP:_.__ COMMENTS:_I.)o_. �/._`�__T TOTAL: �.�9•�?� - -- -----� - --- sc-- _.__ PATIENT RECEIVED BY: X ry ..n n.^ (SIGNATURE) 4ksr F::'ing OMS-I _�O CONTRA COSTA COUNTY AMBULANCE `� PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION 0 �3 1� Z9!93 CHECK OR FILL IN APPROPRIArE SPACES DATE: Ll /'+� 3 --,n• PATIENTS NAME AA wit- A� 6u� O M F COMPANY 0 A� ADDRESS.1 I � ) -Q,2y AGE CITY STATE _ ZIP DOB 'N ❑ Sn O M O T D W VTh O F O S IIp DRIVER'S LICENSE M _ _ PHONEZz 1� ..��.��_ NATURE OF DISPATCH C `y L)CA C _ — IlIJ TYPE OF TRANSPORT: AMBULANCEg OTHER❑ __..._______._.—_.... STATION I(A)_2(B)_3(C)_4(D)_5(E) 1 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOAK) MJ q37 TO SCENE- 0S.O. CALL RECEIVED D P.D. TIME 10-8 : i IL PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Z ❑ PSAP TIME 10-49 f' / ) , . ILI - MILEAGE: pQ,��--//__ E2 OTHER/PVT TIME 10.7 -� EN'_ Curd,- _jX TIME 10-98 � :14/_ `-DOCTOR PMD8 START_17 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME i ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY:,-, S LPT AMBULATORY? PATIENT TAKEN TO AMBULANCE: .iRESPONSE ZONE YES Y�,( NO D WAL'<ED YGUERNEY ❑ OTHER ` _l PATIENT CONDITION: DRIVER. EMT-1A ) TECHNICIAN L-! ��� �-t ARAMEDIC 7 Hx: ` � DISPATCHER: Ia R:�F_ i s CHIEF COMPLAINT: _ CAW CT� DRY RUN: Cl YES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ) i PATIENT REFUSED SERVICES: (SIGNATURE) X �l MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: I • ' S.S. 0 PRIVATE INS. CO.: BASE RATE: Ila'ar/ KAISER M: MULTIPLE PTS. BASE RATE _ !ME TOTAL MILES: XDICARE `3�� - �� 37 A E.O.B. ATT. ROUND TRIP: OYES ❑ NO /O .-J1l❑ YES ❑ NO NIGHT: (19:00-07:00) dY CHP PHP EMERGENCY RUN: ' i DI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) ' P.O.E.STICKER O YES ❑ NO NEONATAL: (INCUBATOR) q 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: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: STATE: ZIP: ' COMMENTS: TOTAL:J yG'• � - PATIENT RECEIVED BY: X._-, _ PMVid0r rrtair• White lr.d Nr.k ,•,,I,p Aaturr (SIGNATURE) / CMS-I •�: t f?!:. uh.� !i! i n.� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION { CHECK OR FILL IN APPROPRIATE SPACES DATE: Z)rq/ PATIENTS NAME ❑ M F COMPANY N /f2 I ADDRESS _ Z C I Fl S ( ' AGE" ',1' A h e? CITY '�'-- t TATE(_-A. ZIP '� DOB 9/ ~S7 O Sn ❑ M ❑ T OWTE3h ❑ F S (C/'• '1'1('1Ci)!Lr DRIVER'S LICENSE 1t ___..._ PHONEI, _— NATURE OF DISPATCH( — r1�n TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ - STATION 1(A)_2(B)_3(C)_4(D)_5(E)_•...... INCIDENT LOCATION; RESPONSE CODE: EOISTED BY: TIME- (24 HOUR CLOCK) n TO SC E - O CALL RECEIVED D-S�C- TIME 10-8 PATIENT DESTINATt6N: �. FROM SCENE- ❑ FIRE TIME 10-97 2-7- 1 ❑ PSAP TIME 10-49 �l .0 MILEAGE: ❑ OTHER/PVT TIME 10.7 f�-�--� END TIME 10-98 DOCTOR J�tC; fZ PM ER START S�y• S� TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME - ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ! CALL BACK M: AMBUL NCE OMP PT AMB AT RY? PATIENT TAK N„70 AMBULANCE: �(Q RESPONSE ZONE ❑ YES ❑ O ❑ WAL'CED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER Z00 MT-1A TECHNICI I LV J PARAMEDIC Hv '� DISPATCHER: (L� ;4� I I CO CHIEF COMP INT: -IJ o DRY RUN: ❑ YES L7 NO REASON FOR DRY RUN I I {�-0 L= - .._ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 11 S.S. a PRIVATE INS. CO.: BASE RATE: l KAISER k: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X % -T_. MEDICARE#: �� ( �' i E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO �. �o .. ❑ YES ❑ NO NIGHT: (19:00-07:00) �•Y CC"”, M: EMERGENCY RUN: ' EDI-CAL a: ' - r j- y C 4' 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-- 1�lj31CJ"C- _ "RELATIONSHIP: �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: �/- �� �� V '.S S t' TOTAL: ' I _ / C.- PATIENT RECEIVED BY: X 1� I TUREI CONTRA COSTA COUNTY AMBULANCE O l+ _ •., PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK 00 FILL IN APPROPRIATE SPACES DATE:1 I "`"l%-�•%L '� C PATIENT'S N_AMEf _ I I ijM ❑ F COMPANY# ADDRESS )� � ' AGE -I�f� /1 A," C CITY.._ I_ _� —,_�— STATE— ZIP L_ DOB ❑ Sn ❑ M ❑ T ❑ W Th OF O S DRIVER'S LICENSE+1 ____:__. _ ,_ PHONE.��—_�.i1.- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEP OTHER❑ __ STATION 1(A1.�2(8)_31C)_4(13)_51E)_ i INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - ❑ S.O. CALL RECEIVED ❑ P.D. TIME 10-8 -�--� ,C.�.'_a•_r ❑ FIRE TIME 10-97 PATIENT DESTINATION: FROM SCENE- �' ❑ PSAP TIME 10-49 ol ' MILEAGE: 1 ' .� OTHER/PVT TIME 10-7 LL:_ END . TIME 10-98 6L .�S DOCTOR i" L PMD/EFi STAR E � )� l i i,7077:) TIME 10 22 HOW CHOSEN TOTAL ,4 - STANDBY TIME ❑ NEAREST ❑ FAMILY 0 TRANSFER �+ � WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY:/^�; t.'7 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: )Q RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �EtvtT-1A' TECHNICIAN ,t t �"l" ���/ T�� PARAMEDIC Hx: �J _ DISPATCHER: CHIEF,C MPLA1T: LI +i i'�JJ1_ r '"`r DRY RUN: ❑ YES C� 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 l ' PRIVATE INS. CO;:' �) ! BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE �~ v �J � BLUE CROSS q: TOTAL MILES: X ' MEDICARE p:` ''+ ' ( " /._ E:O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) _�,,-� 1 CCHP/PPHP q: EMERGENCY RUN ^-' ' G MEDI-CAL#: — CODE 2/3 I 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 DRUGS: (PER ADMIN.) X NAME: I'' / RELATIONSHIP:r.L' 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- �, y�' PATIENT RECEIVED BY: X Ilvuidrr rrt,: . Whilr ,r i 1' r, ,n(b 4r,y 7r'•" ,- " n, ,".h. .+ 1SIGNATURE{ b1t.1 • CONTRA COSTA COUNTY � ' AMBULANCE Q 3 3 4-7 % J' PRE-HOSPITAL CARE FORM 1 UNIT _—� AUTHORIZATION M O 1 CNECK OR FILL IN APPROPRIATE SPACES DATE: ` - 57- 6 3 PATIENTS NAME O2lZI15 fZANU AL-Lf �Q M'�❑� (F COMPANY N ADDREpSSZ��("T/t9A�/� 1 � �/` ✓A•GE�I�-{� `I) G: I (• • CITY I"'l Z SS-TATEL CAL- ZIPri y s z.Z DO���-L-J ❑ Sn ❑ M ❑ T O W O Th XF O S DRIVER'S LICENSE M [_"�L�! �—_ PHONEZ2���6 S�..- NATURE OF DISPATCH P ZV TYPE OF TRANSPORT: AMBULANCfS 7-2--OTHER❑ _� STATION 1(A)_218)_3(C)._4(D)_51E _ INCIDENT LOCATION: 4 RESPONSE CODE: R UESTED BY: TIME - (24 HOUR CLOCK)j /L f /) � /�t 45_f_ TO SCENE - 3 S.O. CALL RECEIVED J (� /1 II-�"C !-S P.U. TIME 10.8 PATIENT DESTINATION: FROM SCENE 2 ❑ FIRE TIME 10.97 d0 Lv N G col ❑ OTHER/PVT TIME 10.49 �-;.;�; : MILEAGE: D OTHER/PVT TIME 14-7 '�-tt-- /� END 7 S ' TIME 10-98 LLQ DOCTOR VC PMD/ R START�� TIME 10-22 HOW CHOSEN: TOTAL 2 ' S STANDBY TIME ❑ NEAREST, AMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ✓❑ -DIRECT ❑ OTHER _J.� CALL BACK#: AMBULANCE COMPANY:-.^ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: `J t RESPONSE ZONE C f1 YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER SChrcr �''� y;-''/ �EM1A O TECHNICIAN v IT LAij 17 Sv�P/IRAMEDIC Hx: S e(Zy•/ s DISPATCHER: j t" '� '•) CHIEF COMPLAINT:�� __yL_ DRY RUN: ❑ YES NO REASON FOR DRY RUN L/G�t� VV'' �` AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ ' -MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. M —9.0 _ t4-7 PRIVATE INS.CO.: `" d-1-1 7-1 et No C.AiT BASE RATE: I KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: `J X MEDICARE M: E.O.B. AT,T. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) J CCHP/PPRP M: EMERGENCY RUN: CJ,'u,' u MEDI-CAL N: no= CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES XNO NEONATAL: (INCUBATOR) t I p DATES BIL►ED: STANDBY: (OVER 15 MIN.) ( t) E.K.G.: (PER EPISODE) '-NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAMED-10a l S� pL* A j n'�'-RELATIONSHIP. E'`'e` E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) - CITY: M 17- STATE-C-&ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: L CobN/T"fNCCU`PRTION:'or-MCNT OTHER: ADDRESS' It 5 8 e r r S T CITY: F &f STATE: CAL zip: _ 3` 57 -C) COMMENTS: T TOTAL: _._.. .. .._..__. PATIENT RECEIVED BY. X Pm i.lor rvt.r.'c :�••. (SIGNAItIRE) r• CONTRA COSTA COUNTY AMBULANCE r PRE-HOSPITAL CARE FORM I UNIT ( AUTHORIZATION • _ I l I I CHECK OR fill IN APPROPRIATE SPACES DATE: ` rr,. I j ( I 'PATIENT'SNAME - -� 0"M 13F COMPANY N� ADDRESS t AGE CITY �••STATE�,TT� ZIP�___�___— DOB ' ❑ Sn O M OT ❑ W ❑ Th OF O S DRIVER'S LICENSE — PHONE NATURE OF DISPATCH 1 12 v2 Q J TYPE OF TRANSPORT: AMBULANCEIQ OTHER❑ — STATION 1(A)_2(8)-3(C)-4(D)_5(E)_ INCIDENT LOCATION:!rI- ./��� RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLO)rK) c �� TO SCENE- F�S.O. CALL RECEIVED : 16 Ly ❑ P.D. TIME 10-8 PATIENT DESTINATION:_ .. FROM SCENE- ❑ FIRE TIME 10.97 44- �,iZ�' ❑ PSAP TIME 10-49 ' O��• 1�" t) =� __� MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 ,;bbCTOfk-l "'� PMD/ER START TIME 10-22Y�— HOW CHOSEN: _._. TOTAL STANDBY TIME ?^`y ❑ NEAREST:!') ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER J CALL BACK K: AMBULANC�,CPKFANY: PT.'AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZO'NE�`JJ ElYES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: 7 DRIVER 6 ` MT-1A TECHNICIAN QJZ LY1 VARAMEDIC 1 Hx: _�+� DISPATCHER: V C+ CHIEF COMPLAINT: DRY RUN: ) YES ❑ NO REASON FOR DRY RUN - A ORtZATlO F� U S USE ONLY) (� ,gAJI(';,PATIENT REFUSED SERVICES:(SIGNATURE) X .L �=C( t qJ-�L- MEDICAL COVERAGE: _ _. -. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: i( S.S.M PRIVATE INS.CO.: BASE RATE:' KAISER IF: " MULTIPLE PTS. BASE RATE BLUE CROSS M: �' TOTAL MILES: X MEDICARE C ' I E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M:"� I - EMERGENCY RUN: MEDI-CAL K; ` CODE 2/3 OTHER: I ' OXYGEN- (PER TANK) P.O.E. STICKER ❑ YES ❑ NO - NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) .---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: �T CEJ - PATIENT RECEIVED BY: X Fti.•ri.�rr r+•;�. �n r „ (SIGNAI IIRF) r•.• r COUNTY AMBULANCE 1-3 PRE-11110SPHAL CARE FORM I UNIT AUTHORIZA 'y C/PECK JR ILL IN A: -OPRIA E SPACES DATE: C PATIENT'S NAME.T! 'L,,rl&(__ ❑ F COMPANY jv -41--x) ADDRESS _:�_-3-a, , --- 11 — AGE • CITY_/� STATE._(_�L_ ZIP C��-3 5 D0139.-'7q- 11 Sn 0 M 13 T 0 W 13Th F 0 S t I-t! DRIVER'S LICENSE# PHONE/7— NATURE OF DISPATC �L� TYPE OF TRANSPORT: AMBULANCE CK\OTHEREJ INCIDENT LOCATION: RESPONSE CODE: REOUESTED'BY: TIME— (24 HOUR CLOCK),- ? TO SCENE - 0. CALL RECEIVED P. D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - 0 FIRE TIME 10-97 0 PSAP TIME 10-49 ✓ T7 MILEAGE_ OTHER/PVT TIME 10-7 EN TIME 10-98 el�' DOCTOR PMD/ER START Z -16 TIME 10-22 HOIN HOSEN: TOTAL STANDBY TIME NEAREST 0 FAMILY 0 TRANSFER j WAIT TIME /OPATIENT0 DIRECT 0 OTHER CALL BACK#: AMBULANCE C Y: PT. AMBULJ TORY? PATIENT TAK E To AMBULANCE: RESPONSE ZONE 0 YES NO 0 WALKED 0 OTHER PATIENT CONDITION 5-v) LC DRIVER 0/\) TECHNICIAN PARAMEDIC Flxp -cl-�iILEIL DISPATCHER: • CHIEF COMPLAINT:T DRY RUN: 0 YES 0 REASON FOR DRY RUN AUTHORIZATION 2R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. INDUSTRIAL 0 YE NO NO. OF PATIENTS: S.S. 0 SA PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE ...BLUE CROSS #: TOTAL MILES: MEDICARE#: —E.O.B. ATT. ROUND TRIP: 11 YES ❑ NO 0 YES ONO NIGHT: (19:00-07:00) J V_ CHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 • OTHER:----- OXYGEN: (PER TANK) P.O.E. STICKER C YES XNO NEONATAL: (INCUBATOR) DATES BILLED. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 4-// NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAM E 11 RELATIONSHIP E.O.A.: (IF NOT REPLACED) / ADDRESS. ORAL AIRWAY: (IF NOT REPLACED) CITY: ST ATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK EHQNE-- DRY RUN: (AUTHORIZED) EMPLOYER. I T "0'C,&F R,TI67-1 1-j OTHER: i A 4. ADDRESS- , CITY: STATE:CAL—ZIP:— 17 COMMENTS 7 7, '7,* TOTAL: PATIENT RECEIVED BY:X Sjlifi�G _ITLTAE) ;-'v I, _rd copy when CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM f UNIT P AUTHORIZATION N `d3- 13 09-2 • CHECK OR FILL IN APPROPRIATE SPACES \ DATE: FATIENT•S NAME_ �`�_��� O M OF COMPANY# 7� ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M OT ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M _ PHONE—__.—__—_ NATURE OF DISPATCH I/79 . TYPE OF TRANSPORT: AMBULANCE WtTHER❑ INCIDENT LOCATION: RESPONSE CODE: REAESTED BY: TIME— (24 HOUR CLO K) O 7 �\ TO SCENE- 3 5rS.O. CALL RECEIVED 2 (h � ( Y ) 6U) ❑ P.U. TIME 10-8 �la PATIENT DESTINATION: FROM SCENE Cl FIRE __ TIME 10-97 ❑ PSAP TIME 10-49 t /1 MILEAGE ❑ OTHER/PVT TIME 10-7 i✓ END TIME 10-98 I DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN TOTAL STANDBY TIME I ❑ NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK a: AMBULANCE,S9MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: so RESPONSE ZONE 1 ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY O OTHER //^^ -/ PATIENT CONDITION: DRIVER-MLP v/ EMT-lA_ I TECHNICIAN UI--JA� ��'� AMED Hx: DISPATCHER: 1A; CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN I -2 Z AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_. / MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS:/ S.S.# Y 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 ONO 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 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) __ga PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: S`TATE: ZIP: COMMENTS: TOTAL:JV_ ('ATrI'n)T nrr(ivrn nY X CONTRA COSTA COUNTY `' AMBULANCE �3�-l�S �2 PRE-HOSPITAL CARE FORM i �( UNIT © AUTHORIZATION N ' CN[CR OR FILL IN APPROPRIATE SPACES DATE: / `PATIENTS NAME I OM ❑ F COMPANY N `� ADDRESS ' AGE ^" CITY STATE—,ZIP�_ DOB ❑ Sn ❑ M ❑T ❑W ❑ Th *Y F O S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH •-C'';eV C C5 TYPE OF TRANSPORT:,AMBULANCE 10 OTHER 0 STATION 1(A 2(8)_3(C)_4(D)_51E)_ INCIDENTLOCATION1 L N RESPONSE CODE: FOUESTED BY: TIME— (24 HOUR CL K) C�-7 l�k � v , TO SCENE-r� � S.O. CALL RECEIVED � /K)Q .J ❑ P.D. TIME 10-8 _^0Z AS- 0 — PATIENT DESTINATION:- FROM.SCENE- ❑ FIRE TIME 10-97 T ; N{� _ ❑ PSAP TIME 10-49 I l✓°' ,r '�� 1 z 7 MILEAGE OTHER/PVT TIME 10.7 END TIME 10-98 i DOCTOR _ I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME P NEAREST, ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANWC NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 V RESPONSE ZONE ❑ YES ❑ NO.,.. ❑ WALKED ❑ GUERNEY ❑ OTHER �•���_ f 1'. PATIENT CONDITION.- - ' DRIVERy� r P 330 ��•1tj, ' TECHNICIAN Kell: Q PARAMEDIC Hx: DISPATCHER: ��[/ > QCHIEF COMPLAINT: DRY RUN: itYES ❑ NO REASON FOR DRY RUN v 09% (� J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) REFUSED SERVICES: (SIGNATURE)X 95a- MEDICAL COVERAGE: I INDUSTRIAL 11 YES ONO NO. OF PATIENTS: S.S.N PRIVATE INS. CO.: L BASE RATE: KAISER N: 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 N: EMERGENCY RUN: MEDT-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: z TOTAL• PATIENT RECEIVED BY: X Pr»vidir• rvtafa vhit• f r'.:: ,.,p� .k.n r r• �., (SIONArURE) r� i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT , a AUTHORIZATION NS3 CHECK OR FILL INAPPROPRIATE SPACES DATE:3 �PATItNTS NAME - O M ❑ F COMPANY N ADDRESS 4 '' AGE, ��� L CITY STATES ZIP DOB - ❑ Sn OM O T O W 13 Th CEF O S DRIVER'S LICENSE – ""( PHONE NATURE OF DISPATC►earc\"cg . 1 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ -- STATION 1(A)_2(B)_3(C)V4(D)_5(E)_ INCIDENT LOCATION:; -~ REPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLACK) - TO SCENE- lk S.O. CALL RECEIVED C �O3 :\�3C't'RrJ`tr'W.�,, J VJ O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- / ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 ' j MILEAGE: ❑ OTHER/PVT TIME 10-7 _ u, END TIME 10-98 FDbCTOR L`Lf)'�: _ f PMD/ER START TIME 10-22 HOW CHOSEN: ) TOTAL STANDBY TIME 21,j O.NEAREST"? O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: CQ-o PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE S , -tr• ❑ YES.,O NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:' DRIVER A� � �_C� EMT-1A✓ TECHNICIAN (,2 PARAMEDIC 90? Hz: DISPATCHER: L T-7 CHIEF COMPLAINT: DRY RUN:AYES ❑ NO REASON FOR DRY RUNkO' 2, C_F Lf Y q AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I '� �� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N I :1•S PRIVATE INS.CO.: BASE RATE: KAISER N: I MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE Nr E.O.B.ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCH001-10 N:iI , 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 RELATIVEIRESPONSIBLE 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) � � oz) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: `- COMMENTS: - _ TOTAL: . PATIENT RECEIVED BY: X CONTRA C OSIA COUNTY AM(3U1_ANCE 83130 12 0 PRE-HOSPITAL CARE FORM I � I uN,T AUTHORIZATION M �J _ I CHECK OR FILL IN AVI�ROnRIA7r I;pA f s DATE: ____—_ 0,5' 8✓ PATIENT'S NAME Ill-I k t= f), I ��f1 ir►i y A.......... ❑ M F COMPANY p T . . �.� 'T ADDRESS ._—._. . .__... .__.._. _../.�% ..�.-_----------- ----. AGE��- ; CITY _..J4CJJIV(t_%ID13 . STATE..---e'/l- ZIP_-- ---.-- _ DOB..(o_-01F75'10 O Sn O M ❑ T ❑ W ❑ Thn D F OS f•i DRIVER'S LICENSE n _. a3�� 30 oO �C 19aKw)v _. . PHONE ..._ _ NATURE OF DISPATCH O TYPE OF TRANSPORT AMBULANCE O CTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK), y TO SCENE - S.O.._—_-- CALL RECEIVED /4 :�•- "� O P.D _ TIME 10-8 / 0 PATIENT DESTINATION: FROM SCE N - O FIRE _ TIME 10-97 ❑ PSAP TIME 10-49 (( ,l ' O OTHERiPVT TIME 10-7 6- END TIME 10-98 � :� '• ' DOCTOR _-. U- D 0 ._..._._.__..._ PMD/ER START_ __��` _ - TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME - O NEAREST O FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER Ji' CALL BACK q AMBULANCE COMPANY- PT.AMBULATORY7 OMPANY•PT.AMBULATORY7 PATIENT TAKEN TO AMBULANCE RESPONSE ZONE- / —YES Cl NO O WAL':ED 2 GUERNEY O OTHER PATIENT CONDITION. DRIVER .-_-1-R V.-__.. /—�_ S wv/�- EMT-lA- 0I TECHNICIAN .. .P�'_ -^�F-_1�" - PARAMEDIC Hx: _. ATIA%E�_FISH-� -IV1<ITuft ..f�.C.O -t`�MDISPATCHER: --Ai)—�. - '"1 DD j 1` CHIEF COMPLAINT SL� 'C 11^��:-._IJAU��fjO DRY RUN: ❑ YES VNO REASON FOR DRY RUN � �//'--/&JAUTHORIZATION FOR DRY RUN /EMS USE ONLY) *1�'��ATIENTTREFUSED)SER`JC ES rNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S's PRIVATE INS. CO.'. _._--..__ --_— _. . _ BASE RATE: KAISFR MULTIPLE PTS. BASE RATE P! ,Ir rROSS 4'-...._. _ TOTAL MILES:-_—. X ,-'r, ,MAPF is _ _ -___... E O B. ATT ROUND TRIP: O YES ❑ NO J O YES ❑ NO NIGHT: (19.00-07:00) CCHP,'PPHP#:__... ._____. EMERGENCY RUN: d MEDI-CAL#:-_-_ -___ .. . .-__.____-__ _- . 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) j ,1 .NEAREST RELATIVE.'RESPONSIBLE PARTY: I.V.. IPER ADMIN.)— X - ' DRUGS: (PER ADMIN.)_ X NAME. V-O . RELATIONSHIP S.--Fhn 4 O A. (IF NOT REPLACED) 11 1 ADDRESS: L G� if' i� .S . --- ORAL AIRWAY: (if NOT REPLACED) I I CITY . . .loVC0/V)(.)`� STATE C4I ZIP:7W"71 C-COLLAR: (IF NOT REPLACED) PHONE: ..� �-3 '�'f WORK PHONE -2q3 UU,3 DRY RUN: (AUTHORIZED) EMPLOYER: N�� OCCUPATION:_ .__- OTHR: ^� s ADDRESS:.—_... '-c-, r ._r' • co S CITY: -. __.___..._..-...._ STATE:—_ZIP:--- COMMENTS:—. TOTAL /s/ .SD ------ ----- --- ------------------- '.._ ------- —__-._____. PATIENT RECEIVED BY: X ...'.• r.... t' .r•I a�.- 4r 1:?I i• A INS-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I !\ UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: r�—�� I �•. PATIENT'S NAME ❑ F COMPANY ��E_ ✓ iii}/L�� L. C, �.M ADDRESS _2 / C f'l °,tom r T 7 /�L�t. I AGE -� •.. IZ I ( 1 I CITY STATE C-1"4— ZIP DOWE 7� ❑ Sn OM OT OW O Th,�G [3S___", DRIVER'S LICENSE n _______ PHONE 2J' =�FF�PNATURE OF DISPATCH A'y7 d TYPE OF TRANSPORT: AMBULANCE7 OTHER❑ _ _ STATION 1(A) 2(8)_3(C)_4(D)_5(E)=•— 1 INCIDENT LOCATION: /` i I �• RESPONSE CODE R QUESTED BY: TIME— (24 HOUR CLQG CK) 3 LC11 '��� TO SCENE .O. CALL RECEIVE D '_��_L/ - � ❑ P.D. TIME 10-8 — -s :j _� I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1-1 ,r7 ` ❑ PSAP TIME 10-49 } MILEAGE: ❑ OTHER/PVT TIME 10-7 END--�33- 2- TIME JO-98 •: DOCTOR S G����/�� / PM� START �I TIME 10-22 HOW CHOSEN: TOTAL -3 STAmbBY TIME O NEAREST FAMILY O TRANSFER WAIT TIME Cl PATIENT ❑ DIRECT ❑ OTHER (� CALL BACK N: AMBUL)2�E CO PANY: r_J PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES/"MNO ❑ WAL'<ED ty-bUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER a 60 t ( TECHNICIAN �� PARAMEDIC L H.: ,sSl%c' '" DISPATCHER: /411 < `A n �I CHIEF COMPLAINT: Ti i2 L- t2- DRY RUN: O YES ;GT NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I i PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: c!J_- KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: y X ✓ �-"' 1 MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ' 1 ❑ YES ONO NIGHT: (19:00-07:00) _ CCHP/PPRP#: EMERGENCY RUN: � MEDT-CAL N: CODE 2/3 i OTHER: OXYGEN: (PER TANK) I -� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 DATE"ILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X NAME C'yrR1Tv /1L "RELATIONSHIP:ItI 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: PATIENT RECEIVED BY: X hvvidrr ratair lAitr Udr. (SIGNATURE) "T� �ct�r+, Y�:1•v vp� t .9Mf uhen !f1 ink CONTRA COSTA COUNTY AMBULANCE 9 ,. ' PRE-HOSPITAL CARE FORM I UNIT E7] AUTHORIZATION N CHECK OA FILL IN APPROPRIATE SPACES - DATE: �`✓! • PATIENT'S NAME.4--� ` � UAQ M D F COMPANY K 9 1 ADDRESS 77 1 ,101 l�S Fn� Y AG �� iy CITY_YAN PAC36y STATE ` A ZIP e_`(/ = DOB2+ / ( ❑ Sn D M D T ❑ W ❑ Th F ❑ S I DRIVER'S LICENSE M _ PHONE ___� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ -- STATION 11A)_21B)_31C)_41D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE-2 ❑ S.O. CALL RECEIVED / c ❑ P.U. TIME 10-8 j 1 PATIENT DESTINATION: FROM SCENE -Z ❑ FIRE TIME 10-97 77 •1<'. I� Z-- 13PSAP TIME 10-49 l ' (- 4 MILEAGE: p � ❑ OTHER/PVT TIME 10-7 77 END / TIME 10-98 'DOCTOR C PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER �/ WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER .i ! CALL BACK N: AMBULANCE COMPANY: l 'y PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE:_ RESPONSE ZONE-J DCYES ❑ NO ❑ WALKED Q GUERNEY ❑ OTHER / / PATIENT CONDITION: DRIVER < j o/v �/ •.` EMT-1A //L e�d L /�N, TECHNICIAN >;, �'/ �� .PARAMEDIC _ Hx: DISPATCHER: ^yur I < < < �� I ''I-, �) CHIEF COMPLAINT: SI s- DRY RUN: ❑ YES �g 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.« PRIVATE INS. CO.: BASE RATE: f KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: � X MEDICARE M: `� �-3 � y%-d_ E n R ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: `f MEDI-CAL M: CODE 2/3 X955 OTHER: OXYGEN: (PER TANK) /d 0 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 11'jATES 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: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: __-._.. VAIli NT FILCEIVED I Y X vr�ur,r�- n.I,,r, varl, ... r , •ruruw X30 CONTRA COSTA COUNTY AMBULANCE fir . PRE-HOSPITAL CARE FORM I ` UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ❑ M COMPANY ADDRESS (U ; c( 4 C7�� AGE .� `10 CITY_ CA LZIP_ DO(B' C' S 13Sn ❑ M 13T o W ❑ Th 13S-1 DRIVER'S LICENSE p ___»r-_ PHONE a� _.�1_ 7�— NATURE OF DISPATCH ETRE US P44TE aASS TYPE OF TRANSPORT: AMBULANCE THER❑ _ _ -- STATION 11A1 (B)_.3(C)-41D)_5(E)1•„ ,. INCIDENT LOCATION: RESPONSE CODE: BY: TIME- (24 HOUR CLACK) y" ) TO SCENE- O. / CALL RECEIVED !1 ` ❑ P.D. TIME 10-8 . PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49. : - — MILEAGE: ❑ OTHER/PVT TIME 10-7 � �j ••! I 1/ END t 7 TIME 10-98 DOCTOR k.'s-i-L_T-�is PMD(jp START QS TIME 10-22 t 1 HOW CHOSEN: TOTAL 1 STANDBY TIME �i- ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: _ MBULATORY) PATIENT TAKEN MBULANCE: RESPONSE ZONE - S ❑ NO ❑ WAL'<ED (;�GUE EY ❑ OTHER PATIENT CONDITION: DRIVER �D ' EMT-1A TECHNICIAN PARAMEDIC '- Hx .�0_N1 5 l� N DISPATCHER: l CHIEF COMPLAINT: M U_�JTp ivlJk'0e -• DRY RUN' ❑ YES REASON FOR DRY RUN ((�) -IN(7 c US - BJLkL L,,5 -MSS 'JX'6THOV(ZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— - C M AL COVERAGE: INDUSTRIAL ❑ YES NO. OF PATIENTS: `S.S�,. S 6 s - �j LlJ O 1 RIVATE INS. CO.: BASE RATE: ) 1 KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSS p• TOTAL MILES: J X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO a �• Q( 5TP,II S PC) SNS" ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: C> MEDT-CAL M: CODE 2/3 '1: 1 j OTHER: — OXYGEN: ,(PER TANK) 11 P.O.E. STICKER ❑ YES NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RE IVE/REFP NSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X (•. 11'I Q I NAME: _ RELATIO SHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: `�? �'n� K--� IAO ORAL AIRWAY: (IF NOT REPLACED) CITY: -_��Tl _L _. -_ STATE-`ZIP: C-COLLAR: (IF NOT REPLACED) - -. -- PHONE: `� �-�-- ( � WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - -•- - ADDRESS: CITY: STATE: ZIP: 4 COMMENTS: I S (�1 f'y PIZ ZV CTS fn HA'S V0 IQ f� TOTAL: �9 PATIENT RECEIVED BY:X WdkATURE) PmviAer rrtara V6ite ••I Pi,: Yl7ia'V ro,.0 LW5 LArn bii'inp Oli-t CONTRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I \ < UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY a I ADDRESS AGE— CITY GE CITY STATE ZIP— _— DOB--_ ❑ Sn OM OT ❑ W ❑ Th ❑ F ❑ S ' DRIVER'S LICENSE« _____– _. ._..___. ___...___ PHONE __ _..- __... _. ___ NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE D OTHER❑ __ ___...-._–.-_._.__ .... STATION 1(A)_2(B)-3(C)_4(D)_5(E)_ 1 .: INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME – (24 HOUR CLOCK) TO SCENE ❑ S.O._--__ CALL RECEIVED ❑ P.D. — TIME 10-8 _ \` PATIENT DESTINATION: FROM SCENE ❑ FIRE -- TIME 1D-97 O PSAP TIME IO-49 T MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _ PMD/ER START TIME 10-22 1 HOW CHOSEN: ITOTAL — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- O PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: SL) RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER _ r c . . . /� PATIENT CONDITION: DRIVER1 EMT-tA TECHNICIAN <it _ PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: El YES ❑ NO REASON FOR DRY RUN 1I`' `� _– 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 R: MULTIPLE PTS. BASE RATE y BLUE CROSS TOTAL MILES: X _ MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) n CCHP/PPRP 4: EMERGENCY RUN: / MEDI-CAL a: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ O NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSI LE 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) ,nl PHONE: W RK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: CCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ -- --- -- – -.. TOTAL: ------- -- - r PAI IENT HI!CTIVED 13Y X rl�ir ri, Illnn - RONA COSTA COUNT AMBULAN E PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONp$��3Og� L" CHECK OR FILL INAPPROPRIATE SPACES - - GATE: :i PATIENTS NAME Jvrh^K,-D- O M F COMPANY pill CAS UCL LL I ADDRE C '2 Cl C!) 1 AG l -1 I L/ CITY STATE-1�T_ ZIP_ / DOB_ __ D Sn D M D T D W ❑ Th D FS DRIVER'S LICENSE p ) PHONE �`�-/.._ NATURE OF DISPATCH�SOLQL 10 CJ TYPE OF TRANSPORT: AMBULANCE OTHER INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME— (24 HOUR CLOCK) 3 9� TO SCENE- I S.O. CALL RECEIVED / ❑ P.D. TIME 10-8 'PATIENT DESTINATION: FROM SCS- ❑ FIRE TIME 10-97 �? ❑ PSAP TIME 10-49 ' ' `�-ll�'l� 1\�Cµ MILEAGE: 11OTHER/PVT TIME 10-7 1L� :0 � END TIME 10-98 J� r�� ;DOCTOR ' _ ' PMDt(kH 1 START �/7 TIME 10-22 HOW CHOSEN: �J TOTAL _ 0 STANDBY TIME ��.., ❑ NEAREST, ❑ FAMILY ❑ TRANSFER WAIT TIME J1 PATIENT ❑ DIRECT ❑ OTHER / CALL BACK a: AMBULANCE C PANY: PT. AMBUOTORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WALKED GUERNEY ❑ OTHER ' PATIENT CONDITION: fl DRIVER _ U EIAT-tA %YF?I TECHNICIAN _ O PARAMEDIC Hx: DISPATCHER: ZV iv� /'�.•r to lU 4o CHIEF COMPLAINT: DRY.RUN: ❑ YES �KNO REASON FOR DRY RUN GJ rfv AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL OYES NO NO. OF PATIENTS: S. p � v P VATE INS.CO.: BASE RATE: zlo.�-. k, KA SER p: MULTIPLE PTS. BASE RATE BL E CROSS p: TOTAL MILES: ,�X (CARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) urJ CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL p: 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),, f / PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: --CITY' - STATE: ZIP: '—-COMMENTS:- _ TOTAL: cx;PJ 4� PATIENT FIECF IVF D (lY X va h 4V. CONTRA COSTA COUNTY AMBULANCE % .1,Sy si PRE-HOSPITAL CARE FORM { UNIT®® AUTHORIZATIO - A ' I CHECK OR FILL IN APPROPRIATE SPACES DATE: PATFENT'S N E G11- Z1 /�(�1• /❑ F COMPANY M_f c{ v 5^; ADDRES t1 AGE b �/ r CITY STATE ZIP DOB/;) A_-/9 ❑ Sn ❑ M D T+O W O Th 10 F 0.S.- DRIVER'S LICENSE# PHONE _ NATURE OF DISPATCH ., TYPE OF TRANSPORT: AMBULANCE OTHER O — I'STATION 1(A)-2(8)_3(C)_4(D)_-S(E)—!.;_ � INCIDENT LOCATION: RESPONSE CODE. E UESTED BY: TIME— (24 HOUR CIL Ci C TO SCENE- 2 S.0. CALL RECEIVED ^�K) -� oC / J ❑ P.U. TIME 10-8 I T;. PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 c�c7 �I , ❑ PSAP `TIME 10-49;! MILEAGE- D OTHER/PVT TIME 10-7 " END ' TIME 10.981 DOCTORS PMD/ER START TIME 10-22 HOW CHOSEN: tOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME' O PATIENT D DIRECT ❑ OTHER j� CALL BACK#; AMBULAN NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE Z NE ❑ YES ❑ NO ❑ WAL'<ED d GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �� EMT- ! , TECHNICIA / DIC Hx: DISPATCHER: ��J L7L AW I C �_ { r ' CHIEF COMPLAINT: DRY RUN: ❑ YES _)d NO 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. # - , PRIVATE INS.CO.:L' ;Isi' L�t 'q C S BASE RATE: "- KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X \ MEDICARE C ��G ZZ / E.O.B. ATT. EJ j)•i "'1 QOUNp TRIP: DYES ❑ NO ..: - �` ❑ YES ONO NIGHT: (19:00-:07:00) IV CCHP/PPRP#: EMERGENCY RUN: `��• MEDI-CAL#' CODE 2/3 OTHER:_J - — OXYGEN:' (PER TANK) C�I — J'tfOT P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) -�-vc, \DATES�ILLEU: STANDBY: (OVER 15 MIN.) L�L '3�'Q/ _ E.K.G.: (PER EPISODE) 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: OCCUPATION OTHER: ADDRESS: CITY: STATE: ZIP:—. - ' COMMENTS: od TOTAL: - PATIENT RECEIVED BY:X r. _ .... rC1l7NATt1gFl , CONTRAT COSTA COUNTY AMBUL N E PRE-HOSPITAL CARE FORM I UNIT , AUTHORIZATION k CHECK OR FILL IN APPROPRIATE SPACES DATE: ATIENTS NAME a�� rl �'WL.1 ❑ M 0(/F COMPANY N i n rl ADDRESS / ���//�� (� AGE� ter' CITY_ � L� STATE_J.'t _ ZIP�1� �<<� DOB_ � 16_6�❑ Sn ❑ M ❑ T O W ❑ Th ❑ F S DRIVER'S LICENSE N — =----------- PHONE� a._a1:5/ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A) 2(B)-31C1-41D)— IEI_ INCIDENT LOCATION: RESPONSE CODE: RUESTED.BY. TIME- (24 HOUR C4OCK) �✓ r TO SCENE S.O. --___ CALL RECEIVED ❑ P.U. TIME 10-8 ' PATIENT DESTINATION: FROM SCENF�- ❑ FIRE _ TIME 10-97 / �� TIME 10 98 ? ❑ PSAP TIME 10-49 _ ry LlGTl 1 / `1 :1n �) � MILEAGE: ❑ OTHER/PVT TIME 10-7 6 END �' "DOCTOR PMD ER START— TIME 10-22 HOW CHOSEN: TOTAL 'L STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER , WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE. OMPANY: Eo B LA ORY7 PATIENT TAKEN TO AMBULANCE: � RESPONSE ZONE�O ❑ WAL'<ED GUERNEY ❑ OTHER t,PATIENT CONDITION: U ti`�r�t3� _ DRIVER EMT-lA TECHNICIAN L�NS ^' PARAMEDIC Hx: NAL DISPATCHER: CHIEF COMPLA NT: n 0C _ DRY RUN: ❑ YES NO . REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— T MEDICAL,COVERAGE: JJ IN USTRIAL ❑ YESANO NO. OF PATIENTS: S.S.k - �n�D �I1� PRIVATE INS. CO.: BASE RATE: / KAISER R: MULTIPLE PTS. BASE RATE 1 BLUE CROSS k. - LIp�r�l�`� TOTAL MILES: -� X \ MEOIARE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO I I,'� \ \ J ❑ YES ❑ NO NIGHT: (19:00-07:00) VV`` CCCCH/P/PPRP k: EMERGENCY RUN: MEDT-CAL M: 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: _ 8y.oa -----.___ _ ---- TOTAL: PATIENT RECEIVFII BY X _ Provider reta:r, white x..d ;,i, ,T, r (SIGNATURE) .. ! .. •,�. tV :'k. 1n.. CMC I } I e C`DoTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATIO N U CHECK OR FILL INAPE40PRIATE SPACES DATE: '6TIENTS NAME , ❑'M ❑ F COMPANY 0 ADDRESS,7 AGE N I CITY l STATE______.,_ ZIP DOB -0 Sn ❑ M O T ❑ IN ❑ Th ❑ F ❑ S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH - TYPE OF TRANSPORT:•AMBULANCE❑ OTHER❑ — -- STATION I(A)_.2(8)_3(C)_4(D)_5(E)_ W l SI, RESPONSE'CODE.'' RE STI:D 9Y: TIME- (24 HOUR CLOCK) 3 - INCIDENT LOCATION:) �/ TO SCENE- S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ TIME 10-49 :. '_L.. .Pi% I`'± � MILEAGE: 11OTH OTHER/PVT TIME 10-7 , END TIME 10-98 156cfOR ^-{ I `',PMD/ER START TIME 10-22 HOW CHOSEN: M TOTAL STANDBY TIME 2'j_❑,NEAREST., ❑ FAMILY ❑ TRANSFER _ WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: • :510 RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER' 1 PATIENT CONDITION: 1 DRIVER 5 _ EMT-IA ��lei TECHNICIAN -PARAMEDIC Hu: DISPATCH R: CHIEF COMPLAINT: ' DRY RUN: ES ❑ NO REASON FOR DRY RUN. AUTHO TION FOR DRY.RUN(EMS USE ONLY) or Iq9 q f 1:,:_;PATIENT REFUSED SERVICES: (SIGNATURE) X moi/ MEDICAL COVER E: y 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 C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT:(19:00-07:00) CCHP/PPHP N:'' I I 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: . <"9) PATIENT RECEIVED BY. X irlelf'IAT„nrl II CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: g^ i PATIENT'S NAME ) .1�� N rllCO. COMPANY ktlll� / C ADDRESS C � CILhlL J� lC}1YI_ AGE 00 S � J CITY CNYV STATE_.—_3 ZIP_ DOB- a 4 `j❑ Sn O M O T ❑`W O Th O IF i DRIVER'S LICENSE# ____- PHONE d3S�037(5- NA RE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ ^. ci STATION 1(A► 2(e)_3(CI_4(D)_5(E)_I INCIDENT'LOCATION: ]�� 44iI l I fWU�- RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOD• K) r r �` � �•1 JJ �j.,, f TO SCENE- S.O. CALL RECEIVED J_L 3 - -- 3G1 � ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1 r 14 � �^ ❑ PSAP TIME 10-49. MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR �L�_ PM /ER START TIME 10-22 HOW CHOSEN. TOTAL d STANDBY TIME j ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME L�PATIENT ❑ DIRECT ❑ OTHER rpt CALL BACK#: AMBULANfE(FMPANY: i PT AMBUL TORY? PATIENT TA EN TO AMBULANCE: -� RESPONSE ZONE ❑ YES NO ❑ WAL'<ED GUERNEY ❑ OTHER - i PATIENT CONDITION:C�j DRIVER ( `'C 0 EMT-tA TECHNICIAN r PARAMEDIC Hx: taODISPATCHER: CHIE00&u lu 7 DRY RUN: ❑ YES,,0 NO REASON FOR DRY RUN i C�)31(L• 244t, 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: KAISER it: 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: ��J'c(JG 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: k!h q RELATIONSHIPTI E.O.A.: (IF NOT REPLACED) ADDRESS: L r �1�Z_- �T'L ORAL AIRWAY: (IF NOT REPLACED) CITY:_ __ _ STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE�3� Sb DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: D ADDRESS: �-'-%! 1 J "'.�i✓ JJ CITY: STATE: ZIP: COMMENTS: l � I 1 // jC C �l✓ ` TOTAL: *�`Jv -- —_._ PATIENT RECEIVED BY:X Providrr Y ta.'c Aitr .rd Pia: :•nn� Fes•:,- .�, (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 `1 , 4 CHECK ON RILL IN APPNOPPIATE SPACES DATE: 1 . PATIENT'S fyA ❑ M O F COMPANY M ADDRESSAGE LU CITY STATE ZIP��� DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F DRIVER'S LICENSE N PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT:, AMBULANCE 0 OTHER 0 STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:? I/ } RESPONSE CODE! REDUESTED BY: TIME- (24 HOUR CLOCK) �. .\ V j 2 S T TO SCENE- r ❑ O. CALL RECEIVED l; c P.D. TIME 10-8 w.._ PATIENT DESTINATION: ) FROM SCENE- ❑ FIRE TIME 10-91 ❑ PSAP TIME 10-49 I D- MILEAGE: ❑ OTHER/PVT TIME 10-7 ` END TIME 10-98 DOCTOR' PMD/ER START TIME 1(Il-22 — HOW CHOSEN: TOTAL STANDBY TIME 't ❑ NEAREST! ,, ❑ FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT D DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE p�.. YES ❑ NO D WALKED O GUERNEY ❑ OTHER PATIENT CONDITIODRIVEREMT-1A TECHNICIAN �^-YN £'" PARAMEDIC ��,r Hx: 17 `-L7- DISPATCHER: - �L��i C cEd y CHIEF COMPLAINT: nAv RUN: 9Q YES ❑ NO REASON FOR DRY RUN t✓ A H I I N F DRY U ( M$USE ONLY) �`I ; PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE/. INDUSTRIAL ❑ Y S ❑ NO NO.OF PATIENTS: u 'r S.S. N � I i I PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RAT BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: YES ❑ NO / • ❑ YES ❑ NO NIGHT: -07:00) CCHP/PPRP N;' EM ENCY RUN: MEOI-CAL N: CODE 2/3 OTHER: z OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) . K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: 1. (PER ADMIN.) X. \lQRU (PER ADMIN.) X NAME; ELATIONSHIP: E.9,A.: ( NOT REPLACED) ADDRESS: ORAL'AIR Y. (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: 11 NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHQRIZED) EMPLOYER: OCCUPATION: OTHER: \\ ADDRESS: CITY: STATE: ZIP: COMMENTS: . %1 TOTAL: 4- PATIENT RECEIVED BY: X. I ) Y + CONTRA COSTA COUNTY AMBULANCE SS PRE-HOSPITAL CAREF RI(l� I UNIT AUTHORIZATION p r Z o'yr� �. =/V CHECK OR FILL (INN �APPPROPRIATE SPACES ` \ DATE: I ' -,11 PATIENT'S NAME L..2S 5 M d'16 $&L&fN ❑ M OF COMPANY M ADDRESS lk OS\C`nSKV C T AGE rl q CIT1(__� STATEGC ZIP -_ DOB2k�U D Sn ❑ M ❑ T O W ❑ Th ❑ F 9S DRIVER'S LICENSE N -__ PHONE NATURE OF DISPATCHtn Cll.` TYPE OF TRANSPORT AMBULANCEQ OTHER❑ _, _-_,.__-._ -- STATION 1(A).,2(8)-31C)' 41D)_51E).- INCIDENT LOCATION:; RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) rt TO SCENE S.O. CALL RECEIVED !1` _ © ❑ P.D. TIME 10-8 / PATIENT DESTINATION: FROM SCENE • ❑ FIRE TIME 10-97 / Lc� <z ❑ PSAP TIME 10-49 MILEAGE: , ❑ OTHER/PVT TIME 10-7 END TIME 10-98 ADOCTOflPM tER STARTTIME 10-22 HOW CHO EN: TOTALSTANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c t ,�, RESPONSE ZONE ..� •. ❑ YES t NO ❑ WALKED XGUERNEY ❑ OTHER PATIENT CONDITION. DRIVER MlL til (� TECHNICIAN _15c. PARAMEDIC Hx:� lY�`� DISPATCHER: ECIC Ffd t.• L.C.'t CHIEF COMPLAINT: S l _LCr_ - K _�,' C�� DRY RUN: ❑ YES Z NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__ MEDICALCOVERAGE: INDUSTRIAL ❑ YES 'g NO NO. OF PATIENTS: S.S. R S r)tl n1 �-,,l S PRIVATE INS. CO.: BASE RATE: KAISER it: MULTIPLE PTS.BASE RATE UE CROS 1 �ITOTAL MILES: X I ARE .e r) rl ti(�_-� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) { CCHP/PPRP R: EMERGENCY RUN: `r MEDI-CAL M: CODE 2/3 y J OTHER: OXYGEN: (PER TANK) tj' P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) Jl - NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X / t 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: "`---- _ - PATIENT RECEIVED BY. X I�I�NATURE) t.tis-1 !'n,u dar rntaic Whtto ..n,/ t•r.,e upH ..rr�,++ ,. ,.;•• !tr :h.rn t:. CONTRA COSTA COUNTY AMBULANCE I ?J f{ PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# - J ' CNECK ON FILL IN APPROPRIATE SPACES DATE: 3+ 6 PATIENTS NAME ' � � t � O M ❑ F COMPANY a � ADDRESS - AGE I?fe CITY STATE ZIP DOB O Sn O M ❑ T IJ W O Th ❑ F DRIVER'S LICENSE# } ( PHONE NATURE OF DISPATCH AOL* TYPE OF TRANSPORT:, AMBULANCE Q OTHER O — STATION 1(A)_2(B)-._a(C)_4(D)_5(E)_ u INCIDENT LOCATION' �Q L/ ':7,all AESPONSE COOED RE UESTED BY: TIME- (24 HOUR C OCK) +L-%- � ��� �O SCENE- - O. CALL RECEIVED ` CTT V� 0 p K- ,('•' - P.D. TIME 10-8 i PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 4- { ❑ PSAP TIME 10.49 QJ-14 ( MILEAG ❑ OTHERIPVT TIME 10.7 t END TIME 10.98 --7� )'DOCTOR' " i PMD/ER START TIME 10.22 _1 L HOW CHOSEN: TOTAL STANDBY TIME O NEAREST;:.-) ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANNC�COMPANY: ` PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ` RESPONSE ZONE_ O YES O NO ,_ ❑ WALKED ❑ GUERNEY O OTHER J .i.Yi . M _ PATIENT CONDITION: - - DRIVER EMT-lA TECHNICIAN C- a1 1�� PARAMEDIC P Hx: L-L- } - t�.1 IJ`� t'V� T DISPATCHER: _cl✓c <- �/ zJC} CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN lII/I/L/ luTO AUTHOR, I N FOR DRY RUN(EMS USE ONLY) 7 PATIENT REFUSED SERVICES: (SIGNATURE) X /ZAlMEDICAL COVERAGE: _- . INDUSTRIAL ❑ YES ONO O. OF PATIENTS: ` S.S. N i PRIVATE INS.CO.: I BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS 0: �' TOTAL MILES: X MEDICARE#: t E.O.B. ATT. ROUND TRIP:' ❑ YES ❑ NO O YES ❑ N NIGHT: (19:00-07:00) CCHP/PPRP C I EMERGENCY RUN: f MEDI-CAL#: CODE 2/3 �J OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 13NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: V.: (PER ADMIN.) X D GS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.. F NOT REPLACED) ADDRESS: ORAL AIR Y: (IF NOT REPLACED) - '—CITY: SLATE--Z1 C-COLLAR. ( N T REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X (SIGNATURE► . . • CONTRA COSTA COUNTY AMBULANCE • PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATI N N D-13 7 CMECR OR TILL IN APPAOPRIAI'E SPACES DATE; d PATIENTS NAME ❑ M ❑ f COMPANY N r A /2l� ADDRESS AGE I CITY STATE ZIP_r T^ DOB D Sn ❑ M ❑ T ❑ W ❑ Th O F DRIVER'S LICENSE N _ ! PHONE _ NATURE OF DISPATCH, •t A V '6dw TYPE OF TRANSPORT: AMBULANCE 1) OTHER 0 _ -- STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ - INCIDENT LOCATION:, I v RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)5 i1 TO SCENE- O. CALL RECEIVED t�J ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 n 1 ❑ PSAP TIME 10-49 Jh S f} J�J t �-� MILEAGE: ❑ OTHER/PVT TIME 10-7 TEND TIME 10-98 6OCTOR t PMO/ER START— HOW TART 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 ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �� �-L- `" ' EMT-1A TECHNICIAN U l'�1 -� PARAMEDIC Hx: DISPATCHE,.R,:� CHIEF COMPLAINT: DRY RUN: e-YES ❑ NO REASON FOR DRY RUN,112-LL 'FtJkQ&6� / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X C�-- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N I 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 ❑ NO I ❑ 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 ❑ YES ❑ NO NEONATAL: (INCUBATOR) \ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) X 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: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL PATIENT RECEIVFD BY. X . CON 1 RA COSTA COUN I Y AMRI.ILANCE 3 - 13 — Ij4 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N O CHECK OR illL IN APPROPRIATE SPACES DATE: � .... PATIENT'S NAME '�/ //LL%lt. ( f 1 M ❑ F COMPANY M �'� 3� ►" ADDRESS( AG / c) 7,5 4 CITY STATES ZIP -5-3 DOB16� ` l IkSn El ❑.T O IN 13Th O F DRIVER'S LICENSE» ____ _--_ PHONE;?;Z —�2 e�07NATURE OF OISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ _ - STATION 11A)-2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 1 -- �� L�_i,�l ��D � �)(.Ct/J� TO SCENE-2 p P.D. TIME 10-8 RECEIVED �� ❑ FIRE TIME 10-97 J PATIENT DESTINATION: FROM SCENE - �, f-_ �" ❑ PSAP TIME 10-49 -j MILEAGE: �O r 13OTHER/PVT TIME 10-7 (� END TIME 10-98 DOCTOR �_1\�.J�S� t PMD STAR TIME 10-22 `' I HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMP/VY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ,J(ti RESPONSE ZONE 7- -!' ❑ YES tpr__NO ❑ WAU ED KGGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �w��F� /0" EMT-11A� TECHNICIAN lxll l ;/ �4` 1 LL PARAMEDIC Hx: _ DISPATCHER: j CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN - (1AUTHORIZATION FOR RY RUN(EMS USE ONLY) - - . PATIENT REFUSED SERVICES: (SIGNATURE) X..- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a '7- PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE - BLUE CROSS q: TOTAL MILES: / X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO Jr ❑ YES Cl NO NIGHT: (19:00-07:00) "� V CCHP/PPHP#: EMERGENCY RUN: �, 6 MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES Cl NO NEONATAL: (INCUBATOR) ( ` DATES BILLED: STANDBY: (OVER 15 MIN.) /G'- .i0• 0 E.K.G.: (PER EPISODE) _ U NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X TQC/.-may'' DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: Lam' �G 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: PATIENT RECEIVED BY:X (SIGN TU 015-1 Prouider retain white rrd T'ir,: COrL .4QLurn Ye'1<n+ '+nyp t• EMS when Cii:ing CONTRA COSTA COUNTY AM NCE, PRE-HOSPITAL CARE FORM ( UNI7� AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NA - { Om ❑ F COMPANY N �L, 3 a 7 1 ADDRESS I = AGE CITY TATE ZIPS-_ DOB 'Sn O M ❑ T ❑ W O Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH J'4eCl I TYPE OF TRANSPORT: AMBULANCE Irl OTHER❑ _ STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION J g RESPONSE CODE: EOUESTED BY: TIME— (24 HOUR CL K) //� ,, 1/ I' ---j TO SCENE 292�,S-O- CALL RECEIVED :L_ .�G � M r l f kAE-:, v— ❑ P.D. TIME 10-8 PATIENT DESTINATION: .. 1 FROM SCENE- ❑ FIRE TIME 10-97 �—' O PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10-7 II� ( END TIME 10-98 `:DOCTOR.`T T-{ i PMD/ER, START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST.•6 FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CC PAN PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: V RESPONSE ZONE ❑ YES .❑ NO. O WALKED ❑ GUERNEY ❑ OTHER '>m ' PATIENT CONDITION:, DRIVERL�T! �1C- �'' EMT-1A v TECHNICIAN PARAMEDIC / Hz: DISPATCHER: '461 N f U'L L, CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN / AUTHOR` TION FOR DRY RUN(EMS USE ONLY) '.:''PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RASE:- Y/ F KAISER N: 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/PPHP N: I EMERGENCY RUN: 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: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) e 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: is TOTAL: CR) PATIENT RECEIVED BY: X Iti ;{ ri•, �,. (SIGNAYURE) �,. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION./ ?j CHECK OR flLl IN APPROPRIATE SPACES DATE: ,.._ I PATIENT'S NAME_t -_[/� _.` t/��. L M O COMPANY N ! 6_31 WADDRE I- /./,' – t t_' /- C` AGE CIT � v J✓ STATE_� ZIP_ ` DOB M O T O W O Th: 13 F 0 s— t DRIVER'S LICENSE a __. _ —_ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE9j OTHER❑ STATION l(A)_2(8)_3(C)_t4(D)_5(E)... - INCIDENT LORATION: � RESPONSE CODE: IE�UESTED BY: TIME– (24 HOUR CLOCK) C C y� .0. – CALL RECEIVED �L / b TO SCENE � 5❑ P.D. TIME 10.8 PATIENT DESTINAT N: FROM SCENE -V ❑ FIRE TIME 10.97 : l /� / O PSAP TIME 10.49; -`1 41 . MILEAGE: ❑ OTHER/PVT TIME 107 :;. �� END ' 7 TIME 10.88 DOCTOR Zv PMDLER/ START _ TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME y L/ 1 ❑ NEAREST L7 FAMILY ❑ TRANSFER WAIT TIME `�, _ j ❑ PATIENT ❑ DIRECT ❑ OTHER ) CALL BACK N: AMBULANCE COMPA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �1 O YES X NO ❑ WAL'CED IR'GUERNEY ❑ OTHER c PATIENT CONDITION: DRIVER Jf d J EMT-tA ( ? TECHNICIAN () PARAMEDIC Hx: ^ f: Ca� L'?v it/ DISPATCHER: ? 1 7 ( CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) L PATIENT REFUSED SERVICES: (SIGNATURE) X_ �'- C MED1C(�L COVE��G ` INDUS IALC YES I NO NO. OF PATIENTS: S.S. N_ ( � b A 7 PRIVATE INS. CO.: BASE RATE: �� KAISER x: MULTIPLE PTS. BASE RATE { BLUE CROSS N: TOTAL MILES: X 'J Z✓�� MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ' O YES ❑ NO NIGHT: (19:00-07:00) l I CCHP/PPHP N: EMERGENCY RUN: _ MEDI-CAL+� CODE 2/3 ER: OXYGEN: (PER TANK) ' P.O.E. STICKER ❑ YES RINO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) Xyvlj DRUGS: (PER ADMIN.) X � NAME- aAR IONS I E.O.A.: (IF NOT REPLACED) ADDRES L / ORAL AIRWAY: (IF NOT REPLACED) CITY `�iI- STAT �!ZIP: C COLLAR: (IF NOT REPLACED) -- PHONE:L 7 3�j WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTH5R: ,? ADDRESS: CITY: STATE:NOZI� _... ._. COMM TS: t � ,4 t,t. {tet' TOTAL: � PATIENT RECEIVED BY: 5` (SIGNATURE) as-I Provider retain White rdN vj•� Sega+: }'v'Iur, r �?!.' ukv, bit"in CONTRA COSTA COUNTY AMBUI,4NCE (moi PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION w " CHECK OR PILI INAPPROPRIATE SPACES DATE: PATIENT'S NAM I O M ❑ F COMPANY 0 1r) 1 ADDRESSAGE D !? ' � CITY I STATE ZI DOB Sn ❑ M ❑ T ❑W ❑ Th PF ❑S DRIVER'S LICENSE 0 1 - PHONE NATURE i PAT H ' i- • E E •S C � < Call TYPE OF TRANSPORT:. AMBULANC OTHER❑ - STATION 1(A�2(B)_3(C)_4(D)-5(E)_ CIDENT LOCAT O ( RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED r. r ❑ P.D. TIME 10-8 -2- FROM PATIENT ESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 r,, �/� _ �I ❑ PSAP TIME 1D-49 �5 �! lbad � �1 lY AI 'P, NAV A V MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR"'- PMD/ER START TIME 10-22 1 3 HOW CHOSEN: TOTAL STANDBY TIME ��•_ ❑ NEAREST -FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRE ❑ OTHER CALL BACK k: AMBULANCE CO A Y• PT. AMBULATORY? PATIENT AKEN TO AMBULANCE: C) RESPONSE ZONE ❑ YES ❑ NO ❑ WALK ❑ GUERNEY ❑ OTHER ' PATIENT CONDITION; DRIVER TECHNICIA r PARAMEDIC -- Hx: DISPATCHER: c CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN }�-�j AUT IZATION FOR DRY RUN(EMS USE ONLY) (fin 1 L/ PATIENT FUSED SERVICES: (SIGNATURE) X �C�y MEDICAL COV RAGE: .. - INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: J S.S. r PRIVATE S.CO.: BASE RATE: KAISERR, i MULTIPLE PTS. BASE RATE BLUE CROS ' " TOTAL MILES: MEDICARE M:: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0::1 EMERGENCY RUN: MEDT-CAL K: ! CODE 2/3 OTHER: OXYGEN:. (PER TANK) P.O.E. STICKER ❑ YES ❑ N NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MI E.K.G.: (PER EPISO ) ..-NEAREST RELATIVE/RESPON ISLE PARTY: - I.V.: (PER ADMI X DRUGS: (PE ADMIN.) X ---NAME:— RELATIONSHIP: E.O.A.: (IF N T REPLACED) ADDRESS: ORAL AIRW Y: (IF NOT REPLACED) - CITY: STATE--ZIP: C-COLLAR: ( NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AU HORIZED) EMPLOYER:• OCCUPATION: OTHER: ADDRESS: CITY: TE• ZIP: -COMMENTS: — TOTAL: -._-• --.----------_------_...---. .. ..- _ - PATIFNT RECEIVED BY X�- -._-- CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITr�,� AUTHORIZATION / 1 •, CNECK ON PILL INA OPAIATE SPACES I DATE: vz?L 3 PATIENT'S NAME J Om ❑ F COMPANY M ADDRESS - ' / AGE _ R U�1 CITY STATE ZIP DOB )9�Sn O M ❑ T El w O Th O F OS DRIVER'S LICENSE It _ PHONE _ NATURE OF DISPATCHy4'��-n1 ne TYPE OF TRANSPORT: AMBULANCE 0 OTH STATION 1(A)_218).._3IC)_4fD)_..5(E)_ INCIDENT LOCATION. i RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- O. CALL RECEIVED LL : re1-- u P.D. TIME 10-8 -�-.� ; L.-Z" PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10.98 f'DOCTOR ' ,f PMD/ER START HOW CHOSEN: - TOTAL STANDBY TIME c'7 ❑ NEAREST' O FAMILY ❑ TRANSFER WAIT TIME -- O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY- ;LAS OMPANY: nS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c_) RESPONSE ZONE_ ,..�� ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER M PATIENT CONDITION: DRIVER F� �� EMT-tA 1 TECHNICIAN A'G u 771 PARAMEDIC Hz: DISPATCHER: /7 CHIEF COMPLAINT: DRY RUN YE 13 NO REASON FOR DRY RUN./0-71 G0 A AUTHORI TION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1 I!� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: J S.S. r PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHF/PPRP N: 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.) 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: /y�oAN e L LU_A C,,,n j ,Dr Tin �S��n � c/p1c0 I 1 c T TOTAL�TC'' PATIENT RECEIVED BY: X.. P-44P Mtn(n 011 I• . ,nl I'i n� (SIONATURE) •,.I,� N�fur' Y. i.• ....I.� 1 ffl.' t�tion f�(I i�yl CNS-1 \ CONTRA COSTA COUNTY AMBULANCE `7 _ RE-HOSPITAL CARE FORM I UNIT AUTHORIZAN N CHECK OR PILL IN APPROPRIATE SPACES DATE: TI 7 PATIENTS NAME, O tv; O F COMPANY N ADDRESSA AGE`S_ C v CITY S ATE_ . ZIP DOB DOB "n O M O T O W OC Th O F O S DRIVER'S,LICENSE N _ PHONE—_ NATURE OF DISPATCH AQ ..L . TYPE OF TRANSPORT: AMBULANCE OTHER — STATION 11A)_2(81-3(CI 41D)_5(E)_ INCIDENT;tOCAT10Nt — - k RESPONSE CODE: RE ESTED BY: TIME— (24 HOUR CLOCK) C v 7 3� TO SCENE- 0. CALL RECEIVED : Z/ V.D.. TIME 10-8 PATIENT DESTINATION: -" FROM SCENE- ❑ FIRE TIME 10-97 O PSAP . TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END��T TIME 10-98 A DOCTOR�' •7'.., i._.. ~1 PMD/ER START ` TIME 10-22 _ G S, HOW CHOSEN: TOTAL STANDBY TIME El.3 ❑ NEARESTr,,, O FAMILY O TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT O OTHER CALL BACK M: AMBULANCE COMPAIr PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J l RESPONSE ZONE (( ❑ YES ❑ NO I ❑ WALKED ❑ GUERNEY ❑ OTHER 1. Af PATIENT CONDITION:— DRIVER � � �L� EMT-1A 7 JS I Fi i .. 11 .• TECHNICIAN �' V PARAMEDIC I Hx: DISPATCHE t-( �l CHIEF COMPLAINT: -'CORY RUN: YES NO REASON FOR DRY RUN/�` Q 1 --AUT.HQBIZATION 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 N; MULTIPLE PTS. BASE RATE BLUE CROSS N TOTAL MILES: X MEDICARE If: - E.O.B. ATT. ROPND TRIP: '0 YES O NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPHP 041 ' 1 EMERGENCY RUN: MEDI-CAL N: I CODE 2/3 OTHER: "' ' OXYGEN: (PER TANK) P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) — NEAREST RELATIVE/RESPONSIBLE PARTY:"'" - " 1.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: S COMMENTS: v TOTAL;'57 C-22 I V± # I I PATIENT RECEIVED BY: X I i � PATIENT'S NAME: Crockett Fire Department i ADDRESS: 74A Loring Ave • Crockett Ca DATE OF SERVICE: Qg_07_83 1 . f AUTHORIZATION NUMBER:81 11219 AMOUNT DUE: INCIDENT LOCATION: 2Q Command Post ( Standby PATIENT DESTINATION: Stand By No pick Up .,Seg' 7{ ;i�� ' �,�jki �.�•.c. .:l^ Auc 7 4 04 PM AR 7 4 os PM '83 AuG 7 4 os IM 183 .1.2 63 39 11.1fif p (All WCEIVID AMBULANCE DISPATCHED AM8U1ANCE ENROUTE 10.8 CALLED BY-- p PATIENT INFORMATION 0 1 IUD D AGENCY _ CUSTOMER t, (PT. 1): DOB > : DEPT FLOOR,ROOM - _INAME r zm z CAURACK It INS. TYPE: PVT MCAR MCAL KHP PHP CHAMPUS > VA IND _41 INCIDENT LOC: . A k POLICY'MCAL (7,r- n 0 u m MCAR z CROSS STREET: VERBAL PRIOR: IkIRIS city 00,( DOCTORi DESTINATION: PT. #2 NAME: DOB: NATURE. F1 DOB: c 0 /t CUST. # u yp5'- A NA E'- — — 7 UNIT 011 f -_ z TYPE OF CALL: TRANS TIME CREW SC)thft _;10.�e VZ_ -WAIT TIME: YES NO REASON: Z 0 UNIT TYPE: �cT� BLS WC RESPONSE CODE:, 01 3 41 REASON FOR )0-22: 0 C INCREAS&_Q_E_C`RE_A_,�E CODEQ)3 10-49 CODE: 0 1 2 3 4 CANCELLED BY: m x U BY. END MILEAGE: COMMENTS:su 0 z TIME. BEG MILEAGE: DISRQTCHE TOTAL MILES: IV 9DNV1no,, 6t-01 ONINNnlgd gDNvinowv 86-OL 3.19V11VAV 3:)Nv1nsw v L-01 lvlld IV 3:)NV1n8;V1� Ego Wd go 6 L soy E1. WJ 90 6 L Dnn Jz' Ar Z. W 1 -77. 4ry if IL vL J 4,4 FT 7771 ix C;! 4Q T 17 r. .. .......... 7, CONTRA COSTA COUNTY AMBULANCE C - PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES _, DATE: PATIENTS NAME_�J,f �T ��43ni ( �/�LU /'� 1 �M ❑ Ff COMPANY• ADDRESS AGE-? 0 F' 'L7 V i CITY�c� ( fK�►'� STATE ZIP'27!/_e_ D083-- l- L/ n M E3 T.O.W-❑Th 4 F p DRIVER'S LICENSE# _ - PHONEQ� 7/ NATUR OF DISPATCH TYPE OF TRANSPORT: AMBULANCE PSOTHER❑ _ STATION 1(A) (B)_3(C)_4(D)_.._5(EI�....�J INCIDENT LOCATION: RESPONSE CODE! REOUESTED BY: TIME- (24 HOUR L CK) -7 TO SCENE- S.O. CALL RECEIVED ❑ P-D. TIME 10-8 PATIENT DESTINATION: -�J� FROM SCEN ❑ FIRE TIME 10-97 / ❑ PSAP (TIME 1D;49-'A dr JA MILEAGE: ❑ OTHER/PVT TIME 10-7 0 ✓ : f`�� END ' Z TIME 10-98, ; DOCTOR v L PMD/ER START TIME 10-22 HW HOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER eL12 ' WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALLiBACKN: AMBULA C M NY: PT. AM ORY? PATIENT TAK N T AMBULANCE: v RESPONSE ZON ❑ YES z NO ❑ WAL'<ED ❑VERNEY ❑ OTHER PATIENT CONDITION: DRIVER C' �U ' �� EMT-1A - 1 :I TECHNICIAN ;K71. / o-/15->r';�2 70 PARAMEDIC ~� Hx: _ IG/J P r 0lJDISPATCHER: P, 1 CHIEF COMPL INT: 4 LQ DRY RUN: ❑ YES NO REASON FOR DAY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES 4-NO NO.OF PATIENTS: S.S. M J• 1 J-`` PRIVATE INS.CO.: BASE RATE: -'`' c •tC!� KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: r X MEDICARE»:�`1`e .7-G S'- 7,C-,14 11- E.O.B. ATT. ROUND TRIP: YES ❑ NO , - �1 i:•�a ': -,?�.4.moo �� ❑ YES ❑ NO NIGHT: (19:00-07:00) CC «: EMERGENCY RUN: �D Fnl-CALM DC7 7�, EJG �, V .' O�'��7� j CODE 2/3 ��" ,JC •� 1 s�tl'1.:— OXYGEN: (PER TANK) r P.O.E. STICKER ❑ YES ❑ NO NEONATAL' (INCUBATOR) " �'v i 3 3./' IX.� ,. DATES BILLED: STANDBY: (OVER 15 MIN.) E-K.G.: (PER EPISODE) - �/ NEAREST RELATIVE/RESPONSIBLE PARTY: - I.V.: (PER ADMIN.) -�*-- "]� DRUGS: (PER ADMIN.) X NAME: � oy1 /� S �� RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - --� -- - - ADDRESS:- S••� . ORAL AIRWAY: (IF NOT REPLACED) CITY: -STATE- ZIP: C-COLLAR: (IF NOT REPLACED)------ PHONE: EPLACED)-----PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: L/,o_elll T�! — OCCUPATION OTHER: - •_-.. ....__.-_ _ __ _ ADDRESS: CITY: r STATE: ZIP! - - COMMENTS: ClG� Ct t �J ✓� V� " _.. TOTAL: - ---�•- PATIENT RECEIVED BY:X Pr•-,,irirr rota: whim rxd N,;, :•��� votu— Yt:?r,u v^s t fw uhrn Frim (SIGNA URE) DIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATEN N o.._... .. ��—� CHECK OR TILL INAPPROPRIATE SPACES DATE: PATIENTS NAME 1 - � ❑ M ❑ F COMPANY N ADDRESS. - k D J2 0IJ i • AGE` ((�� CITY STATE ZIP DOB tl^�Sn ❑ M ❑ T ❑ W ❑ ThO F 13S ' ! DRIVER'S LICENSE N _- -i PHONE NATURE OF DISPATCH P031 be,0i2 i TYPE OF TRANSPORT: AMBULANCE 0 OTHER O _ 1 STATION t iA)_2(B)_31C1._4(D)_51E)_. INCIDENT.LOCATION n �7 • .'i•s RESPONSE CODE` REQUESTED BY: TIME— (24 HOUR CLOCK) ' ri S(� ` TO SCENE- S.O. CALL RECEIVED r Z 1 r ` 1•', '�1 - 13P.D. TIME 10-81 PATIENT DESTINATION: .-- FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: OTHER/PVT TIME 107 - END TIME 10-98 J ( : ?T^— � >-bOCTOIi `^ ' r' PMD/ER' START TIME 10-22 HOW CHOSEN: TOTAL�— STANDBY TIME Zlr-i ❑ NEARESTi'Z? ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: C1-1 ,) 2 2— PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J�) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: - DRIVER l-y$l I«1� ',),l� E M T--1 2 7 ! TECHNICIAN IC , 3 _-PARAMEDIC F DISPATCHER: qqCHIEF COMPLAINT: DRY RUN. YES ❑ NO REASON FOR DRY RUN qqI AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l I 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 C. E.O.B. ATT. ROUND TRIP: OYES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: ` EMERGENCY RUN: MEDT-CAL It: i CODE 2/3 OTHER: t" ' 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) �2J EMPLOYER:- OCCUPATION: OTHER: ADDRESS: CIN: STATE: ZIP: COMMENTS: 7 TOTAL: ' PATIENT RF('FIVFD (1Y X ✓, I 1 CONTRA COSTA COUNTY AMBULANCE _ P PRE-HOSPITAL CARE FORM I UNIT / AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: D✓ - PATIENTS NAME ( n c�p,�s �1 C- 5 ( C• - C ti n � M O F COMPANY M ADDRESS 7 r) V LL MP yQ� AGEE CITI'�LO d e w o STATE ZIP DO& W O Sn O M O T O W 13 Th O F p S " DRIVER'S LICENSE N ____ PHONE _— NATURE OF DISPATCH— //- '71 TYPE OF TRANSPORT: AMBULANC&AL OTHER❑ _ -- STATION 1(A)_2(B)_.3(C)-4(D)_5(E)_ " INCIDENT LOCATION: RESPONSE COO REOUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED ❑ P.D. TIME 10-8 i I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 73 - (� O 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 ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CO�MMPAN: �7T \ \AMBULATORY? PA ENT TAKEN TO AMBULANCE: RESPONSE ZONE - YES ❑ NO WAL'<ED ❑ GUERNEY ❑ OTHER !!!! PATIENT CONDITION: DRIVER TECHNICIAN IC Hx: DISPATC CHIEF COMPLAINT: DRY RUNYES 13NO REASON FOR DRY RUN AG _ AUT' ORIZAT FOR DRY RUN(EMS USE ONLY) t PATIENT REFUSED SERVICES: (SIGNATUR X „/�� �,7 -4.2 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: --•�✓ S.S. N -- i 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 ❑ NO _• ""`' O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: I ---I 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: PATIENT RECEIVED BY:X C Pmvider reta:r• white vd Pia% rop4 5etwrn Ye'luw mpu t �l.S when Dil"inp (SIGNATURE) SIS-� CONTRA COSTA COUNTY AMBJ11 PRE-HOSPITAL CARE FORM I C t UNIT AUTHORIZATION N ULANCM _ I CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME Tr��r d M ❑ F COMPANY N ADDRESS � -� �,' C�` AGE I , ' CITYSTATE ZIP DOBL 3 J O SM T OW ❑ Th OF O9a DRIVER'S LICENSE q _ _ PHONE NATURE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A)_2(8),3(CI_4(D)_5(E)___ INCIDENT LOCATION: RESPONSE CODE: EOUESTED BY: TIME— (24 HOUR O K) {. TO SCENE- S.O. CALL RECEIVED D. TIME 10-8 PATIENT DESTINATION: S FROM SCENE O FIRE TIME 10-97 CIL }, ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 10-2• END 17'.S TIME 10-98 L24l- - - DOCTOR ��� Z PMD START TIME 10-22 :------ HOW HOW CHOSEN: TO ' STANDBY TIME -l NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT O OTHER CALL BACK K: AMBUL CE O PANY: PT. AM LA DRY? PATIENT TAK N TO AMBULANCE: 1510 RESPONSE ZONE �- ❑ YES NO ❑ WAL':ED UERNEY, O OTHER —) PATIENT CONDITION: DRIVER C_ r K6_tA f2l_ac_ 7/ L 510 EMT-1A f 77 � TECHNICIAN�' � Boa PARAMEDIC L-- " r Hx: �' /v1 Bb / "�� C 6�C��i/�)S� DISPATCHER: CHIEF COMPLAINT: DRY DRY RUN: O YE (IN REASON FOR DRY RUN r I AUTHORIZATION RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X c / MEDICAL COVERAGE: INDUSTRIAL El YES ❑ NO NO. OF PATIENTS: •, J S.S. 0. - PRIVATE INS.CO.: BASE RATE: ' KAISER MULTIPLE PTS. BASE RATE , / I LUE CROSS l' �, 2 4 C TOTAL MILES: X % �J j �� / ' L '2 E.O.B. ATT. ROUND TRIP: O YES O NO a; ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN:' �'�— —U MEDT-CAL K: CODE 2/3J Z1 7 OTHER: OXYGEN: (PER TANK) ..— P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) XJ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X _-- n ) DRUGS: (PER ADMIN.) X �l d�J 1.sc'3v NAME: ���I RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - ADDRESS: S Ay ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE:_ DRY RUN: (AUTHORIZED) EMPLOYER: lc dk NA5'._ OCCUPATION: "ld e*" OTHER: i 7 ADDRYE CITY: C �i 6V /1 TATE: ZIP: �� COMMENTS:i.1MQ IN L ;,; u / TOTAL: <7i PATIENT RECEIVED BY;X Provider ret a-,. Vhito <rd Tic= a < < (SIGNATURE) �• T. at�rn YO�i!'V •nri t• E.?L, when Cif'inp 01f-1 CONTRA COSTA COUNTY \ AMBULANCE $!; PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M ' r O CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME{ (ACPtLu i)Ss� RnEs -lI. I O M\ COMPANY p ADDRESS y WtSTAGE_LZ� 1 /^ CITY RTC�-t STATE ZIP 2 I04 DO ❑ T ❑ W ❑ Th ❑ F O S DRIVER'S LICENSE R _ PHONE 7 NATURE OF DISPATCH TYPE OF TRANSPO T: AMBULANC 7HER❑ __ _---_. -____- STATION 1(AL (B)_3(CI_4(D)_5(E)_ INCIDENT LOCATION: i t RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK)` f TO SCENE- ❑ S O. _— CALL RECEIVED �- : =rcH oz ,AL.1j4 C( purr ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 J� �) �= O PSAP TIME 10-49 ;7 MILEAGE: 4 ® OTHER/PVT TIME 10-7 �CLEND U TIME 10-98 DOCTOR P ; .� �` I, {`'�- ` r PM ER START TIME` TIME 10-22 HOW CHOSEN TOTAL—7— STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER> WAIT TIME —_ O PATIENT ❑ DIRECT ❑ OTHER ( CALL BACK 4: AMBULANCE COMPANY: ("A PT. ❑ AMBVLA�Y? PATIENT TAK M ULANCE: RESPONSE LZ�O�NEhYES V{LNPI ❑ WAL'CED UERN13 OTHER PATIENT CONDITION: DRIVER l i�n` �^ -L 1`� ---� MT-tA TECHNICIAN _r��1�,�r � 7 Z. PARAMEDIC Hz: 730 t) - P25 1 r C21121) DISPATCHER: CHIEF COMPLAINT,- G-fV LILA"W w 6qY RUN: ❑ YES REASON FOR DRY RUN �4 Uuo 0 s 1-O£ LL ; (,.iti%5 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO OF PATIENTS. SS y t� �� - PRIVATE INS. CO.: BASE PATE- KAISER v: ATE-KAISER'•: MULTIPLE PTS BASE HATE I _ BBL S 0: TOTAL MILES: // X ' /' / I ,- MEDICARE L03- ( Iy " It 53 E.O B. ATT. ROUND TRIP: ❑ YES 0 NO ' ❑ YES ❑ NO NIGHT: (19 00-07:00) CCHP/PPRP M: EMERGENCY RUN: ' MEDT-CAL 4- CODE 2/3 OTHER: k I OXYGEN: (PER TANK) P.O. . STICKER ❑ YES 0�NO NEONATAL: (INCUBATOR) N,PATS 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: 1 ZIP:— COMM E NTS: IP:COMMENTS: (-) C. I1 TOTAL: PATIENT RECEIVED BY: X P L+�tA RE) mwi•ior retain Yhite ..n./ /'ins ,•.,ISM !wfur+i i, ,. •1•� ! F;pi: ul.,•n fit in,I ( EMS•1 CONTRA CO%IA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I I UNIT E] AUTHORIZATION M - / CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME_�I ._}'_._I_'-".'�:, :._.__.. Ir r_• /❑ M OF COMPANY 0 ADDRESS _�Z2��c > S Y' CCj�^ p IG'-� #(LI'bAGE 1 I , G CITY I�`"� �' STATE Ct-j�_ ZIP 7 `I' DOB - ❑ Sn �rM ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE n PHONE_ _____ NATURE OF DISPATCH l-n1CC�� �C�'S CY1^"�`��' TYPE OF TRANSPORT: AMBULANCE0 OTHER❑ . .__.__...._ ._....__ STATION 1(A)_20,31C)_..40_51E)_ 7. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK). TO SCENE - 3 JL &S.O. _ CALL RECEIVED v j ! l ❑ P.D. TIME 10-8 /i PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 c:7 MILEAGE: �. ❑ OTHER/PVT TIME 10-7 _2 U n END TIME I0-98 J Z DOCTOR <lIC( PMD/ START-22• - TIME 10-22 HOW CHOSEN: YYY TOTAL — STANDBY TIME ` ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: CAS PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: c cl RESPONSE ZONE YES ❑ NO ❑ WAL'(ED 0. GUERNEY ❑ OTHER (� 5- PATIENT CONDITION. DRIVER I)A EMT-1A 11''ti�LC�ii . �u_L ( TECHNICIAN —bu E � r PARAMEDIC y H, _tL _ t t �i 'r �_L*— DISPATCHER: ' GUy (. CHIEF COMP AINT: ' .,I'I' r c^ t t� E«I DRY RUN: ❑ YES krNO REASON FOR DRY RUN �f �,�(� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X___ 1 ( MEDICAL COVERAGE. INDUSTRIAL ❑ YES 0 NO NO. OF PATIENTS: /G) S.S. # PRIVATE INS. CO.: / BASE RATE: L: ^T S MULTIPLE PTSBASE RATE KAISER R: ��S'' 3 i; ��''� ,: v �-y�l�,..) 1.1 . .. BLUE CROS C� A 17 A TOTAL MILES: /3 X M G /� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO J 5 ?` ❑ YES ❑ NO NIGHT: (19 DO-07:00) J CCHP/PPRP a: EMERGENCY RUN: MEDt-CAL a: CODE 2 1 3 �� 7 OTHER: OXYGEN: (PER TANK) U�7 1 P,O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) y DATES BILLED: STANDBY: (OVER 15 MIN.) •I f�JI E.K.G.: (PER EPISODE) ~ I1 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: OT R: ^ ADDRESS: I CITY: STATE: ZIP: COMMENTS: TOTAL PATIENT RECEIVED BY:X 7'.,vi,lrr rr•• r cr (SIGNATURE) -*0 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I \ uNITAUTHORIZA( TION CHECK OR FILL IN APPROPRIATE SPACES DATE: ) Its — PATIENTS NAME I ❑ M O F COMPANY. ADDRESS K ` AGE CITY- Q�`��il� STATE ZIP DOB5�1.�/6S/❑ Sn M ❑ T 11W ❑ Th 13 F O S DRIVER'S LICENSE R .T- PHONE �_Z,_14ATURE OF DISPATCHS� • - TYPE OF TRANSPORT: AMBULANCE-Er OTHER❑ __ STATION 1(A)_218)_3(C)_4(D)_51E)_ ' t INCIDENT LOCATION:' �� RESPONSE CODE: RE.OGESTED BY: TIME- (24 HOUR CLOCK) TO SCENE El S.O. CALL RECEIVED ❑ P.D TIME 10-8 /' Z PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10.97 _ ❑ PSAP TIME 10-49 4 lj (� MILEAGE: ❑ OTHER/PVT TIME 10-7 2 (� END TIME 10-98 L DOCTOR:Ilk L�/�T7-w PM /ER ST TIME 10-22 HOW CHOSEN: TOTA_L STANDBY TIME ❑ 1I.EAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER I_ l 1 CALL BACK a: AMBULANC `COM ANY: [EO'YES BULATORY? FPATIENT TAKEN30 AMBULANCE: �� RESPONSE ZONE❑ NO L'(ED 'pr-Tl ❑ OTHER PATIENT CONDITION: DRIVER�l�C-{�cV1 ) L���-�-t Try/, EMT-1A ; TECHNIC IA�� ,�-LSU'PARAMEDIC J) Hx: s�CY 5��1 'p(J DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ,glNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— / MEDICAL COVERAGE: 14D STRIAL ❑ YES 11 NO NO. OF PATIENTS:CD ' (S.S. N _�' PRIVATE INS CO CZ-K BASE RATE: �" t .� KAISER R; MULTIPLE PTS. BASE RATE B E CR SS N: TOTAL MILES: X MEDIC E E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO C}�'/G f• 'l•% ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP_N:� f EMERGENCY RUN: "I ' / MED(-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) e, 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) 1 CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) - / PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: �-� STATE: ZIP: COMMENTS: — ---- TOTAL: _ 7L•�1�- _. - ---- -- PATIENT RECEIVED OY. X Prrvidvr rotair, h. i �i Whit, ...l l •,' p (SIGNATIME) �� �t:.ni , LMS•1 CONTRA COSTA COUNTY AMBULANCE r s PRE-HOSPITAL CARE FORM I UNIT ' AUTHORIZATION 0 �-� 13 2 � c � CHECK OR FILL IN APPROPRIATE SPACES DATE: J (� •� PATIENTS NAME f1L L E Om F COMPANY M ADDRESS Z Y49 K MAINZ 1 .S AGE CITY RI C-H MVQD STATE C114p �T ZIP / y�— DOB 5_ –S� ❑ Sn PM OT ❑ W O Th ❑ F ❑ S DRIVER'S LICENSER __ PHONE Z 3�_�? 3_� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ __ -- STATION 1(A)-2(B)-3(C)_4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME — (24 HOUR CLOCK) / TO SCENE- z O S.O. CALL RECEIVED CD 1j �) �f�(QN� /�t� 1_/(L �F 4_ W ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - Z ❑ FIRE TIME 10-97 .� 1� _ _ O PSAP TIME 10-49 'VALLtJC+ ZQ_oA1)wAV L)/11 ti MILEAGE: S X.pTHER/PVT TIME 10-7 r END 4 � r'3 TIME 10-98 DOCTpRV PMD/ER START /tV3 y.i .) t_ � \ 11 - TIME 10-22 HOW CHOSEN: TOTAL, 1 7 •hSTANDBY TIME ❑ NEAREST O FAMILY `TRANSFER , . 1 WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER 1 ' ` I CALL BACK C AMBULANCE COMPANY: L�S PT.,-AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 19 ES ❑ NO ❑ WALKED %,GUERNEY ❑ OTHER r r PATIENT CONDITION: DRIVER T-lA ., _ TECHNICIAN WI S t>,�{ r PAR EDIC j > Hx: -'1-(t "AI-A LD t S O R,PE2 DISPATCHER: r .� CHIEF COMPLAINT: 5( S U DRY RUN: ❑ YES WNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) /7.l PATIENT REFUSED SERVICES: (SIGNATURE) X .t= M OICAL COVERAGE: INDUSTRIAL ❑ YES kNO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RTE: KAISER a: MULTIPLE PTS. BASE RATE r— BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHPIPPR N: EMERGENCY RUN: �D A ( Qy '"d5o CODE2/3 OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O 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: 9"loLw'-4 . o L I r RELATIONSHIP: rH� E.O.A.: (IF NOT REPLACED) '7 ADDRESS: '47` 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: P7- • vJ 00 L DIN T_ �"N f�•a' _..-- :I — ---- TOTAL:._-2Z2 __o --- PATIENTRECEIV[DBY. X r.- (';IC;NA 7 1 r(IF) - CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I ` 1 UNIT ® AUTHORIZATION N o1Z - _ " .. ,.. ,..., •. �; � amu- �3 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NA,6i j ' "mow ❑ 1, ❑ F COMPANY N ADDRESS: Z, '; AGE` I CITY ----STATE-----,,.ZIP DOB ❑ Sn b(M OT OW hO Th OF O $ DRIVER'S LICENSE N ' -- ( - PHONE ,._� NATURE OF DISPATCH 12'1 i TYPE OF TRANSPORT:'AMBULANCE OTHERO STATION 1(A)_2(B)_3(C)_4(D)_5(E)_'*b_- INCIDENT L CATION:r ---� RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) ! TO SCENE S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATTEN DESTINATION: J FROM SCENE, ❑ FIRE TIME 10-97 � � { ❑ PSAP TIME 10-49 ��� �•-` ��`!/�'(�^ ± MILEAGE: ❑ OTHER/PVT TIME 10-7 -• ,r ENDTIME 10-98 r DOCTOR PMD/ER STAR- TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST.-:- ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPY:c PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE I ❑ YES ❑ NO _ I ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: --' DRIVER Li CAS 2 1 O E -1A .J TECHNICIAN TE� 't 05 ARAJIMEOIC Hx: E l 'Z �' , DISPATCHER: (Ce I e UU LI lob CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN I �, t AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Ili/ SSU' L� '.. �; ):PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: _ ._ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �/�� /•� r S.S. N PRIVATE INS.CO.: BASE RATE: KAI MULTIPLE PTS. BASE RATE B UE CROSS N: TOTAL MILES: X MEDICARE C. r E:O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) - CCHP/PPHP N:) ' EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER O YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/R SPONSIBLE PARTY: I.V.: (PEA 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: l ADDRESS: CITY:` STATE: ZIP: f --COMMENTS: - - TOTAL: c'7 CJ',C-2 - _ ._. ..-. _.. .". I1ATIr.1T nr�rivr-rn nv v � ( f CONTRA COSTA COUNTY j AMBULANCE ? PRE-HOSPITAL CARE FORM I UNIT _ ( AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: 14 ` PATIENTS NAME 1_�+\L.0 ����`� L7 M ❑ F COMPANY R /'?' li1 ADDRESS 1� //> 1 I ( AN a u�\1.�=1 AGE,"5 i CITY nl'1A-AN r> STATE GAL- ZIP 11y.C�..)- DO/_8 �?' ❑ Sn �M ❑ T O W ❑ Th O F t1 S DRIVER'S LICENSE 0 ��_���.�"^^- PHONE5.�+ .!-5? 4_ NATURE OF DISPATCH �'� ( ► `r�( � ' 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 3 S.0. -_ CALL RECEIVED O P.U. TIME 10-8 <� PATIENT DESTINATION: FROM SCENE ❑ FIRE -- TIME 1D-97 / , ,^- ❑ PSAP TIME 10.49 f ,!•. 1 c1 �J� ✓� r -` MILEAGE: ❑ OTHER/PVT TIME 10-7 END �i ( ` TIME 10-98 r•: DOCTOR �O Q I ( PMDQF START L�G TIME 10-22 HOW CHOSEN: TOTAL —�� STANDBY TIME I*EAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER ( ) CALL BACK K: AMBULANCE COMPANY A S KAMBULATORY? PATIENT TAKE TO AMBULANCE: 'I RESPONSE ZONE ES ❑ NO ❑ WALKED GUERNEY Cl OTHER J I�UN PATIENT CONDITION: DRIVER - � r � � �L�L�S EMT-1A • /n] TECHNICIAN ���� PARAMEDIC �- Hx. !y5 -�r`` DISPATCHER: -2OV'ceL CHIEF COMPLAINT: TA;R.3 DRY RUN: ❑ YES jb�NO REASON FOR DRY RUN A IZ 11/1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) C� I PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES N NO. OF PATIENTS: S.S. Ky.1\L.. u L,,-•" V PRIVATE INS. �� BASE RATE: KAISER R: _ vh��"L,', TY P� MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X �" J t� • :J MEDICARE it: E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES .O NO NIGHT: (19:00-07:00) CCHPIPPHP C EMERGENCY RUN: 150'`nJ MEDT-CAL R: (l OhC� CODE 2/3 7 OTHER: OXYGEN: (PER TANK) U/ 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#_A L-, L.v C i L L,_- RELATIONSHIP�� E.O.A.: (IF NOT REPLACED) ADDRESS: S P ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHOII IE:6 f�-`/1.5'-i DRY RUN: (AUTHORIZED) EMPLOYER: E-7L> STAR 4''6?CbPATION:Dn I V ER OTHER: ADDRESS:�l5 �'�'I�S /�► v .T �� O���� CITY: - 0 4 K LA h+D STATE: CA ZIP: COMMENTS: LV- -P,-7el Ac ,-.,s 4-f IZE it 51672 , H CIE HAS /AJS✓/ZANl�.-- -- TOTAL �. ._. PATIENT RECEIVED BY X P-widrtr• rvt.Iic Ll 71 .. CONTRA COSTA COUNTY AMBO NCE 7 PRE-HOSPITAL CARE FORM I UNIT _ AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: V PATIENTS NAME _ - ❑ M ❑ F COMPANY# y� E� ADDRESS AGE ADRI� Pilo CITY STAJE .. ZIP DOB ❑1 ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# ---,. PHONE_ —__-_._ NATURE OF DISPATC TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT OCATI RESPONSE CODE: EQUESTED BY: TIME- (24 HOUR LOOJK)� TO SCENE - O. — CALL RECEIVED L O P.U. TIME 10-8 1 PATIENT DESTINAT N: FROM SCEUV ❑ FIRE TIME 10-97 l _ ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10-7 Y) END TIME 10-98 !' DOCTOR PMD/ER START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT O DIRECT Cl OTHER CALL BACK#: AMBULANCE C�QMP� PT AMBULATO ? PATIENT TAKEN TO AMBULANCE: Jo RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CO DITION: DRIVER 7� ��pp_�� EMT-tA ` TECHNICIA _ iY_I �!1_ PARAMEDIC Hx: DISPATCHER:- CHIEF COMPL INT: DRY RULES ❑ NO REASON FOR DRY RUN t� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT RINSED SERVICES: (SIGNATURE) X___ (�7 ✓' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: r KAISER#: - MULTIPLE PTS. BASE RATE P BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#; Z EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER YES ❑ NO NEONATAL: (INCUBATO DATES BILLED: STANDBY: (OVER 15 M ) E.K.G.: (PER EPISODE) NEAREST RELA VE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER IN. X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPL CED) CITY: _ STATE-_ZIP: C COLLAR: (IF NOT REPLAC ) PHONE: - WORK PHONE: DRY RUN: (AUTHORIZED) �— EMPLOYER: OCCUPATION: OTHER: r ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: __. PATIENT RECEIVED BY: X rslcNA rupEI 1 .{ ( CONTRA COSTA COUNTY 1 AMBULANCE p, ? , / Z PRE-HOSPITAL CARE FORM 1 !�+ UNIT AUTHORIZATION N b J ! J „ CHECK Ott FILL IH APPROPRIATE SPACES DATE: 4 'PATIENTS NAtu(E `�' ❑ M OF COMPANY N ADDRESS;t'" " ( _ ( ` AGES CITY - STATE_ •ZIP__-_y__DOB ❑ Sn OT OW O Th ❑ F OS ; DRIVER'S LICENSE N L---- •• PHONE (NATURE OF DISPATCH _ V t L T�.A 1 TYPE OF TRANSPORT:, AMBULANCE 0 OTHER 11 _ ' — STATION 1(A)_2(9)_3(C)_4(D)_5(E) INCIDENT LOCATIONI RESPONSE CODE': OUESTED BY: TIME— (24 HOUR CLOCK) R TO SCENE- S.O. CALL RECEIVED O P.D. TIME 10-8 PATIENT DESTINATION: - FROM SCENE- O FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END N TIME 10-98 DOCTOR PMD/ER START J TIME'10-22 � HOW CHOSEN: r TOTAL STANDBY TIME O NEAREST;''; ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMP Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �- O YES..13 NO. i ❑ WALKED ❑ GUERNEY O OTHER H 1- PATIENT CONDITION: DRIVER �� < < ��M �I UJ EMT-tA j TECHNICIAN nC/ $Er2I CG F 1� Hx: DISPATCHER: i L L6 LEL CHIEF COMPLAINT: DRY RU YE NO REASON FOR DRY RUN PT R c i=v JA L AU MT O FO R RUN(EMS USE ONLY) •,.I ".'PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE( . 1 INDUSTRIAL O YES O N NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: f KAISER N: ' I MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO t. . O YES .O NO NIGHT: (19:00-07:00) CCHP/PPRP N: ' ' EMERGENCY RUN: MEDI-CAL N: ' CODE 2/3 OTHER: -T=' 1 OXYGEN: (PER TANK) 1 P.O.E.STICKER ❑ YES O 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) 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: ��•. CrC PATIENT RECEIVED BY:X _ fginN&i f inF) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N 3=� 3 34 CNECK ON FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME O M El COMPANY N ADDRESS AGE S, CITY STATE ZIP DOB Sn ❑ M T ❑ W ❑ Th O F ❑ S DRIVER'S LICENSE N _ ' PHONE�_5'�-Q= NATURE OF DISPATCH NJ 1J Q TYPE OF TRANSPORT: AMBULANCE❑ OTHER Cl _ -- STATION 1(A)_2(B)_3(C)X4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK nq� �2yuy�s I Pe �' TO SCENE- PS.O. CALL RECEIVED 7/ // Ir ❑ P.U. TIME 10-8 J PATIENT DESTINATION: N PU FROM SCENE- ❑ FIRE TIME 1D-97 rA • ' �^ ❑ PSAP TIME 10-49 N G L C MILEAGE: ❑ OTHER/PVT TIME 10-7 - ' END TIME 10-98 DOCTOR y a w Lz PMD/ER STAR TIME 1x22 :C� HOW CHOSEN: f TOTAL T STANDBY TIME ' ❑ NEARESTI ,! ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT. ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: _, ^ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ° .. 13YES ❑ NO..., 13WALKED 11GUERNEY O OTHER r Q ePATIENT CONDITION: j DRIVER �` J/���� (� EMT-1A r.1 TECHNICIAN 120 � PARAMEDIC Hx: DISPATCHER: 00 CHIEF COMPLAINT: DRY RUN ✓�YES ❑ NO REASON FOR DRY RUN /� Lt__/QQ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 PRIVATE INS. CO.: BASE RATE: r 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 N: / EMERGENCY RUN: MEDI-CAL C 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: 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: S1 4�1 Of Txts �A ,� SS L v2 hn�(6s-&Vaal CL fl I p i l TOTAL: _ �I• PATIENT RECEIVED BY: X Pr•ni�irr rot 71• A:I, •! I'i-! .", 5nf:, ' L' I r., �. I ! ,,..r (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N1334 CHECK OR/Il IN APPROPRIATE SPA-43 DATE: b //�/.� PATIENTS NAME OM ❑ F COMPANY N ADDRESS'i' AGES- I CITY STATE ZIP DOB - ❑ Sn O M QST OW O Th 'O F OS DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH I TYPE OF TRANSPORT: AMBULANCE O OTHER 0 — -- STATION I(A)_2(B)_3(C)._4(D)_5(E)— fiNCIDENT LOCATION:, RESPONSE CODE: REOUESTED BY: TIME– (24 HOUR CLOCK) 3& ^^ 1 TO SCENE- S.O. CALL RECEIVED J4 �� (A Oyt3pJ /Z t!jr �/C� S O P.D. TIME 10-8 ^ PATIENT DESTINATION: FROM SCENE - 11FIRE TIME 10-97 C71 t�l-I' O PSAP TIME 10-49 i r MILEAGE: ❑ OTHER/PVT TIME 10-7 ; END TIME 10-98 DOCTOR `' ' I = PMD/ER START HOW CHOSEN: TOTAL STA IME ❑ NEAREST;" ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK w: AMBULANCE COMPANY^ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: s RESPONSE ZONE_ /-�- ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ LA EMT-1A TECHNICIAN PARAMEDIC Hx: _ DISPATCHER: 11--[ � ! L qo-j_ CHIEF COMPLAI I: DRY RUN: YES ❑ NO REASON FOR DRY RUN _(( ('J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Vq. IlPATIENT EFUS D SER ICES: (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 C E.O.B. ATT. ROUND TRIP: ❑ 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 ❑ 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: p ZIP: 154 COMMENTS: �V�Z L �r�IRa<�� 5- o. if TOTAL:__v PATIENT RECEIVED BY X-_ . . (SIRNATIIRf) . ..i CONTRA COSTA COUNTY 1, �' AMBULANCE -+ PRE-HOSPITAL CARE FORM i C UNIT AUTHORIZATION M ( �3 J CHECK OR FILL INAPPROPRIATE SPICES DATE:�. L L�3 PATIENTS NAME ❑ M ❑ F COMPANY a ADDRESS l) N AGE ) I CITY_ STATE ZIP DOB— ❑ Sn ❑ M ❑ W ❑ Th ❑ F O S. DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH A, f1 0 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _- __. _-___ STATION 1(A),2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: R ESTED BY: TIME - (24 HOUR CLOCK) + I (` TO SCENE- CALL RECEIVED P.D. TIME 10-8 i PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 16-97 ( ❑ PSAP TIME 16-49 ILEAGE: ❑ OTHER/PVT TIME 10-7 ND TIME 10-98 DOCTOR PMD/ER TART ' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBUL(NEE`COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ; ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER i w PATIENT CONDITION: DRIVER I )N S�r-� EMT-tA TECHNICIAN `� `� PARAMEDIC Hz: J " L�' N'� 1 V DISPAT HER: ) CHIEF COMPLAINT: DRY RUN: S ❑ NO REASON FOR DRY RUN t AVT A I NFO ,RU (EMS USE O Y) ( �! PATIENT REFUSED SERVICES: (SIGNATURE) X '- - C�- i MEDICAL COVERAGE: INDUSTRIAL ❑ Y ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTI A7E t BLUE CROSS R: TOTAL MILESX MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ O ) ❑ YES ❑ NO NIGHT: (19:00 CCHP/PPRP#. EMERGENCY MEDI-CAL>•: C00 2 OTHER: OXYGE . (PE P.O.E. STICKER ❑ YES ❑ Ni TAL: OR) DATES BILLED: `�� SDBY: (OIN.) G.: (PER )NEAREST RELATIVElRESPONSIBLE PARTY:,.` I.V.: (PER AD . X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLAC 0) CITY: STATE_ IP: IC-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUP ION: OTHER: ADDRESS: CITY: �L STATE: ZIP: COMMENTS: - -- --- TOTAL: - - - - - — PATIENT RECEIVED BY.X Provider rets:.• Nhitc vrd Pi,.*, •� o .4et�i+ Ye' qc (SIGNATURE) f�• CONTRA COSTA COUNTY AMBULANCE 13_ 13, G R PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION K J CHECK OR/ILL IN APPROPRIATE SPACE? DATE: PPATIENTS NAME ODM " O F COMPANY K '� ADDRESS. if AGES„ �, 1eL U/V CITY ----STATEtl)otIZIP POB ❑ Sn ❑ M ❑ T ❑W O Th O F ❑ S DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE❑ OTHER❑ L — STATION 1(A)_2(B)_31C1_41D1_51E1_ r INCIDENT LOCATIOW V S RESPONSE CODE` REOUESTED BY: TIME— (24 HOUR C�LpCK) (� TO SCENE- S.O. CALL RECEIVED i 6 29 rt 7,11 . W 't' i ❑ P.U. TIME 10-8 PATIENT DESTINATION::-. I FROM SCEN ❑ FIRE _— TIME 10-97 —T , ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHERIPVT TIME 10-7 _ _ 'It END TIMES ID-9 -' T� DO_CTOR'1i7- �� 1 PMD/ER START HOW CHOSEN: r-- •-"- TOTAL STANDBY TIME 1 i'I`�_:O.NEARESTI• ' O FAMJ ❑ TRANSFER WAIT TIME —_ ❑ PATIENT O DIRECT D OTHER CALL BACK M: AMBULANCE COMPANY- OA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ .O.YES ,❑ NO. . •, O WALKED ❑ GUERNEY ❑ OTHER ' "{ �ATIENT CONDITION: _==� DRIVER EMT-lA TECHNICIAN _ `% '() PARAMEDIC Hz: "'" DISPATCHERS: Q_�I� CHIEF COMPLAINT: DRY RU I: PrYN FOR DRY RUN(EMS USE ONLYES 0 NO REASON FOR DRY ) 7 PATIENT REFUSED SERVICES:(SIGNATURE) X 9b/� MEDICAL COVERAGE- -"-" INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: i S� S.S.# - . 1 i PRIVATE INS.CO.: - BASE RATE: " KAISER It: 1 MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE K: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES "❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#:L—', - EMERGENCY RUN: MEDI-CAL M; CODE 2/3 OTHER:_.A.- 1 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/RESPO SIBLE 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: ATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK ONE: DRY RUN: (AUTHORIZED) —EMPLOYER, OCCUPATION: OTHER: ADDRESS: CITY: STATE` ZIP: "COMMENTS' J 5•Q TOTAL: "ff - "i PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBU NCE :21J , PRE-HOSPITAL CARE FORM I UNIT IV AUTHORIZATION w CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N ` 4 ADDRESS Y , L AGE ��v r CITY STATE ZIP DOB ❑ Sn O m ❑ W ❑ Th ❑ F ❑.S a Sa DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: / RESPONSE COO : REQUESTED BY: TIME— (24 HOUR CLOCK) /V( �jC2(S.O. ___( TO SCENE- ❑ P.D. TIME 0-8 RECEIVED t TL PATIENT DESTINATION: FROM SCE ❑ FIRE _ TIME 10-97 ❑ PSAP TIME 10-49 ��- w MILEAG ❑ OTHER/PVT TIME 10-7 END _ TIME 10-98 DO ATY___ PMD/ER STAR TIME 10-22 HOW CHOSEN: TOTAL / \ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE CO PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE 20NE�1�� ❑ YES ❑ NO ❑ WAL'<ED 13GUERNEY ❑ OTHER PATIENT CONDITION: DRIVE � EMT-1A TECHNICIA Ag f tj VT L7 PARAMEDIC ` -�� ► Hx: _ DISPATCHER: r C'-• /'L i CHIEF COMPLAINT: DRY RU�S ❑ NO REASON FOR DRY RUNf e, 'c AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERV CES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: } KAISER#: MULTIPLE PTS. BASE RATE / BLUE CROSS#: TOTAL MILES: X ' MEDICARE#: E.O.B. ATT. ROUND TRIP: 13YES ❑ NO t ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: EMERGENCY RUN: MEDT-CAL av: CODE 2/3 /y OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 11NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE P PITY: 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) All 4 PHONE: WOR PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OC AT ION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ----- TOTAL:-� –------ - PATIENT RECEIVED BY:X_.—_ Provider retair, White rid Pir,K ropy .hete., YL•':.`� 'nF"t C. fit' when hi1'ing (SIGNATURE) EMS-! r . CONTRA COSTA COUNTY I,. AM13ULANCE �( PRE-HOSPITAL CARE FORM I UNITZ r AUTHORIZATION 0 I CHEf.K OR Flll IN APPROPRIATE SPACES DATE: a P6 PATI NT'S NAME_J.�._! Il d � '��'� IM 1�� c ( e`-+ O M F COMPANY 0 1 ADD &Z 'I I-� —� AGE CITY=` :��iI V STATE ZIP k ZS^ _ QD(OB� �❑ Sn OM OT.OW OTh. ,OF Og""� DRIVER'S LICENSE K _ � PHONE3.�S V�v� SS NT"RE OF DISPATCH TYPE OF TRANSPORT: AMBULANCO OTHER❑ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_j- INCIDENT A)_2(B)_31C1_4(D)_6(E)�' INCIDENT LOCATION: 1 RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) � i C TO SCENE- S.O. CALL RECEIVED '�� -- ------- � --- ❑ P.D. TIME 10-8 PATIENT DESTINATION: —� FROM SCENE - ❑ FIRE TIME 10-97 1• � :rTf c�.l�1 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 r /I END TIME 10-98! DOCTOR 1-'�L`' I N PM /E START_: Z-- TIMEIG-22 HOW CHOSEN: TOTAL 1-KZ STANDBY TIME ❑ NEAREST O FAM{LY ❑ TRANSFER WAIT TIME PATIENT 0 DIRECT O OTHER ) CALL BACK 0. AMBULANCE COMPANY: ICA -� EOT AMBULATORY? PATIENT TAKE Tqq AMBULANCE. C�J'� RESPONSE ZONE YES (g NO ❑ WAU',ED TAKEN ❑ OTHER PATIENT CONDITION: DRIVER e`� O "'� T-IA— 1—D TECHNICIAN PARAMEDIC Hx: DISPATCHER: r i CHIEF COMPLAINT: . A I DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION AR(RY RUN(EMS USE ONLY)— PATIENT NLY)PATIENT REFUSED SERVICES: (SIGNATURE) X_ r MEDICAL COVERAGE: INDUSTRIAL ❑ YESA NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: P1 V O�✓1 _ BASE RATE: r KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X ---f MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00; ��2'.CIO CCHP/PPHP#: EMERGENCY g MEDI-CAL R: CODE 2, 3/ !) cv OTHER: OXYGEN: (PER tANM .-.�, G�CJ ,,�---•� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATd L�!3 G•L). –( DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) &j NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) - S Tr-- DRUGS: (PER ADMIN.) X NAMER 1J C'—_ FAK '–"—RELATIONSHIP:_fC E O.A.: (IF NOT REPLACED) ADDRESS: S•A' ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: .(AUTHORIZED) FAi11F-R5 EMPLOYER: OCCUPATION@ OTHER: I'JpIGjcrlADDRESS: CITY:F�^ IZ STA TZIP: /J- 60 .fL COMMENTS: ICA 3 11-e h/ A V T,:> rL'f All 7 Ll Z 7 TOTAL:-- -- –'-�' PATIENT RECEIVED BY:X Provider ret:2f: Vki•r ,,rd " :nnp ceh..-I W:,•v - M, hit"i•W (SIGNATURE) �•M.� DIS-1 V CONTRA COSTA COUNTY AMBULANCE J PRE-HOSPITAL CARE FORM I UNIT _ AUTHORIZATION a�jo 3 13'�ys •�' �' CHECK oR FILL IN APPROPRIATE SPACES DATE: 'f PATIENTS NAME Le�g-sp_ ff„/ Sa e_1c ❑ M P(F COMPANY A ADDRESS I_Ok a _� AGE ' 3 ,,�� CITY - STATE ZIP DOB 1 r��-0 O Sn OM T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M _ _.---. PHONEZ-3� NATURE OF DISPATCH C"►"ten CC(1 r11 r TYPE OF TRANSPORT: AMBULANCE Tt OTHER &CO N"way W4 S. r). INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR LOCK) �C TO SCENE - 2 lX S.O. -_ CALL RECEIVED O P.U.^ TIME 10-8 rPATIENT DESTINATION: FROM SCENE p ❑ FIRE TIME 10-97 /�� _ ❑ PSAP TIME 10-49'.�5 •^' ` MILEAGE: ❑ OTHER/PVT TIME 10-7 — END_5_'�' TIME 10-98 DOCTOR /ER START C, ��_ TIME 1D-22 HOW CHOSEN: TOTAL STANDBY TIME >, i .NEAREST.- ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULAN E COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 15- RESPON E ZONE �. r. k.YES ❑ NO ❑ WALKED a GUERNEY Cl OTHER = PATIENT CONDITION: DRIVER �� r� �'��U EMT-1A_ r 1 ; . l t � �}{ TECHNICIAN PARAMEDIC Hx: "� DISPATCHER: /�� CHIEF COMPLAINT: {r r LNS c DRY RUN: ❑ YES NO REASON FOR DRY RUN / / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X �7 MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: T; S.S. M f y7'',5;.r PRIVATE INS. CO.: BASE RATE: r KAISER M: MULTIPLE PTS. BASE RATE I BLUE CROSS M: (t'y TOTAL MILES: X MEDICARE M: �l4 clod E.O.B. ATT. ROUND TRIP: O YES ❑ NO orCU 0_5 r Q p, ❑ YES ONO NIGHT: (19:00-07:00) "•� �PPHP M: EMERGENCY RUN: MEDI-CALM: CODE 2/3 ' f d� OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) - NF REST RELATIVE/ ESPONSIBLE PARTY: I.V.: IPER ADMIN.)— X 11RUGS: (PER ADMIN.)_ X NAME:��_���� d.f d�1_aokLATIONSHIP: coSE.O.A.: (IF NOT REPLACED) ADDRESS. _ ORAL AIRWAY: (IF NOT REPLACED) CITY: _._____ STATE-_—ZIP:--__... C-COLLAR: (IF NOT REPLACED) - PHONE: 0 1 WORK PHONE._ DRY RUN: (AUTHORIZED) LILI L'D Gam- _— EMPLOYER: OCCUPATION: OTHER: vJ[ ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: 77V, TOTAL.- ��5�- ---- - -- PATIENT RECEIVEn BY X ISIt,,NarusaEl � IT nii,ler Iw h11r: Yhi re „nl Iii,;: ,..,I,p h.,h,r+ , ;,is I - 1.7t • ,,,: I r. , , LMS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N _ I . CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME�� �1��� O M ❑ F COMPANY N ` f ADDRESS,,:• ;',j______� AGE�, C, (J CITY STATE ZIP DOB ❑ Sn ❑ M T ❑ W ❑ Th ❑ F O S - ! DRIVER'S LICENSE N t PHONE — NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE OTHER❑ — STATION 1(A)_2(B)-3(C)_41D)_5(E)._ INCIDENT LOCATION', - 't'.3 RESPONSE CODE: RE ESTED BY: TIME- (24 HOUR CLOCK) i ` - TO SCENE- S.O. CALL RECEIVED i? -7377-;p;77 ❑ P.D. TIME 10.8 -_L"_ I I �9 PATIENT DESTINATION: (N �}_Z FROM SCENE�� ❑ FIRE TIME 10-97 � :`t7 a ❑ PSAP TIME 10-49 ; MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 . :OcToll PMD/ER START - TIME 10-22 HOW CHOSEN: S t TOTAL STANDBY TIME i0 NEAREST: U FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT . ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANC CO PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPO SE ZONE ❑, YES..❑.NO f ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITIONI DRIVER /� + __ •, TECHNICIAN PARAMEDIC Hx: 1 G^� DISPATCHER: JI 5� CHIEF COMPLAINT• ) DRY RUN: ES ❑ N REA O -AOR DRY RUNPE AU HO Z ION FOR RY RU �(EM//USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X '� MEDICAL COVERAGE; - INDUSTRIAL ❑ YES ❑ 10 NO. OF PATIENTS: ✓ �/ S.S.N I } PRIVATE INS. CO.: BASE RATE-- • ! KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS N: " " TOTAL MILES: X MEDICARE Ox. ' E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-.07:00) CCHP/PPRP N: ( 7 EMERGENCY RUN: MEDI-CAL N: 1 CODE 2/3 OTHER: _ OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES ❑ NEONATAL: (INCUBATOR) f 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: - R LATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY:• - TATE, ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WO PHONE: DRY RUN: (AUTHORIZED) EMPLOYER!" CCUPATION: OTHER: ADDRESS: - CITY:- - STATE: ZIP: COMMENTS:- - TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: X Rrini,{er r.�.iln Vtii rr r�.l f r•t (SIGNATURE) "fY 4•lur1. .., f n.• t:" !i 1 in,t UIS-1 r CONTRA COSTA COUNTY ' AMBULANCE PRE-HOSPITAL CARE FORM I - UNIT AUTHORIZATION M 83 CHECK OR FILL IN APPROPRIATE SPACES DATE: ()8 - 05- PATIENTS NAME ❑ M O F COMPANY ADDRESS AGE— CITY GE CITY STATE ZIP- __ DOB__—._ ❑ Sn ❑ M aT ❑ W O Th O F O S DRIVER'S LICENSE M -_-__._. -.._-_-_ PHONE_____ _-___-___ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _-_ .-_ STATION 1(A)_�_2(B)_3(CI_4(D)_5(E)_-_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) j I TO SCENE - S.O.-_ CALL RECEIVED L. 1/9/yLr ,C Z ❑ P.D.- TIME 10-8 PATIENT DESTINATION: I FROM SCENE ❑ FIRE TIME 10-97 1� ` l" -" ❑ 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 ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C A"2,'L!/1c PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: - RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY Cl OTHER PATIENT CONDITION: DRIVER �VJTlATECHNICIAN ,��— DIC Hx: kjI i C DISPATCHER: CHIEF COMPLAINT: DRY RUN: ® YES ❑ NO REASON FOR DRY RUN ,G1/�1dlFG,tir' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 5 S.S. a PRIVATE INS. CO.: BASE RATE: KAISER x; - MULTIPLE PTS. BASE RATE BLUE CROSS N: 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 a: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ Y S ❑ NO NEONATAL' (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/ ESPONSIBLE PARTY: IV.: (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 .-- -- -- -- -- --- ----.- ------_._.... _- PATIENT RECEIVED BY' X...._..__------ ISIGNA MAE) . .1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N It ✓i I CHECK OR FILL INAPPROPRIATE SPACES DATE: J �l _ a l� PATIENT'S NAME.. 0 a 1c. ti." ( 1 1 n in . _--__ D(M ❑ F COMPANY(l I� _ ADDRE=SS -JUJ: AGE-.1-2- J --i1.'! .LA'.tl.'_L ' I `, ^---------- - CITY_----_LAE _._._--_ STATEZIP DOB 1� `�1. ❑ Sn ❑ M/11 T ❑ W O Th O F O S..... DRIVER'S LICENSE # __. _. PHONE _23.._�t G_3y NATURE OF DISPATCH /Q- TYPE OF TRANSPORT: AMBtJLANCEM OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) i TO SCENE-� P(S.O. - CALL RECEIVED � 37 (7 3 ❑ P.U. TIME 10-8 : ( 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 fl� �/Z'; Je', Z ❑ PSAP TIME 10-49 MILEAGE: (/ ❑ OTHER/PVT TIME 10-7 END.- __._ _�^:__l__= TIME 10 98 DOCTOR _..L�/JC'.'.' r� ...__........._. PM !ER.I START-_7L _ _ TIME 10-22 HOW CHOSEN: TOTAL ,(� STANDBY TIME ❑ NEAREST ❑ AMILY ❑ TRANSFER WAIT TIME ❑ PATIENT DIRECT ❑ OTHER (� I. ) CALL BACK#: AMBULANCE COMPANY:. CAJ ZZ PT/ AMBULATORY? PATIENT TAKEN TO AMBULANCE 4;C RESPONSE ZONE YES ❑ NO �YVVAL"ED ❑ GUERNEY ❑ 01HER PATIENT CONDITION. DRIVER it % t�7 EMT-1A 2 Z TECHNICIAN.1 �_AL ' / ^�' RAK4EDIC:L -� I, HX' /�/S1.L[._)L___..C:J .t ---/ :_� ,�u._it_(.._.'7L�� ,Cc _ DISPATCHER C� � I CHIEF COMPLAINT A�_/c ,8.r?1.c_LJ_' 5./J �1_L�s=— DRY RUN: ❑ YES XNO REASON FOR DRY RUN [/O�� FOR DRY RUN(EMS USE ONLY) ]] 55/ 7 c PATIENT REFUSED SERVICES (SIGNATUREr)(____..-__.______ �/ MEDICAL COVERAGE INDUSTRIAL ❑ YES-yCNO NO. OF PATIENTS: • PRIVATE INS. CO.:_ -__ BASE RATE- KAISER#: _ -_ MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X !�/1 MEDICARE #: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO Q f ❑ YES ❑ NO NIGHT: (1900- 07:00) tea. U6 CCHP;PPHP#: -.._ -_ __..__.. EMERGENCY RUN: rME DI-CAL It: - ..-._-__ _- CODE 2 13 OTHER_..-. _.__-___.___- _ -._. OXYGEN:,(PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR)� DATES BILLED:.-._.-._._. .. ..-_ _----_. . STANDBY: (OVER IS MIN.) �"�•• E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIEI LE PARTY: I.V.: (PER ADMIN.) - X DRUGS: (PER ADMIN.) X NAME' ._......_____. ._.._._. .. _ RELATIONSHIP:.—.__._... E.0 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: "ll ADDRESS:---- - - --- -- -- /J JJ 3 CITY' - -- - ----- -- STATE:----ZIP:-- — COMMENTS:_1N..-_.�,�_-_�� _ - -- --- - - ) c.�L. TOTAL:_ 17/ c-i uj PATIENT RECEIVED BY: X !I',' uh:•: Fil iVp (SIGNATURE) 015-1 CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM 1 UNIT AUTHORIZATION M 12 Li CU CHECK ON FILL IN APPAOPMATE SPACES DATE: Q__(T _ PATIENTS NAME-moo�� �L� ❑ M OF COMPANY N ,/ ADDRESS AGE CITY STATE_ - ZIP DOB 'O Sn O M 'AT E) WjThO Ft O S r . DRIVER'S LICENSE N I PHONE NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE OTHER O -- STATION 1(A)_2(B)_3(C)-4(D)_5(E)_ 16Y w C.. . INCIDENT LOCATION: 1 RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- 3 �'s.0. CALL RECEIVED , ❑ P.U- TIME 10-8 -7 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 r •� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 ,;'DOCTOR 1 '' I I PMD/ER START �– TIME 10-22 HOW CHOSEN: - TOTAL STANDBY TIME i', :• O NEAREST: ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: � cNS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: i DRIVER Slit, r C1`ckEMT-1A t 11 F_• TECHNICIAN t 7 w PARAMEDIC -7 Hx:._ U F n DISPATCHER: 1LCP� , ��� ���I CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN V Z L VAC. C%- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) FCL SC CC. (� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N I PRIVATE INS.CO.: BASE RATE: j KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS It: TOTAL MILES: X MEDICARE N:' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:n ' EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER O Y S ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESP NSIBLE 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: WOR PHONE: DRY RUN: (AUTHORIZED) C } EMPLOYER: OC PATION: OTHER: ADDRESS:— CITY: STATE- ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X (910NATUnF) I ( � CONTNA COSTA COUNTY AMEIULANCE � PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M �5 -f 3V 0 3 CHECK OR Fit iIN APPROPRIATE SPACES DATE: PATIENT'S NAMf__'!-�,_.\<�1 �'-_I.E- . t�\C�� ��) n� / 1 'n,u Vl " /^� ❑ M COMPANY N /-e., h� I I vi�_� - �� f'l w"AGE L /1 R 7 Z I ADDRESS CITY — STATE—___-- ZIP QQ. DOB Q3 ❑ Sn ❑ M ❑ T ❑ W�Th ❑ F O $ DRIVER'S LICENSE a __ _ PHONE _.;056,L3 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE ❑ OTHER❑ STATION 1(A)_2(8) 3(C) (D)_5(E)— := ' ✓O(:IDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ' Ce f l TO SCENE- .Z ,<S.O- CALL RECEIVED ❑ P.D._ TIME 10-8 �1L PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 C �t.� (� � O PSAP TIME 10-49 __l,�_ _ MILEAGE: ❑ OTHER/PVT TIME 10-7 Q� _. END MILEAGE: ' TIME 10-98 DOCTOR���\r���" __._- PMD R START__ TIME 10-22 1 HOW CHOSEN: TOTAL �L STANDBY TIME ,NEAREST ❑ FAMILY ❑ TRANSFE WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK s<: AMBULANCrF COMPANY: - v EPT AMBULATORY? PAT T TAKEN TO AMBULANCE: SU RESPONSE ZONE YES ❑ NO WALED ❑ GUERNEY ❑ OTHER PATTEN CONDITION: DRIVER L1 C� EMT-tA �a "'v ► 1 T f j� ' TECHNICIAN � �'U PARAMEDIC � y n Hx; . �Li. _ DISPATCHER: ��/"� I I 0 t CHIEF COMPLAINT: t> �' _ DRY RUN: ❑ YES : NO REASON FOR DRY RUN ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ( PATIENT REFUSED SERVICES: (SIGNATURE) X I IC MEDCOVERAGE: NDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S 0���_I//1{���v��ni t, PRIVATE INS. CO.: Nl0k.57_ BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X G•�O ,3q.C�- p" MEDICARE a:_;w_(\ IE E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 20 cv �J C CCHP/PPHP M'. - EMERGENCY RUN: 30•�,p��.' MEDT-CAL M: 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 1_ ` DRUGS: (PER ADMIN.) X RELATIONSHIP 1['1 E O.A.: (IF NOT REPLACED) - ADDRESS: -_ ___ ORAL AIRWAY: (IF NOT REPLACED) CITY: _. __-__....._._._ STATE--_ZIP:__ C-COLLAR: (IF NOT REPLACED) -" PHONE: 12�n WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY —.___, STATE: ZIP: - COMMENTS:_ TOTAL: PATIENT RECEIVED BY: X r.. ,,.,. _•.,..:• .. (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-MOSPITAL CARE FORM I UNIT AUTHORIZATION# Z 3 -1����•-• CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME Fv ❑ M O F COMPANY• Z ✓ '3 Z_ I ADDRESS AGE 9, K U CITY STATE ZIP DOB O Sn O M O T,.�A/ O Th,O F O g' `t 1 DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH ' TYPE OF TRANSPORT: AMBULANCFeLT OTHER❑ ATION t 1A1 2(8)_3(C)_4(D)_5(E)�r•+--► INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) \rl TO SCENE Z ❑ S.O. CALL RECEIVED D P.D. TIME 10-8 '\\ PATIENT DESTINATION: FROM SCENE- IRE TIME 10-97 �-( ❑ SAP TIMEID`49 MILEAGE: OTHER/PVT TIME 10-7 END TIME 10-98 I DOCTOR PMD/ER START.' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME,. ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ` ❑ PATIENT D DIRECT ❑ OTHER CALL BACK Z ' AMBULANCE COMPANY- ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: - RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED D GUERNEY ❑ OTHER C J PATIENT CONDITION: DRIVER 12`� EMT+1A '1� i TECHNICIAN PARAMEDIC _ / Hx: DISPATCHER: E-I E L O c ;7- CHIEF .'CHIEF COMPLAINT: DRY RUNES ❑ 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: — S.S PRIVATE INS. CO.: BASE RATE: KAISER c MULTIPLE PTS. BASE RATE t--"'-1 ► BLUE CROSS M: TOTAL MILES: X r----) MEDICARE C E.O.B.ATT. ROUND TRIP: D YES ❑ NO til ;t' . ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: __.�ar- MEDI-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) ^ ,�.,7�_ P.O.E. STICKER 13 YES O NO NEONATAL: (INCUBATOR) Hr I l DATES BILLED: STANDBY: (OVER 15 MIN.) _ E.K.O.: (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) r ID PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP• F COMMENTS: TOTAL•So 00 - PATIENT RECEIVED BY:X -- , (SIGNATURE) Pmoider Teta-r Vhite ,rd Pi.:S ropy Retun Ye'low cmpy t, ENS when biking Du-v CON I I1A (:()!;IA C(1UN 1 Y AM(IULANCF. PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION Irk[ l�y LSA CHECK OR FILL INAPPR11OPAIATE SPACES DATE: kk PATIENT'S NAME_ �L-W-(�:k•) ,cam .1�_____ _ JKM ❑ F COMPANY ADDRESS �L( �L_t� k-,1n Lc_d—_�_LL ------- AGE — ` f•�? C F 'Z GTV_._��-LSTATE._L-.,___..—_ ZIP—L�(Z.`(_ —. DOB__ �_Z� ❑ Sn ❑ M O T A W O Th O F O g - DRIVER'S LICENSE is _.__ ...___. . __._. _. - PHONE_.)3 3_ SZ — NATURE OF DISPATCHttitkwy--', TYPE OF TRANSPORT. AMBULANCE OTHER❑ STATION 1(A)-2(B)-3(C)-4(D)-5(E)— INC IDENT A)-2(B)_3(C)_4(D)_5(E)_INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) + 1{ TO SCENE Z S.O.-- CALL RECEIVED _�L'_ _.+5—hnE - (-��U��1---4---- — - ---J- ❑ P.U. TIME 10 8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 5 I _ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 1` ` END •3 TIME 10-98 _ I DOCTOR PMD/6 START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME �' 1 ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME - ' ® PATIENT ❑ DIRECT ❑ OTHER CJ j CALL BACK a: AMBULANCE COMPANY: - 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S Q RESPONSE ZONE . YES ❑ NO ❑ WAL';ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER— ISbli EMT-IA TECHNICIAN— ' PARAMEDIC XC Hx: l r DISPATCHER: CHIEF COMPANT: (�r��t ��__�r i, S�tT— DRY RUN: ❑ YES NO REASON FOR DRY RUN �.• / i f Ib, _ '_� —_ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ' J PATIENT REFUSED SERVICES: (SIGNATURE) X r S MEDICAL COVERAGE: INDUSTRIAL ❑ YES {T NO NO. OF PATIENTS: S.S a Z z PRIVATE INS. CO.: BASE RATE: ' KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS L r "1 TOTAL MILES: X �e • /9,50 ' ' MEDICARE a: 1 Z z E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑•NO NIGHT: (19 00-07:00) I CCHP/PPRP a: _ EMERGENCY RU(V: �fV(1'DI-CAL It: h r. C •_:rl �.�c..�c._�.�e_ CODE 2(3 OTHER: OXYGEN: (PER TANK) V'P,7 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 ^ DRUGS: (PER ADMIN.) X NAME: .��II` c` _ RELATIONSHI hfc^`IIF E.O.A.: (IF NOT REPLACED) ADDRESS:—�L<<' �l:.r.�i! �(��`< < �' _ ORAL AIRWAY: (IF NOT REPLACED) CITY: —.^L� 'C _.__._..-.- STATE-c._ZIP:_— C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: __ _— OCCUPATION OTHER: r ADDRESS: ��. '_'. r r2 /D•UZJ J✓ CITY: STATE: ZIP: COMMENTS: TOTAL:�"'�•: , c,'7 � -- _ PATIENT RECEIVED BY: X Provider ret:rr whItr .r.' . . ;� Gr(sr: 1:' ry nr^ e•h�n hi i .•r� (SIGNATURE) CON111A COSTA COUNTY AMFIULANCE PRE-HOSPITAL CARE FORM I UNIT IZ AUTHORATION# CHECK OR FILL IN APPROPPIATF SPACES DATE: PATIENT'S NAME 'U r_f'�.��`":_ LTJ ❑ M Cl F COMPANY# --- _ ADDRESS , I U J C �'ti AGE 3 , , 7 I- ' _ O d- CITY__M�. STATE_jZIP_ DOB I_ ❑ Sn OM O T ?/W O Th OF O.8\. DRIVER'S LICENSE b ___.. __...___.._... PHONE', NATURE OF DISPATCH \A� 5 ` TYPEOFTRANSPORT: AMBULANCE ❑ OTHER❑ STATION I(A)_2(8)_3(C)_4(D)_5(E)_::.. --j INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) � p TO SCENE- j S.O. CALL RECEIVED 2_ L ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE Cl FIRE TIME 10-97 � -7 2 ! �.� O PSAP TIME 10-49: �C MILEAGE: n / ❑ OTHER/PVT TIME 10-7 : ---� J ,� END �� t--o TIME 10-98 .:: DOCTOR _!'�c.fzo PMDo START TIME 10`22 " 1- HOW CHOSEN: TOTAL STANDBY TIME •�--� NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT .❑ OTHER 3) -CALL BACK#: AMBULANCE COMPAjJY;� �� PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: J RESPONSE ZONE ('4- ❑ YES NO ❑ WAL'<EDXGUERNEY O OTHER PATIENT CONDITION: DRIVER EMT-1A ~� TECHNICIAN co C RAMEDIC Hx: _1Q\ I `1 V� f�C)I VA C U S� DISPATCHER: � (( >> CHIEF COMPLAINT: DRY DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN + / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 'P PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YENO NO.OF PATIENTS: S.S. # i PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE 1 BLUE CROSS#: TOTAL MILES: 3 X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: - Q� MEDI-CAL#: CODE 2 3 � f I J \ OTHER: OXYGEN: (PER TANK) , 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.: I.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: l STATE ZIP: COMMENT 1� Y ��� �1 TOTAL: I? 50 _. . PATIENT RECEIVED BY:X I Provider ref— ✓hi•e ? ' URE) (� .•-r� ., Rr u►,.•., h�1-ire 01E-1 CONTRA COSTA COUNTY AMBULANCE g 3 / y cy 9 PRE-HOSPITAL CARE FORM 1 UNIT2( AUTHORIZATION N CN[CK OR RLL IN APPROPRIATt SPAC[i DATE: `PATIENT'S NAME t O M ❑ F COMPANY N�Z CD , ADDRESS:"..". AGE Irp tcV l CITY - STATE ZIP DOB -❑ Sn ❑ M ❑ T tSW O Th ❑ F 17 S [ . DRIVER'S LICENSE N ( PHONE _, NATURE OF DISPATCH TYPE OF TRANSPORT:LAMBULANCE OTHER STATION 11Ai_2(B)_3(C 4(D)_61E)s J �t7INCIDENT LOCA TION• _ Rai RE0ON§E CODE: ( EOUESTED BY: TIME-(24 HOUR CLACK) 1 G R ) F TO SCENE- S.O. CALL RECEIVEDV �' ?� g + 4 �, j ❑ P.D. TIME 1D-8 ,LX- PATIE T DESTI ATION:. . _ 1 FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49: i ('t' MILEAGE: O OTHER/PVT TIME 10-7 \ �r ENDS,_ TIME 10-98.1. :1_� pp I A.DOCTOR T!S�' _� PMD/ER START - TIME 10-22 .L�' . n __ } HOW CHOSEN: _ IOTA} - STANDBY TIME - 1 27`j"D NEAREST,-2 Q FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANQF CO,�ulCAyy:, �� { PT. AMBULATORY? ' PATIENT TAKEN TO AMBULANCE: ! 9�0 RESPONSE ZO 0,YESNO ❑ WALKED ❑ GUERNEY O OTHER- J I i PATIENT CONDITION: - DRIVER ` 1 d �S EMT-1A -- TECHNICIAN ( I^ • PARAMEDIC HK: DISPATCHER: t4 CHIEF COMPLAINT: DRY RUN: 15,,o-ES O NO REASON FOR DRY RUN NA pIr cF� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) J.jIPATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N '" . w PRIVATE INS.CO.: . BASE RATE-- - KAISER N: I MULTIPLE PTS.BASE RATE BLUE CROSS 0: ` TOTAL MILES: X MEDICARE N; E.O.B.ATT. ROUND TRIP: O YES ❑ NO I r• ❑ YES •O NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: '_; `'i ; +.:,�• CODE 2/3 .) E OTHER: OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES OO NEONATAL: (INCUBATOR) ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '- NEAREST•RELATIVE/RESPO SIBLE PARTY: - - - I.V.- (PER ADMIN.) X DRUGS: (PER ADMIN.) X cl '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:— PATIENT OTAL:PATIENT RECEIVED BY:X , Provider evtoln Yhlte c"d Pini (SIONATUHE) • 1 1 1 CONTRA COSTA COUNTY AMBULANCE X-13 �S r PRE-HOSPITAL CARE FORM I UNIT 1 AUTHORIZATION 1 CHECK 011 Fltl IN APO IATE SPACES DATE: �+.�/ PATIENT'S N E I A ❑ M O F COMPANY N Icl� ADDRESS AGE CITY STATE 21P DOB O Sn 0 M ❑ T W W O Th O F O S . DRIVER'S LICENSE N PHONE ._ NATURE OF DISPATCH 7 - • TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 1(A _2(B)_3(C)_4(D)-_5(E)_ r - INCIDENT LOCATION:1 ti. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR Ci OCK) p TO SCENE- S.O. CALL RECEIVED 1c � NA �11�. t', ` ! 'S'ij ' O P.D. TIME 10-8 PATIENT DESTINA—TIOON: FROM SCENE - ❑ FIRE TIME 10-97 1 V9 P-,',i • ,ry �?� ❑ TIME 10-49 Y 1 t� MILEAGE: O OTHER/PVT OTHER/PVT TIME 10-7 END TIME 10.98 ` OOCTOR7Tc I PMD/ER START TIME 10-22 HOW CHOSE _.... TOTAL STANDBY TIME l c. , O NEAREST; -, ❑ FAMILY 13 TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBU RY7 PATIENT TAKEN TO LANCE: Q RESPONSE ZONE ❑ YES NO ❑ WALKED UERNEY ❑ OTHER J C, 77 PATIENT CONDITION: DRIVER I EMT-1A TECHNICIAN PARAMEDIC HX: . DISPATCHER: r' i-1U (JO CHIEF COMPLAINT: DRY RUN: DYES ❑ NO REASON FOR DRY RUNJO 124A (( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: . INDUSTRIAL ❑ YES O NO NO.OF PATIENTS: S.S.# PRIVATE INS.CO.: BASE RATE: r KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS K: TOTAL MILES: X MEDICARE 0: ' E.O.B.ATT. ROUND TRIP:: ❑ YES 0 NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 111:, ' EMERGENCY RUN: MEDT-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) C P.O.E. STICKER O YES ❑ NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: SS(OVER 15 MIN.) E.K.G.: (PERIEPISOD4) i NEAREST RELATIVE/RESPO IBLE PARTY: I.V.: (PER ADMIN.) I I 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: i '1 PATIENT RECEIVED BY: X idor Pitoin Vhiti and Pink oopy Return YI'!ou mpy t• EH,Suhin til:inp (SIGNATURE) EMS-] 2 i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION>r CHECK ON FILL IN APP =ATE SPACES DATE: PATIENTS NAME7 OM OF COMPANY M ADDRESS AGE C OR LK0^2 . CITY STATE ZIP DOB ^❑ Sn O M O T O W O Try OF OS DRIVER'S LICENSE M _' PHONE _ NATURE OF DISPATCH ( � :� TYPE OF TRANSPORT:;AMBULANCE❑ OTHER❑ _ -- STATION 1(A)_2(B)_3(C),4(D)_5(E)_ INCIDENT LOCATION:(. _ RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CL 1,K) 3 TO SCEN ❑ ._ CALL RECEIVED 0 i ❑ P.U. TIME 10.8 PATIENT DESTINATION::• FROM ❑ FIRE TIME 10-97 pi. ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10.98 DOCTOR T �•rr' PMD/ER STAR TIME 10-22 HOW CHOSEN: \ TOTAL STANDBY TIME " O FAMILY O`TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPAN PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SO J RESPONSE ZONE n' ❑ YES 13 NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:. DRIVER �� L) EMT-1A TECHNICIAN PARAMEDIC Hx: DISPATCH R _�- r�, I L IU 1/0(0 CHIEF COMPLAINT: DRY RUN: YES O NO REASON FOR DRY RUN ,- / AUTHOR ZATION FOR DRY RUN (EMS USE ONLY) LC� PATIENT REFUSED SERVICES: (SIGNATURE) X J MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 S.S. K PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL C CODE 2/3 OTHER: OXYGEN:, (PER TANK) i P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) c 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: WORK PHONE: DRY RUN: (AUTHORIZED) -`EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL":�� "Z" PATIFNT RF!`FIVFn RY X .. .. _ i ONT14 COSTA COUNTY AMBULANCE Q ` PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONAll 1 - CHECK OR FILL IN APPROPRIATr JPAC[J DATE: w - _• ' PATIENTS NAME ❑tM ❑ F COMPANY 0 I o ADDRESS * ` = AGET_ CITY ST TES.ZIP DOB O Sn O M OT OW O Th O F. 13S - DRIVE LICENSE N �• PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEV OTHER O STATION 11A)_2(8)_3(C) 4(D)_51E)_ INCIDENT LOCATION: I '47, RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CO�CK) 1 ` _ TO SCENE- S.0. CALL RECEIVED 3 n .y c O P.D. TIME 10-8 .oLQ•: , PATIENT DESTINATIONS _ FROM SCENE- ❑ FIRE TIME 10-97 p ❑ PSAP TIME 10-49 ' � F '�� 'w 1 `•' ( MILEAGE: O OTHER/PVT TIME ID-7 F.. - END I . ____ TIME 10-98 rt'DOCTORT"C e' - PMD/ERr START TIME 10-22 HOW CHOSEN: 1 TOTAL STANDBY TIME r ❑ NEAREST,-.,-, ❑ FAMILY O TRANSFER I WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK Ni AMBULANCE-COMP NY: r PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: L'v L j RESPONSE ZONE X I, O YES. ❑ NO O WALKED ❑ GUERNEY O OTHER ' PATIENT CONDITION: 7 DRIVE R'VFVE/oor X.70 EMT-1A✓ I,!L' ' TECHNICIAN_S ,•�"�`�� ,5U PARAMEDIC Hx: DISPATCHER: Cnre� 146 CHIEF COMPLAINT: 1 DRY RUN: RYES ❑ NO REASON FOR DRY RUN k 0-:2 2 ((J - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 95� MEDICAL COVERAGE:___.__ INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: S.S. 0 PRIVATE INS.CO.: BASE RATE:- - - KAISER/1: MULTIPLE PTS. BASE RATE BLUE CROSS M: "A A ` � TOTAL MILES: X MEDICARE N;' E.O.B,ATT. ROUND TRIP: ❑ YES O NO O YES .fl NO NIGHT: (19:00-07:00) CCHP/PPRP 8:0 1 EMERGENCY RUN: MEDI-CAL K: + ` F CODE 2/3 OTHER: "' "Y t OXYGEN:I (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) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) —EMPLOYER--- OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP:----.:- -COMMENTS: IP: --COMMENTS: _') TOTAL`'�-' r_� - � I • __ PATIENT RECEIVED BY:X 19rONA rLIRF) Art" i �C.3- I 1 COSTA COUNTY AMBULANCE CONTRA 111 PRE-HOSPITAL CARE FORM I UNIT 2 AUTHORIZATION j I CHECK OII/4R IN 'KOPOIATE SPACES DATE: 1` PATIENT'S NAME O M ❑ F COMPANY M - 1� ADDRESS r AGE— A 'p CITY STATE ZIP DOB ❑ Sn ❑ M O T•.O W O Th OF OS i DRIVER'S,LICEN'SE N I PHONE NATURE OF DISPATCH— TYPE ISPATCH TYPE OF TRANSPORT:, AMBULANCE OTHER 0 _ - STATION 1(A)_2(B)_3(C)-4(D)_5(E)_ INCIDENT.LOCATION-"µ ! :, RESPONSE CODE: REOUESTEO BY: TIME- (24 HOUR CLOCK) ! t TO SCENE CALL RECEIVED 1 u P.D. TIME IG-8 r PATIEN*DI TION: _ FROM SCENE ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49 �- I a ) MILEAGE: ❑ OTHER/PVT TIME 10.7 • :_�` END TIME 10.98 DOCTOR' I ' PMD/ER START TIME TIME 10-22 N: HOW CHOSETOTAL STANDBY TIME �!y ❑ NEAREST ' O FAMILY ! ❑ TRANSFER' WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: s+ RESPONSE ZONE ' ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER /7 �) EMT-IA ! TECHNICIAN / v PARAMEDIC—L�d / Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN:,AYES ❑ NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY.RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ��la MEDICAL COVERAGE: _fir.. ., 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 k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 CCHP/PPRP N:' I EMERGENCY RUN: MEDI-CALM: '"I I` " `'„1 CODE 2/3 1' OTHER: ' OXYGEN: (PER TANK) 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) , t _ DATES BILLED: r STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSI LE 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 PHONE: I VORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: a _ PATIENT RECEIVED BY:X /�„.{,!�.. �•I,.f� cn.:., r:. c ... ... ISIGNA'i URE) ♦... CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION • /�P CHECK OR ML IN OPRIATE SPACES DATE: /� I PATIENTS NAME ` /�1 ❑ M OF COMPANY l ADDRESS AGE ( 0 I CITY STATE ZIP DOB -O Sn ❑ M OT O`W O ThC�O F OS DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH--- TYPE ISPATCH TYPE OF TRANSPORT:.AMBULANCE 0 OTHER❑ _ _ STATION 1(A)_2(B)_3(C)-4(D)_5(E)_ .I ENCIDENT LOCATIONI RESPONSE CODE: RE STED BY: TIME— (24'HOUR CLOCK) �- 7 2 "j TO SCENE- S.O. CALL RECEIVED J VV �� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SC EN ❑ FIRE TIME 10-97 ��Y `_`• j l ❑ PSAP TIME 10-49 - ' —T �J MILEAGE: ❑ OTHER/PVT TIME 10-7 • :�: END TIME 10-98. .�_ FDOCTOR * ' ) PMD/ER START TIME 10-22 � : HOW CHOSEN: ---- TOTAL —1 1— STANDBY TIME 'i`.. ❑ NEAREST: O FAMIL� O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SU RESPONSE ZONE O YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER j PATIENT CONDITION: DRIVER 's� EMT-tA I 1 TECHNICIAN If PARAMEDIC Hx: DISPATCHER: l) /� i CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RU wr� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) L ,(4,y / 3•�• PATIENT REFUSED SERVICE SIGNATURE) X MEDICAL COVERAGE; I INDUSTRIAL 11 YES ❑ NO NO. OF PATIENTS: I —�•' I f S.S. M i PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X -' MEDICARE N: E.0 B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) - CCHP/PPRP N: ' I EMERGENCY RUN: MEDI-CAL N: -CODE 2/3 1 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/RESP NSIBLE 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:— PATIENT OTAL:PATIENT RECEIVED BY: X P,..,;'•- _ -- ISIGNA iURE) .«. ✓ -j 1 r 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONQN 1 /[Q 0 CHECK ON FILL INAPPROPRIATE SPACES DATE: u /O F3 - ' ��.�. Liss/ �� O M m' N ) l PATIENT'S NAME F COMPANY J /J I ADDRESS . r ."C)// AGE CITY �</(�/({/1'1��'��. STATE DOB O Sn Om ❑ T XW O Th O F C3'8 ' DRIVER'S LICENSE N __ — _ PHONE tel't. NATURE OF DISPATCH 14U 4!'r F%oT TYPE OF TRANSPORT: AMBULANCE7>OTHER❑ _ — STATION I(A) 2(6)-3(C)-4(D)_5(E)l' ••• INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK), W TO SCENE- 'OS.O. CALL RECEIVED as R t y� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 r�> ❑ PSAP TIME 10-49. �'-� •"� MILEAGE: ❑ OTHER/PVT TIME 10-7 / END I TIME 10-99 - DOCTOR `- ) V� PMD START / 2 TIME 10 22 _j HOW CHOSEN: TOTAL STANDBY TIME ?ff NEAREST ❑ FAMILY ❑ TRANSFER l WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER C 1� CALL BACK N: AMBU E MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: -c O RESPONSE ZONE _ ❑ YES--5,N0 ❑ WAL':ED'*JLfGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER C �, �"� EMT-IA TECHNICIA S PARAMEDIC Hx: _ � _ DISPATCHER: '. �fC' C� _ j EF COMPLAINT: A � �i' ��14 Lf ORY RUN: ❑ YES NO REASON FOR DRY RUN l AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVEl7 ❑ YES`- RA NO. OF PATIENTS: S.S. PRIVATE INS. CO.: T BASE RATE: /so. KAISER N: MULTIPLE PTS. BASE RATE _ BLUE CROSS N: TOTAL MILES: '� X ,So 13-&D—s MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00 07:00) -0-c CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 - OTHER: OXYGEN: (PER TANK) + P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I j1, � •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: I RELATIONSHIP: K6� E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: / �f rhC _ STATE— ' ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: "� J ( �>> �� �ORK PHONE:-'?�' 1 �I DRY RUN: ,(AUTHORIZED) EMPLOYERij OCCUPATION: OTHER: ADDRESS. ` CITY: �� STATE: I TL ZIP: COMMENTS: TOTAL: QX G PATIENT RECEIVED BY: X x �, ProviderSIGNATURE) of-1 vvidrr rota`r. Ilhita ,r !'ir,:�i rnrL, Soturr Yr'; m , . _npv t� Efl.^ uhry t!il'ina CONTRA COSTA COUNTY i'" AMBULANCE PRE-HOSPITAL CARE FORM 1 uNn AUTHORIZATION _ 13 1 CHECK OR FILL IN APPROPRIATE SPACES _ - DATE PATIENT'S NAM 'I GL,,-, c ❑ E ��iS�"L•1S'�C_� { _ ._ M �F COMPANY a _ ADDRESS -47- _`?? �'rc5`�C�( .�`�L - ..._.. -- - . AGE . CITY._t �(Iit 112 ._- STATE..c/� - . _ ZIP DOB(O�,l�C�:� ❑ Sr O M ❑.TT , V�Th ❑ F ❑ S DRIVER'S LICENSE a .-.. PHONE)3-t NATURE OF DISPATCH.1. TYPE OFTRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION"^•:,. RESPONSE CODE: REQUESTED BY TIME - (24 HOUR CLOCK) I • � �, V i� - �j �S S� LL,,, TO SCENE - � so -._. ._ __. CALL RECEIVED P D. _.._-__._ TIME 10-8 �rL! PATIENT DESTINATION FROM SCENE ❑ FIRE _____ .__ TIME 10-97 �Y1 1 ❑ PSAP TIME 10-49 MILEAGE. ❑ OTHERiPVT TIME 10-7 ( - END _.----. '_ -- ----___.-__-- TIME 10-98 DOCTOR _�!�tT ��-_ ._,,IPMU,'ER START--__- y _-__-.___.____ TIME 10-22 1 HOW HOSEN TOTAL --/ _ _ _._.—_ STANDBY TIME EAREST ❑ FAMILY ❑ TRANSFER --_— WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK 4: AMBULANCE COMPANY: EoT AMBULATORY? PATIENT.TAKEN TO AMBULANCE. RESPONSE ZONEYES O ❑ WAL",EO 2,GUERNEY ❑ OTHER PATIENT CONDIT N DRIVER.____ .1 vr1_ A�ED IA___ _ - CV TECHNICIAN ._ _: tiJ1S Hx P -�� - - - ---- DISPATCHER. .��<�i � 1 L-- ----- - CHIEF COMPLAINT: _ .i_ l/ DRY RUN: ❑ YES ONO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY)-- _. PATIENT REFUSED SERVICES (SIGNATURE) X r MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: — __,____ �• = S.S a _ --- - ----- ---- ! PRIVATE INS CO.: ____ BASE RATE: KAISER —._ / __.1_./_ _— MULTIPLE PTS. BASE RATE — E # _S {9_ -4�,�c � T,,� S TOTAL MILES:------ I X r ) (CAR AIS-[__ E.0 B. ATT. /ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (1900-07:00) f CCHP/PPHP a: _ _— __ _ EMERGENCY RUN: r MEDT-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:- _ _____-___--__._ 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 — -- --1 D�--- I'AIII NI HI (:IIVfI) 14V X A Pr.nri.lrr rrra: . w�. CJ NA I11 hl f CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N ���� y-1 CHECK OR FILL IN APPROPRIA)E SPACES _ DATE: }EF�ATIENT5�NAINE" I - O w O t COMPANY N ADDRESS; ' -7 I ' AGE _ C I l R (�-U CITY— - - -STATE ,ZIP DOB= _ O Sn OM OT ❑W O Th O F OS DRIVER'S LICENSE N 1 1 PHONE NATURE OF DISPATC AOO-L✓ T C p O.L(LI TYPE OF,TRANSPORT:, AMBULANCE OTHER❑ STATION 1(A)_2(B)_3(CK4(D)_5(E)_ INCIDENT_4QrATIONj - !f.I RtSPONSE CODE: RE06ESTED BY: TIME - (24 HOUR CLOCK) t/ j --- TO SCENE- N 5.0. CALL RECEIVED -JJ}- , f „ O P.D. TIME 10-9 �L LL 1L12- PATIENT DESTINATION:. _ } / FROM SCENE ❑ FIRE TIME 10-97 C� :t- FzlS2c�ae�J i Ce__N U O PSAP TIME 10-49 :# MILEAGE: ❑ OTHER/PVT TIME 10-7 ' ,.. END TIME 10-99 1 SDbCTOA[T"'T` ._.' PMD/ERI START TIME 10-22 J .. HOW CHOSEN: -_ _1 TOTAL STANDBY TIME - t O NEAREST? cj FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT O DIRECT 13 OTHER CALL BACK N: AMBULANCE COMPANY;2 PT. MBULATORY7 I PATIENT TAKEN TO AMBULANCE: ��� RESPONSE ZON ` YES ❑ NO .. ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER - EMT-11A -1 TECHNICIAN 01–Q t TQ PARAMEDIC t Hx: I - DISPkT EAS 0 CHIEF COMPLAINT: - DRY RUN-X'YES ❑ NO FON-FO Y RUNA FODRYEMS U LY) "t).PATIENT REFUSED SERVICES: (SIGNATURE) X 1 _ MEDICAL COVERAGE;. INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: '+5 S.S.N PRIVATE INS.CO.: BASE RATE: }: KAISER N: i. ; I I MULTIPLE PTS. BASE RATE -z BLUE CROSS N: r i TOTAL MILES: X MEDICARE N;'. J E.O.B. ATT. ROUND TRIP: O YES O NO _ ❑ YES 'O NO NIGHT: (19:00-07:00) ' r CCHP/PPHP Nf I. EMERGENCY RUN: MEDI-CAL N: CODE 2/3 , 1 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) G EMPLOYER: OCCUPATION: OTHER: - ADDRESS: THER: -ADDRESS: -CITY: STATE: ZIP: ' --"'•COMMENTS- • TOTAL: PATIENT RECEIVED BY: X .. _ (SIGNAT�IRE) EMS•1 CONTRA COSTA COUNTY { 1 AMBULANCE s �s PRE-HOSPITAL CARE FORM I C_ UNIT �� Cf AUTHORIZATION 01 F� � CHECK OR FILL IN APPROPRIATE SPACES - DATE: /& ICS-s 'PATIENTS NAME _ A (?� C/' S P-M ❑ F COMPANY M ( I ) ' nn „ ADDRE —7 o./.r -_ AGE. �., CITY✓ our. STATE ZIP DOBE !4 ❑ Sn OM OT O W')3(Th OF O S DRIVER'S LICENSE M _ PHONE 2 S1 J C �L— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER Cl —_-_—_____ _- STATION 1(A)_'%.__2(B)_3(C)_.4(D)_5(E)_ INCIDENT LOCATIQ RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- j 9 S.O. CALL RECEIVED _ /S~ '' t'`J/ O P.U. TIME 10-B 1. -1 .`i 1 `f PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 MILEAGE: O PSAP TIME 10-49tw ❑ OTHER/PVT TIME 10-7 c •7 :2�' ' END TIME 10-98 DOCTOR —7 — PMD/® START TIME 10-22 , .HOW CHOSEN: I TOTAL STANDBY TIME O NEARESTFAMILY O TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER (�.>j CALL BACK M: AMBULA C MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES,6 NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER '' WJA � EMT-IA TECHNICIA�r � (�/`�L-P�I /S('�i PARAMEDIC _ Hz: \- �)R(`. lJ DISPATCHER )�l CHIEF COMPLAINT: O DRY RUN: O YES ANO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. — � ��N�DUSTRIAL ❑ YES�NO NO. OF PATIENTS: ``=� PRIVATE INS. CO.: BASE RATE: !% KAISER of: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X A d _ - E.O.B. ATT. ROUND TRIP: O YES ❑ NO 11 O YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP M: EMERGENCY RUN: MEDI-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) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X In DRUGS: (PER ADMIN.) X NAM ��`S O(r or- RELATIONSHIP:` c li E.O.A.: (IF NOT REPLACED) _ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 571AL STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: I OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - --- TOTAL . --- - -- 7.00 PATIENT HECEIVLD UY. X -- -- -- (SIGNATi1RE) — — �M•, i lh vn dpr I'I fiu r, ✓lir r. �.! i.. .I�. „'�•.r+ � 6.a 1 i , CONTRA COSTA COUNTY I AMBULANCE PRE-HOSPITAL CARE FORM I �• UNIT Z t AUTHORIZATION 0 J 1 ^ J CHECK OR FILL IN APPROPRIATE SPACES DATE: _ I PATIENTS NAME 0M F COMPANYI# ADDRESS 1 I AGE�_ltl 0 �C)\ I 1 CITY "STATE ZIP DOB13Sn 13M ❑ T 13W h—Th ❑ F E3S DRIVER'S LICENSE 0 _ PHONE NATURE OF DISPATCH (=�� TYPE OF TRANSPORT: AMBULANCE OTHER 13 — -- STATION 1(A)_2(8)_3(C(�D)_5(E)_ INCIDENT LOCATION:( )' RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C CK) TO SCENE- �.0. CALL RECEIVED V P.D- TIME 10-8 PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 OTHER/PVT MILEAGE: ❑ OTHER/PVT TIME 10.7 - END TIME 10.98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: - TOTAL STANDBY TIME ❑ NEAREST c; ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE CQ Aj�Y2 ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: '.J J RESPONSE ZON -I a ES ❑ NO. ,- ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER S EMT-lA NI10..' '^ TECHNICIAN b\ Mi & PARAMEDIC Hx: l i✓10 cy� FI C C (CA lil DISPATCHER. jf CHIEF COMPLAINT: ��P�r P S Gy4 I,. DRY RUN: ES ❑ NO REASON FOR DRY RUN -I Y 1 53 1 a!'ZQ P -� U.J,? ATION D UN(EMS USE ONLY) c PATIENT REFUSED SERVICES: (SIGNATURE) X �5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: !)• "� y( S.S. 0 PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X ;• MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07.:00) CCHP/PPRP R:" ' EMERGENCY RUN: MEDI-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) 1252f-? C0 EMPLOYER: OCCUPATION: OTHER: ADDRESS: ' -CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY" X F1widr^ ural- vhi!< ...! (';InNAI(IRE) ►Ma-) CONTRA COST COUNTY ^l AMBULANCE PRE-HOSPITAL CARE FORM I i UNIT AUTHORIZATION a / ' CHICK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME $f COMPANY N ADDRESS '% AGE N I. ` ( , CITY STATE-_- ZIP DOB ' 13Sn 13M O T O W _Th O F O S DRIVER'S LICENSE M PHONE NATURE OF DISPATCH ` 11 TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ —.__ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ (JM� INCIDENT LOCATION: ; RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C OCK)� (/ TO SCENE - IrS.O. _ CALL RECEIVED r ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE 11 FIRE TIME 10-97 Q ❑ PSAP TIME 10-49 MILEAGE. ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR i " ' I PMD/ER START TIME 10-22 Qom_ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK k: AMBULANT COIaAP� I PT, PATIENT TAKEN TO AMBULANCE: RESPONSE�Z.ONf�``ff �.�. L9 YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER' I PATIENT CONDITION: ( DRIVER S SO �"�' EMT-1A TECHNICIAN S PARAMEDIC f HX: r IYLO 1"��.�TO C-C C P tl� DISPATCHER: l_ -/ CHIEF COMPLAINT: e }n(_p Q ✓L DRY RUN: ;N'Yf S NO R ON FOR DAY RUN IR -7 [v� +� �'•�r �� AUT YR N EMS LYf PATIENT REFUSED SERVICES: (SIGNATURE) X 40 0 2 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.0 PRIVATE INS.CO.: BASE RATE: KAISER Ilf MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES NO NIGHT: (19:00-07:00) CCHP%PPHP N: ' r EMERGENCY RUN: 5 MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) I 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: I TOTAL: �I PATIENT RECEIVED BY:X f-r .._� H.ur vr.i., 4A j• ...( _____1 (SIGNATUfIi') C , CONTRA COSTA COUNTY ` AMBULANCE �.���� '7 PRE-HOSPITAL CARE FORM I UNIT ! AUTHORIZATION N �C•/ CHECK OR FILL INAPPROPRIATE SPACES _ (- DATE: . Y ATE: ^ ') I PATIENTS NAME .r't'.'.-fir 1 "`�`v '��� _ O M '❑ F COMPANY ADDRESS ' �r�iL t AGE CITY-! C -+ ' •^�TCr STATE ZIP DOB '" ❑ Sn ❑ M ❑ T ❑ W •13 Th ❑ F ❑ S DRIVER'S LICENSE N PHONE 1 � NATURE OF DISPATCH 1: �'• �� �t L TYPE OF TRANSPORT: AMBULANCE. OTHER❑ STATION 1(A)z2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - �1. ® $.O.__ CALL RECEIVED , L_L ❑ P.U. TIME 10-8 / �� ❑ FIRE TIME 10-97 PATIENT DESTINATION: FROM SCENE- 1"❑ PSAP TIME 10-49 � } j i-. MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR � f 1 ► PMD E5 STARTWI TIME 10-22 HOW CHOSEN: TOTAL _ _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER ( CALL BACK p: AMBULANCE-COMPANY: L -i-I C -r PT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKEGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER- 'Ij. EMT-1A TECHNICIAN � �'I %i /��.-�. / vr. PARAMEDIC X _ ,. Hx: r' t"Gc � iar..� DISPATCHER: 1 CHIEF COMPLAINT: DRY RUN: 11 YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) t,�• PATIENT REFUSED SERVICES:(SIGNATURE) X_ MEDICAL COVERAGF -, ND�STRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.' {��� rl 7 e-1 �� i�1 BASE RATE: l I KAISER N: - 'r�' ` - MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE M: .1,J—�;�� `�__7 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO IIi I ❑ YES ❑ NO NIGHT: (19:00-07:00) / Y CHP/f PHP M: EMERGENCY RUN: M M-tAL 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 1 i _ j DRUGS: (PER ADMIN.) X NAME � �� IK)S RELATIONSHIP:'T� E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL ORAL AIRWAY: (IF NOT REPLACED) _ CITY: "sit STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: /.K.i 7 OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _.----- TOTAL. : -� 2 s• 00 PAI TENT RECEIVED BY X -- I!.IGNI TURF) CONI IIA CO!i 1 A COUN I Y 1'I t AMBULANCE az 1 7&6 PRE HOSPITAL CARE FORM i UNIT AUTHORIZATION M J CHECK OR FILL IN APPROPRIATE SPACES l ,'1 .�72, 77 Il T J 6 C7 I DATE:�' --ice/ �� / ( • I .. _1rJt- =,.:1���_Cc 1 `_ A -VD- M © F COMPANY 0 PATIENT'S NAME.. I ADDRESS jam(_---- )1__•�__ AGE _ CITY_ _T_ _ STATE_ IIP�JZJ,7 D1-j - q O Sn 13M O T O W PrTh O F $ i f ,.. I: 4 ,,.I ., ; ) 1 . DRIVER'S LICENSE q _-__..__.- PHONE 91 2h_)_D L Vf_ NATURE OF DISPATCH- -TYPE OFTRANSPORTi ISPATCH-TYPEOFTRANSPORT: AMBULANCEY OTHERD STATION 11A)_2(B)_3(C)_41D)_61E) I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) } TO SCENE- S.0. CALL RECEIVED -e- 0 P.D. TIME 10-8 PATIENT DESTINATION:• FROM SCENE - ❑ FIRE TIME 10-97 2- ❑ PSAP TIME 1049 _ MILEAG��,, 11 �� ❑ OTHER/PVT TIME 10-7 11END_ TIME 10-98 DOCTOR _4510(ASSS!t�_. PMD/g) START C", TIME 10.22 HOW CHOSEN: TOTAL _SSTANDBY TIME ❑ NEAREST FAMILY O TRANSFER WAIT TIME ) _�._• O PATIENT ❑ DIRECT O OTHER �� ' CALL BACK 0: AMBULANCE COMPANY: 1(7 S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: r r� ' RESPONSE ZONE FW&) ❑ YES NO ❑ WAL'<ED GUERNEY O OTHER _ PATIENT CONDITION: DRIVER � 1( _ EMT-1A TECHNICIAN PARAMEDIC r) ! Hx: DISPATCHER: , �.�. I f;. CHIEF COMPLAINT: _�.L1 �4f C '!hT DRY RUN: D YES ❑ NO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -- PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL OYES g'NO NO. OF PATIENTS: S.S N - 1 PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS: BASE RATE - BLUE CROSS k TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: OYES ❑ NO -- O YES ❑ NO NIGHT: (19:00-07:00) ��) \ CCHP/PPRP C EMERGENCY RUN: { MEDI-C CODE 2/3 11 OTHE OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 'f i E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X NAME: )Lblrsavzfd, RELATIONSHIP: tv") 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) 8Z� EMPLOYER �nnr�Sir�t OCCIUPAT ION: 4L OTHER: - - 6-, _10 ADDRESS: (1urACY11 1 IsJSuCJM�` L 1rJv CITY: CL1J1cbfc:1 STATE: ZIP: COMMENTS: j s - �'� o� kr�.�1 � TOTAL: PATIENT RECEIVED BY: X (SIGNATURE) Rvvidrr rrW:*. L7;i:r i_ra Ii•= o rl Prtu ye -c -npy t• ENL when FcT"ink OIS-1 CONTRA COSTA COUNTY AMBULANCE ' - PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION III CHECK OR fttl INAPPROPRIATE SPACES L DATE: PATIENT'S NAME ��Up� -�� hM ❑ F COMPANY M V A rA ADDRESS /f �-S�2 �n c� GE Z. �, CITY I -� STATE li'2 L_ ZIP DO .�Z O Sn D M O T ❑ w hTh D F 133 DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH ��k TYPE OF TRANSPORT: AMBULANCE FtTHER❑ vy;�,(j�{g J , INCIDENT LOCATION: RESPONSE CODE: ' , EOUESTED BY: TIME-(24 HOUR C K�r L, TO SCENE- .0. CALL RECEIVED1.T,-_ ❑ P.D. TIME 10-85 PATIENT DESTINATION: -�— FROM SCENEFIRE TI D ME 10-97 x'�• '� .. ��T ❑ PSAP TIME 10-49 f` `T MILEAGE: / 13OTHER/PVT TIME 10-7 END .SS / TIME 10.98 Tic �-� d� DOCTOR PMD START ! ) TIME 10-22 �„•( n�T3�.J.� H HOW CHOSEN: TOTAL 2- , STANDBY TIME . �r ' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME "I 13 PATIENT ❑ DIRECT /q+:Z THER 3CALL BACK AMBULANCE CANY• l;i.-2 t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE / SES ❑ NO::]/" O ALKED ❑ GUERNEY ❑ OTHER G ,!/ G O PATIENT CONDITION: DRIVER _ e `I • .,;�+ I 7 , TECHNICIAN PARAMEDIC Hx: .�J 1�� DISPATCHER- n �'O `� CHIEF OMPL 'INT: ���OL� tl,r� DRY RUN: OYES { NO REASON FOR DRY,RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY !-' �jI n,. . ATIENT REFUSED SERVICES: (SIGNATURE) X I 'tom' MEDICAL CQVERAGE: >1 INDUSTRIAL ❑ YES .IRI NO NO. OF PATIENTS: `I•;3 ,87U1 .t �.> PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X r ) MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO S 13 YES ❑ NO NIGHT: (19:00-07:00). CCHP/PPRP#: EMERGENCY,RUN: I _. �eS ; •. MEDI-CAL#: ` COD)/3 I Gis 1.LQV S x RATX3C 'C,•.°{' OTHEWyti �'2� OXYGEN: ( R TANK) ,•�Y:, P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) [Id.� {d1 DATES BILLED: STANDBY: (OVER 15 MIN.) - E.K.O.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) s:.r X,_�_.,_•. "t 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• r� COMMENTS: TOTAL: Ivy V- PATIENT RECEIVED BY:X Provider retain white v+d Pink copy Return YeZZow Cagy to t?IS when billing ( O URE) . CONTRA COSTA COUNTY �;•\� AMBULANCE PRE-HOSPITAL CARE FORM I C ; UNIT AUTHORIZATION3/ N CHECK OR FILL IN APPROPRIATE SPACES \ - DATE: PATIENT'S NAME__kC_!'_- �_ -�-_ ❑ M O F COMPANY# �4 ADDRESS _ ?" AGE CITY - Pt 7Y�Af4�6 —_ DOB__-__ ❑ Sn O M O T ❑ W r_" O F O S I DRIVER'S LICENSE q ________. .... __... . PHONE ._._—.. -____ .____ NATURE OF DISPATCH es { - 1 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: �� I � '.( RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K) _ 40,:'> t / , TO SCENE I�1 S.O. CALL RECEIVED �/V -�% /` �- -- ---- --- ❑ P.U. TIME 10-8 j(`/f/- 1 PATIENT DESTINATION: FROM SCE E - ❑ FIRE _— TIME 10-97 l ❑ PSAP TIME 10-49 MILEAGE. Cl OTHER/PVT TIME 10.7 END ,__ TIME 10-98 f DOCTOR _ __-_ _-_-__. PMD/ER START_— _- TIME 10-22 :� •••� HOW CHOSEN: TOTAL - _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �- J ❑ PATIENT ❑ DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S RESPONSE ZONE—_—� O YES ❑ NO ❑ WAL',ED ❑ GUERNEY ❑ OTHER -_ PATIENT CONDITION: DRIVER A, f G�� � E T-11A TECHNICIAN f-ARAMEDIC tr1' Hx: X_�! ----_ -yy----------- DISPATCHER: -� 4 (/ CHIEF COMPLAINT: �._Q 4�b5_� DRY RUN: ❑ YES NO REASON FOR DRY RUN 4144 U H Of4f ATION 09 Y R Pt(EMS USE ONLY) // 1 PATIENT REFUSED SERVICES: (SIGNATURE) X\ - r" r MEDICAL COVERAGE: INDUSTRIAL ❑ YES/ErNO NO. OF PATIENTS. �3 / S.S. a PRIVATE INS. CO.: BASE RATE: 1 KAISER R: MULTIPLE PTS. BASE RATE I-f BLUE CROSS a:_ _- TOTAL MILES: X v MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO i ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP%PPHP#: EMERGENCY RUN: MEDT-CAL W 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) PHONE:. _ WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: _..-.___.__. OCCUPATION _- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: — _50-0 ------- ----- TOTAL PATIENT RECEIVED BY: X ....... r.•I t - ,.. ..i.., .. (SIGNATURE) UIS-1 CONIItA ('OSTA COUNTY AM©ULANCE PRE-HOSPII AL CARE FORM I UNIT AUTHORIZATION N 1-3 iEK 3 ' •. CHECK OR FILL IN APPROPRIATE SPACES DATE: - PATIENT'S NAME h �� . �c���L._.__ O M Ly F COMPANY ADDRESS _)=_1 1LL.ClC__.C_U.�'L-�.�-r AGE CITY �CIiS STATE CCI--- ZIP DOB l b L ❑ Sn O M O T W O Th O F O S DRIVER'S LICENSE it PHONE �D__O� NATUAE OF DISPATCH ' ---- TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION I(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOC TION: RESPONSE CODE: REgpESTED BY: TIME- (24 HOUR CLOCK) ' ' I' _ TO SCENE S.O._ CALL RECEIVED O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - O FIRE TIME 10-97 Q �y O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END - TIME 10-98 �: DOCTOR \ PM %�`R START,` TIME 10-22 HOW CHOSEN: ` _ TOTAL STANDBY TIME ' Cl NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMP Y• PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �Y YES O NO ❑ WAL"ED EGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A I TECHNICIAN. - PARAMEDIC Hx: YJLi�l_�S\i _ 2A,,,, DISPATCHER- " 1 CHIEF COMPLAINT: ���: l ti�_<�L�,X,zxal(Lib RUN: O YES "lil NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES `J6 NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER a: i MULTIPLE PTS. BASE RATE v LUE CROSS' ' TOTAL MILES: X (MEDIGAREL�� `�L( ' T E.O.B.ATT. ROUND TRIP: O YES O NO ,t- �> I }, YES O NO NIGHT: (19:00-07:00) U CCHP/PPRP N: EMERGENCY RUN: . ICL(l-Uc6 MEDI-CAL N: CODE 2/3 -- (` OTHER". OXYGEN: (PER TANK) ! P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) - .a 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 NAMEC_ lL>`��« RELATIONSHIP: Eb.A.: (IF NOT REPLACED) ADDRESS: f:�'— ORAL AIRWAY: (IF NOT REPLACED) , CITY: —____ STATE_.._ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: moi; ,.� ••t• /d.C1� // CITY: STATE:—.ZIP:— COMMENTS: TATE: .ZIP:COMMENTS: TOTAL: PATIENT RECEIVED BY:X_ (SIGNATU E1 ' Provider reta:r. 61;,.:1, , tf r••.:: _cl,o -;CtUrn Yr*d,L' -n,. r• EMS when DiI'ina D(S-I CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNITAUTHORIZATION k �r3 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: 6TIENrs'NAME I'�' ❑ Iv( ❑ F COMPANY k ADDRESS �( I l AGE�. \ .V l� _ CITY ; -- STATES"SHIP�_ -DOB - ❑ Sn ❑ M O T ❑ W 04� , .C3 F ❑ S _ i I DRIVER'S LICENSE k 1 PHONE —.NATURE OF DISPATCH ��� �I(c f�'l�L��GA7�1 I, TYPE OF TRANSPORT:I AMBULANCE IV OTHER 0 — STATION 11A)_2(B)_3(C)_4(D)_5(E)_ INC1D NT LOCATION:;~ I V� RESPONSE CODE',- REQUESTED BY: TIME— (24 HOUR CLOCK) t TO SCENE- N. CALL RECEIVED 40� ;DLd ' •.C'1 I ❑ TIME 10-8 PATIENT DESTINATION:. --) .FROM SCENE- ❑ FIRE TIME 10-97 _ II ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 _ 1 END TIME 10-98 KID OCf0A1 `�� - PMD/ER START TIME 10-22' . p 71 HOW CHOSEN: 1 - } TOTAL STANDBY TIME ' NEAREST•z C) FAMILY ❑ TRANSFER WAIT TIME D PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPNY' -� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: !>U RESPONSE ZONE _ ❑ YES,j❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITIONY + DRIVER xq[z"0-6- TECHNICIAN wh �144 ) 10 PARAMEDIC i Hz: L ✓ h� ; DISPATCHER: , L L�O CHIEF COMPLAINT: -1 DRY RUN:�ES �1O REASON FOR DRY RUN �Jd (" " AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j i.l�Ef RA;lU .- PATIENT REFUSED SERVICES: (SIGNATURE) X r1 '1 MEDICAL COVERAGE.---� INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M i• .. PRIVATE INS.CO.: BASE RATE: KAISER k MULTIPLE PTS. BASE RATE 1 BLUE CROSS k: ` ' I TOTAL MILES: X - f MEDICARE k.' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO I O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP EMERGENCY RUN: T'1-•-•rte- MEDI-CAL C CODE 2/3 - �. OTHER: I OXYGEN:, (PER TANK)' —,� - P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) $> "'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) _ I `y 'CITY:" ZIP: C-COLLAR: (IF NOT REPLACED) ` j_. ' PHONE: -WORK PHONE: DRY RUN: (AUTHORIZED) j 'i::.—EMPLOYER: OCCUPATION` OTHER: ADDRESS: y�. —CITY: - - STATE' ZIP: COMMENTS: �. TOTAL:- PATIENT RECEIVED BY: X ...rl .. _ �:.. (91nNAl Unn ' w CONTRA COSTA COUNTY 11 I. AMBULANCE t L PRE-HOSPITAL CARE FORM t TJ; UNIT _Z AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES T DATE: PATIENT'S NAMEL7 ❑ M ❑ F COMPANY M ADDRESS AGE CITY STATE ZIP_ DOB _ ❑ Sn ❑ M ❑ T O W ;3{Th OF OS I DRIVER'S LICENSE M _ ---_ PHONE------.--- NATURE OF DISPATCH s TYPE OF TRANSPORT: AMBULANCE O OTHER❑ __ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE 3 S.O. _ CALL RECEIVED - r [(,.Lt Ps ❑ PD. TIME 10-8 PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10-97 ' r ❑ 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 O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C A �. PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES O NO ❑ WAL`<ED ❑ GUERNEY O OTHER S PATIENT CONDITION: DRIVER F ('�` � EMT-1A / 7 Hx TECHNICIAN w`�. PARAMEDIC �t f'V C ���VrC� DISPATCHER: CHIEF COMPLAINT: DRY RUN: X YES O'NO REASON FOR DRY RUN 102 NC_ _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ y MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: 1 KAISER 4: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE x: E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: . MEDI-CAL k: CODE 2/3 1 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) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: I CITY: STATE: ZIP: COMMENTS: — TOTAL:-0 PATIENT RECEIVED BY: X_ — (SIGNATI)RE) 'ji �c f • CONTRA COSTA COUNTY \ AMBULANCE PRE-HOSPITAL CARE FORM I ( uNiT AUTHORIZATION b. / CHECK OR FILL INAPPROPRIATE SPACES �� nn DATE' PATIENT'S NAME-. J ��________ ._SViO L�"< __. ❑ M tkF COMPANY b ADDRESS -- - '�._- ----- T --- --. AGE.�v CITY_s\�L� � STATE __ll!___- ZIP.9_..1 0o '. .__. DOB � �5 ❑ Sn ❑ M ❑ T ❑ W �Th OF Os DRIVER'S LICENSE p ___ _- __ PHONE2��-y0 NATURE OF DISPATCH-.__��_ r - TYPE OF TRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME - (24 HOUR CLOCK) G_ TO SCENE- S.0.__-_.__. CALL RECEIVED ❑ P,.D. _ TIME 10-8 / PATIENT DESTINATION: FROM SCENE - ❑ FIRE -__-. TIME 10-97 _ �. C �� ___-_-___._ ❑ PSAPTIME 10 49 MILEAGE: ❑ OTHERiPVT TIME 10-7 _ 1 /� END.___-_T-. TIME 10-98 DOCTOR PMD% START_- .I� _ ___-_-_-_..__ TIME 10-22 HO,W,/CHOSEN: TOTAL __�__ _ __--___ STANDBY TIME �CJJEAREST ❑ FAMILY ❑ TRANSFER / _ -_____-_—_ WAIT TIME d PATIENT ❑ DIRECT ❑ OTHER i CALL BACK+1. AMBULANCE COfAN PT.AMBULATORY? PA TENT TAKEN TO AMBULANCE: RESPONSE ZONE.___ YES ❑ NO �yVAL"ED Cl GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER _G1 � 7`� '^' ���1-- -------_ EI,AT-tA TECHNICIAN -__ !=���G'"L'_ - PARAMEDIC / Hx: DISPATCHER: 1 J c) Yl CHIEF COMPLAINT: L �V J��'GY DRY RUN: Cl YES lg,NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY)_ r' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVE AGE: INDUSTRIAL ❑ YES ANO NO. OF PATIENTS: SS '�1- T__ — PRIVATE INS. CO.L0'7,'_1 ''jl r"�f��t�lJn•\'- � �- BASE RATE: - 7 I KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS 0: ' � n <y TOTAL MILES: ___-___ . X ME_ D_IC_ARE#: -Z/ /�" �� '� "'S;NE.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19:00-07.00) — i CCHP/PPRP k: EMERGENCY RUN: I MEDI-CAL#: CODE 2/3 OTHER: ( Y�� Y- L l f �_. OXYGEN: (PER TANK) -- ' P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) TES BILLED: STANDBY: (OVER IS MIN.) - - E.K.G (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: LV.: (PER ADMIN)-.--.—.----- X DRUGS: (PER ADMIN.)--_-_ X NAME: RELATIONSHIP: ___. E.0 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: ` ) > �F COMMENTS: TOTAL •psi-., %. 3 7, �y- ---. _ .. PATIENT RECEIVED BY X C ►y^` t CONTRA COSTA COUNTY Ati1BULANC � PRE-HOSPITAL CARE FORM I UNIT 1 AUTHORIZATION a Z/ CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ___ 'Sr hG- rY' �C ✓�' ❑ M ❑ F COMPANY a�I 1 ADDRESS ''/ 4I,,7 5���� ire------G -- AGE/�_ _(/ J CITY. STATE----------STATE_____--___ ZIP.(7 D/v DOB .b.�'�2'_Y6❑ Sn ❑ M ❑ T ❑ W ❑ Th PrF ❑ S Ly v �- � DRIVER'S LICENSE a __-- _..._ _ PHONE C�7J N�TUHE'OF DISPATCH c .._� L_ .- TYPE OF TRANSPORT AMBULANCE PI OTHER❑ :I INCIDENT LOCATION: RESPONSE CODE: EOUESTED BY. TIME - (24 HOUR CLOCK)„ ,� TO SCENE - XS O. -___...___ CALL RECEIVED iL`� �Y C -I��� !/_�2_- - - 1✓ --- _- ❑ P.U. _ ...... ._ TIME 10-8 PATIENT DESTINATION: n //) FROM SCENE ❑ FIRE __.__.- TIME 10-97 ❑ PSAP TIME 10-49 f/1' u `�- (�� f`f MILEAGE: Cl OTHER;PVT TIME 10-7 END 7.3'3_ _ TIME 10-98 DOCTOR --��� ' __. PMD R START_7.j_L___�_ — -- TIME 10-22 HOW C OSEN. TOTAL ,_.!,. __ _._-___—___ STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER ---__. WAIT TIME /❑ PATIENT ❑ DIRECT ❑ OTHER {i' ;I CALL BACK a: AMBULANCECOMP NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. ` ( RESPONSE ZONE YES ❑ NO WAL°:ED Cl GUERNEY ❑ OTHER ___-_--. --- — RIVER. EI`AT-'IA PATIENT CONDITION: TECHNICIAN ?.- L!(� Hx: C t c�.� l��_-Qi�cx_ �LC('t_C_.1-t'�- ----__ DISPATCHER: --. VNO CHIEF COMPLAINT- t - _ � DRY RUN: ❑ YES REASON FOR CRY RUN � E�C1- __ _ ].rrs_t_ AUTHORIZATION FRUN LEMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YE<8N) NO. OF PATIENTS: NS.S. a v Q PRIVATE INS. CO.: Cy( e- BASE BASE RATE: KAISER MULTIPLE PTS. BASE RATE -- B1.L1ELAnSS#:Z TOTAL MILES: _ i� . X MEDICARE a: _E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19 00- 07:00) J G� CCHP/PPHP a: 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: IV.: (PER ADMIN.) ___.-___ -_ X _ yy�� S r7}t� Lr 16ti� DRUGS: (PER ADMIN.)___ X --__ RELATIONSHIP:_--__.. E O.A: (IF NOT REPLACED) -- A�t 'ISS:. ___�1J--MQ t.'J 1.1P__ ._._... _ ORAL AIRWAY: (IF NOT REPLACED) — CITY: i`` I�.��_-._ STATE._ZIP:—___ C-COLLAR: (IF NOT REPLACED) - PHONE:1211�)] 22 1 WORK PHONE: - DRY,RUN:' (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:--ZIP:--- COMMENTS: IP: __COMMENTS: - -- - --- - -- --- - - — TOTAL-.. PAI HI (;F IVF 1) IIY X (I utrl, mill) -- Ir< .i.lv r• r•alr'.. V. r .. ,.. , ., r ►RS-1 VCONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# SJR CNECX OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY 0_ 0\ ADDRESS AGE m I CITY STATEZIP___ DOB,__ ❑ Sn 13M 11T ❑ W CeTh (O F 13S DRIVER'S LICENSE N _ __ _ PHONE-_-._- NATURE OF DISPATCH�CA bu e ti TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION:' r�I ` RESPONSE CODE: RRE�ESTED BY. TIME- (24 HOUR CLOCK) ' n O� C,^ � TO SCENE- 7d S.O.--- CALL RECEIVED o �'✓ 1 ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 12L_ _ ❑ PSAP TIME 10-49 1 0 — MILEAGE ❑ OTHER/PVT TIME 10-7 ) U END : TIME 10-98 DOCTOR PMD/ER START_ TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY: CA� , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: � � 5.7 • RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER IMT-tA.--T— TECHNICIAN__ �`,N Jl,, I3 ARAMEDIC / Hx: DISPATC J CHIEF COMPLAINT: DRY RU YES E NO REASON FOR DRY RUN D & S AUTHORI FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 5� MEDICAL COVERAGE: INDUSTRIAL ❑ YES �rNO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER N: 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: 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: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: .(IF NOT REPLACED) �a PHONE: WORK PHONE: DRY RUN. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL:_ uuFv PATIENT RECEIVED BY X mrjAi I InF1 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT (2aAUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE:A/ fG / yPATIENTS NAME ie7 OM OF COMPANY N ADDRESS 1 AGE CITY STATE ZIP DOB O•Sn ❑ M ❑ T Ow ❑ Th OF ❑ S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ STATION 1(A)_2(8),3(C)_4(D)_ (E), Y INCIDENT LOCATION:f - RESPONSE JCE: RE STED BY: TIME- (24 HOUR CLOCK) TO SCENES .O. CALL RECEIVED [L S P.D. TIME 10-8 IENT DEST N: FROM SCEN O FIRE TIME 10.97 O PSAP TIME 10-49 j MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 r DOCTOR I + PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME c �X ❑ NEAREST!e.' C) FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP�NYA� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J �� RESPONSE ZONE ❑ YES ❑ NO O WALKED O GUERNEY O OTHER co PATIENT CONDITION: DRIVER ( EMT-lA� TECHNICIAN 2 7 PARAMEDIC Hx: DISP�ATCJ _ CHIEF COMPLAINT: . Yfi RUN: YES O O REASON FOR DRY RUNrJ OR DRY RUN(EMS USE ONLY) f, �t �("` �� � , PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: /{�-2 / S.S.M PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES .O NO NIGHT: (19:00-07:00) CCHP/PPHN'M:'' ' 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) P 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:�1•cr) / PATIENT RECEIVED BY:X /}•ni Irr vr..:r; �i r, .rr r.;,; - r•, (SIGNATUiIE) "Aar1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# ' CNFCK OR PILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME 1, AL ❑ F COMPANY STATE ADDRESS ?-� titi�i r ��A AGES/ 3� CITY�.A in►A'Z C� CCA ZIP—1 YLQpp_�, DppOB_Y_41 ❑ Sn ❑ M OT ❑ W ❑ Th P(F O S I DRIVER'S LICENSE#/� �2 �.L�l - PHONE NATURE OF DISPATCH Z TYPE OF TRANSPORT: AMBULANCE'. THER❑ STATION 11A)_2(e)_3(C1_41D)_5(E)_ INCIDENT LOCATION! RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ' 1! 1 1 TO SCENE `� AS.O. — CALL RECEIVED c1t1U.l\E_ ��UC� {- t CZ1M J ❑ P.D. TIME 10-8 PATIENT DESTINATION: —� FROM SCENE- ❑ FIRE —_ TIME 10-97 _ _ ❑ PSAP TIME 10-49 �� ✓ ��t' MILEAGE: ❑ OTHER/PVT TIME 10-7 END - TIME 10-98 DOCTOR �de`C PMD START_Lt0f3- - TIME 10-22 HOW CHOSEN: TOTAL 1 — STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C/-1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE RYES ❑ NO ❑ WALKED kGUERNEY ❑ OTHER - PATIENT CONDITION. DRIVERW EMT-tA ( _ TECHNICIA ' ^ PARAMEDIC l� Hx: �� DISPATCHER: 1 Vl CHIEF COMPLAINT: DRY RUN: Cl YES ANO REASON FOR DRY RUN vim. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /D vv PATIENT REFUSED SERVICES:(SIGNATURE) X �� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: S.S.0 PRIVATE INS.CO.: BASE RATE: _ MULTIPLE PTS. BASE RATE BCROSS M: TOTAL MILES: X ) / MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 0 YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: - MEDI-CAL#: CODE 2/3 r) OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED STANDBY: (OVER 15 MIN.)__ - Ih �' E.K.G.: (PER EPISODE) -'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X // RG c DRUGS: (PER ADMIN.) X NAME:LA�Rel! G RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS:6-t=ftL& - ORAL AIRWAY: (IF NOT REPLACED) _ CITY: 1 L D 5 A� 1�r �=- ,i'`czl� _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: V611-71=0 WORK PPH�OONE: DRY RUN: (AUTHORIZED) �• Y• EMPLOYER: ' i---S/O1YCUPAlfTON: OTHER: , ; r' ADDRESS: U S`t. l'" i1Z.Qp,Jt)A i. ,r (J+-c: /� 1 ✓.. ( ( �� 1 CITY: N L./l/l O STATE: ZIP:- --COMMENTS:, IP--COMMENTS:- 1710 ------------ -- - _ -_. --_— - ---- TOTAL:__-_-- L..__.-._-. PATIENT RECEIVED UY X _ Provider retain White v+J Pi.:; ,•opp 4,tum Yr �,„ I;! ,,, (SIGNATUPEI rr•. U `�f - .I CONTRA COSTA COUNTY r�,.. AMBULANCE C c• PRE-HOSPITAL CARE FORM 1 1 (/ UNIT f AUTHORIZATION CHECK OR FILL IN APPAOPPIATE SPA,CJESDATE: �r � PATIENT'S NAME r S I M I— r 'I ll7 M ❑ F COMPANY ADDRESS-2—Wq-I aGE s,__-- CITY ���'�L`O�j C1 3TATEe�''�G�L`)ZIP------- DlOB0�1IL5� . ❑ Sn ❑ M ❑ T OW 13Th�F ❑ S DRIVER'S LICENSE 0 _ h"�'�� �` _ PHONE_�3.Z-`_t 119_ NATURE OF DISPATCH—V h L 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) F. v �.� \w ,G� f1 TO SCENE- S.O. _— CALL RECEIVED ❑ P.D. TIME 113-8ri1 c PATIENT DESTINATION: FROM SCENE � ❑ FIRE TIME 10-9-9 7 ❑ PSAP TIME 10-49 •� ( • MILEAGE: ❑ OTHER/PVT TIME 10-7 -� r ( ` END��_L����4 � TIME 10-98 Cc DOCTOR PM ER START��Z�' TIME 10-22 ' HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST D FAMILY O TRANSFER WAIT TIME �— APATIENT ❑ DIRECT ❑ OTHER CALL BACK x AMBULANCE COMPANY: P . AMBULATORY? PATIENT TAKEN TO AMBULANCE: , (.', RESPONSE ZONE — YES ❑ NO ❑ WAL!<EDGUERNEY ❑ OTHER _ } PATIENT CONDITION: DRIVER �� ��`� �" r EMT-1A TECHNICIAN 1_,>-LQ!� _ PARAMEDIC r Hx: DISPATCHER: Flol Z 1►-4L; ( C.)( ) CHIEF COMPLAINT. N 'r V DRY RUN: ❑ YES NO REASON FOR DRY RUN I/�� AUTHORIZATION FO DRY RUN(EMS USE ONLY) L� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES 5<NO NO. OF PATIENTS: S.S. K 7-65- PRIVATE 65-PRIVATE INS. CO.: BASE RATE: ;' cl, n;.f KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: MEDICARE x: E.O.B. ATT ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) / CCHP/PPHP N: _ EMERGENCY RUN: C(-,i MEDT-CAL 10. NSF "G CODE 2/3 ' OTHER: OXYGEN: (PER TANK) J P.O.E. STICKER ❑ YES ANO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) I E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: IV.: (PER ADMIN.) X j �J DRUGS: (PER ADMIN.) X NAME:i Fos Na I� B�I I RELATIONSHIP:EiE.O.A.: (IF NOT REPLACED) ADDRESS: S • 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:fT' h ku ^S ✓g 6.7 c2 1 hZ-. GO �� :��-T , — TOTAL'--� -r- —-z _-} _ _ PATIENT RLGLIVI'D HY X (SIGNATURE) 1 a CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M _ W �� '-, rf '; !� / :•1 !/ i`i`i .. CNECK OR FILL IN APPROPRIATE SPACES DATE: r!� 1 PATIENTS NAME , L G� —�� (�� I MINI" f NI ❑ F COMPANY N �� u l` I ADDRESS f AGE ^^ CITY STATE ZIP2Le� DOB iS! W0 Sn ❑ M ❑ T ❑ W ❑ Th F O S DRIVER'S LICENSE M PHONE✓E 4_7AITURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Ef OTHER❑ _ _ - STATION 1(A)_2(8)_3(C)_4(D)^5(E)_ t INCIDENT LOCATION: ` RESPONSE CODE: REgtdESTED BY: TIME— (24 HOUR CLOCK) TO SCENE ErS.O. — CALL RECEIVED ❑ P.D. TIME 10-8 .r PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 T {fu7 L1 -� ❑ PSAP TIME 10-,49 MILEAGE: ❑ OTHER/PVT TIME 10-7 C END TIME 10.98 '- — DOCTOR �.,' PMO ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME Cl NEAREST U FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER �f %1 CALL BACK 4: AMBULANCC COMPANY: PT. BULATORY? PATIENT TAKENTO AMBULANCE: 1 RESPONSE ZONE17 13 YES ❑ NO ❑ WALKED 13 GUERNEY ❑ OTHER 4 PATIENT CONDITION: DRIVE ( EMT-1A . A I TECHNICIAN��!moi�- ) "_ -A5AhwEDIC Hz: DISPATCHER: " ` /�i _ _ _ �I5✓/ CHIEF COMPLAINT: DRY RUN: ❑ YES I b NO REASON FOR DRY RUN tj AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL WR GE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: , S.S. N - 5 5� PRIVATE INS. CO.. •L 1 G BASE RATE: J KAISER M: MULTIPLE PTS.BASE RATE / BtUE-CROSS Nn el Al, ��' � TOTAL MILES: r X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL M; -3G " ' '✓•- �� 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: !j I.V.: (PER ADMIN.) X � * .4+_? -SZ' (i94� DRUGS: (PER ADMIN.) X NAA :� 4 N1�1-LI.-AELATIONSHIP.MON E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE,_ZIP: C-COLLAR: (IF NOT REPLACED) -PHONE: WORK P N DRY RUN: (AUTHORIZED) EMPLOYERI OCCUP I OTHER: l� ADDRESS: CITY: STATE: ZIP: COMMENTS: �j _--- TOTAL.__�a . O_ _._- - ---- I'A111 NT RE:CF IVI n IIY 1( I'n rr In. .•.r. '. hip r - I .rin I I IFI CONTRA COSTA COUNTY AMBULANCE C3 /D PRE-HOSPITAL CARE FORM I UNIT n,-Z( AUTHORIZATION M V Y - IZ- �7 CHECK OR FILL IN APPROPRIATE SPACES DATE; r PATIENT'S NAME _ 01 M O F COMPANY M '• ADDRESS 1 AGE i CITY -STATE ,�ZIP DOB ❑ Sn O M O T O W O Th O F O S DRIVER'S LICENSE N PHONE _ NATURE OF DISPATCHsl��h L..., T S TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_- INCIDENT LOCATIOW j A3 RESPONSE CODE` REQIJESTED BY: TIME—(24 HOUR CLOCK) �� / TO SCENE- 1 Z (TS.O. CALL RECEIVED ( � C ` i r ❑ P.D. TIME 10-8 PATIENT DESTINATION: --_... FROM SCENE-O ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49._ •_ MILEAGE: ❑ OTHER/PVT TIME 10-7 _ END�_ TIME 10.98 SI 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 COMPA(( 4 PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE OYES O NO O WALKED O GUERNEY O OTHER ' :T r ! " c PATIENT CONDITION: ' DRfVER 0 _ EMT-tA TECHNICIAN r �G (182)PARAMEDIC Hx: DISPATCH R: OS CHIEF COMPLAINT: i DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHO IZA ON FOR DRY RUN(EMS USE ONL )C-OG!jye V/LT/ 1/t)(t Sl PATIENT REFUSED SERVICES: (SIGNATURE) X 95a MEDICAL COVERAGE: • INDUSTRIAL O YES O NO NO. OF PATIENTS: r� I 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 ONO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 4:1"' ' I EMERGENCY RUN: MEDI-CAL N: ! iI' ,i ' CODE 21 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 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: DRY RUN: (AUTHORIZED) O EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE! ZIP: - COMMENTS: - TOTAL: PATIENT RECEIVED BY:X — ' • CONTRA COSTA COUNTY AMBULANCENCE �© PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N p,3/5 . CHECK OR FILL INAPPROPRIATE SPACES DATE: ATIENT'S NAME S S I � � �M ❑ F COMPANY M rADDRESS o AGE .. CITY [(:L STATE L.. t" ZIP f DOB�1 ❑ $n ❑ M 13T 13W 13Th �F,O S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH_— z J TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ STATION 1(A1_2(6}_31C1_4(D)^5(E)_ INCIDENT LOCATION: l{f - RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)`1/ 1 f TO SCENE- S.O._. CALL RECEIVED ��c `1LZCP 3 ❑ P.D. TIME 10-8 / { t PATIENT DESTINATION: FROM SCENE- 2 ❑ FIRE __ TIME 10-97 - ❑ PSAP TIME 10-49 �) MILEAGE: ❑ OTHER/PVT TIME 10-7 r END TIME 10-98 .— �L DOCTOR G3- PMD START TIME 10-22 HOW CHO EN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER 1 ! CALL BACK a AMBU OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: t RESPONSE ZONE YES ❑ NO ❑ WALKED Pi�GUERNEY ❑ OTHER — C PATIENT CONDITION: DRIVER v� `� E T-1A TECHNICIAN 1 C' S HxI w - ! DISPATCHER: •` C'('.C CHIS OMPLAINT: I DRY RUN: Cl YES .� NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: IND TRIAL ❑ YESd NO NO.OF PATIENTS: S.S. R U _2 �,�. ' 7 -5 PRIVATE INS. CO.: BASE RATE: Dc a KAISER C MULTIPLE PTS. BASE RATE )SLUE CROSS M: ^ / A TOTAL MILES: X =� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) /PP P R: EMERGENCY RUN: CODE 2/3 l 1J 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.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: ni�Fp &�N�'e RELATIONSHIP: J 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: - /ga-12 OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - ------...___�-- ---- __. TOTAL. ... .. __..._._ PATIENT HEC;EIVED BY X __..._.— /'nwi.trr rubra Nhrr; �r! !•i•: qF .r.. - IS.:NATUAF.) CONTRA COSTA COUNTY AMBULANCE Q I v 1 PRE-HOSPITAL CARE FORM I UNIT ^ AUTHORIZATIONNy:5 CHECK OR RLL IN APPROPRIATE SPACES DATE: ' - . I I 1 PATIENTI S NAME- ❑ M--O F COMPANY N ADDRESS AGE I CITY "STATE ZIP DOB O Sn O M T ❑ W ❑ T11 ❑ F {� S DRIVER'S LICENSE N f I ` PHONE NATURE OF DISPATCH r TYPE OF TRANSPORT:]AMBULANCE OTHER 0 _ STATION 1(A) B)_3(C)-41D1_5(E)_ INCIDENT LOCATION:I ���� . s,3 RESPONSE CODE: I R UESTED BY: TIME- (24 HOUR CLACK) / TO SCENE- O. CALL RECEIVED gat, � � N :: , } P.D. TIME 10-8 1P7� PATIENT DESTINATION: - FROM SCENE- ❑ FIRE TIME 10-97 0 4 i ❑ PSAP TIME 10-49 MILEA 11OTHER/PVT TIME 10-7 <r, END TIME 10-98 .. r DOCTOR r.1 PMD/ER START TIME 10-22 5��1 HOW CHOSEN: TOTAL STANDBY TIME `• ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK R: AMBULANCE COMPANY: RESP PT. AMBULATORY4 PATIENT TAKEN TO AMBULANCE: ONSE ZONE O YES ,O NO 11 WALKED 13 GUERNEY ❑ OTHER ^.� r PATIENT • CONDITION: � DRIVERµ-WT f- Q-7 3 EMT-1A TECHNICIAN ����. D� PARAMEDIC Hx: DISPATCHER: "{� lP ( 4) U Q y CHIEF COMPLAINT: DRY RUN: kYES ❑ NO REASON FOR DRY RUN +firV�Tf AL)jam ^an 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: KAISER N: 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 N:'" EMERGENCY RUN: / MEDI-CAL N: CODE 2/3 OTHER: ' OXYGEN: (PER TANK) 1 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: _ I _ TOTAL: PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBULANCE '1 1 I PRE-HOSPITAL CARE FORM I UNIT fie, AUTHORIZATION N J ! 3� CHECK OR FILL IN APPROPRIATE SPACES _ DATE: PATIENT'S NAMEY > _ O M O F COMPANY k ADDRESS AGE— CITY GE CITY STATE ZIP_ _ DOB—__ O Sn O M ❑ T ❑ W ❑ Th OF S DRIVER'S LICENSE M ___._ ___.-_ PHONE_____-.-__._-__-_..__ NATURE OF DISPATCH— TYPE OF TRANSPORT: AMBULANCE D OTHER O STATION I(A)_2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION -` RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) 5/r� •L yy1�4„l TO SCENE- � �S.O. S�C _ CALL RECEIVED � �! O� �� 44 1�� _ P.D._ TIME 10 8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 n _ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 DOCTOR PMD/ER START TIME 10-22 c C. HOW CHOSEN: TOTAL STANDBY TIME ! ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �`� RESPONSE ZONE�� ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �( � ! I' EMT-IA TECHNICIAN ,ULA I 5 r PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES 11NO REASON FOR DRY RUN Df w'(5 AUTHORIZNION FOR DRY RUN (EMS USE ONLY) 1J t PATIENT REFUSED SER ES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N I / t }�- PRIVATE INS. CO.: BASE RATE: KAISER rf: - MULTIPLE PTS.BASE RATE BLUE CROSS K TOTAL MILES:. X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CALM: 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 L 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: i �� - -- - TOTAL'•J — — -- — - I PATIENT'S NklE: Lisa Kay Eldred AKA: Amy Lee Mayes ADDRESS: No Address �. DATE OF SERVICE: 08-13-83 AUTHORIZATION NUMBER:83-13638 AMOUNT DUE: $235.00 INCIDENT LOCATION: Port & Wanda, Crockett PATIENT DESTINATION: Contra Costa County Hospital _r r.r. i t a is d tr �� Z. '.I� }'11rf3ri� J4� �•'�'L' .'fit •.f. ` •� r:'•• "Y a�tr :� r` � f./ ':;� r w� � .:t n sir'' - •!r"!�w���:-:. .a 4 i //126740 ( Auc 13 3 4? AH '83 Auc 13 3 44 AN 3 Auc 13 3 46 AN '83 VSO NUMBER �j -�� CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 ,., CALLED BY— PATIENT INFORMATION o I NAME: ---- -- ; m o AGENCY: ��-1 CUSTOMER A(PT. 1): DOB: w ErT NEV cR ` u DEPT/FLOOR/ROOM Il: NAME. _ n 1 Z < CALLBACK # INS. TYPE: PVT MCAR V C L KHP PHP VA IND CHAMPUS _ w W INCIDENT LOC: ?. _ _ �/� POLICY/MCAT 0: �UNt n m Q '� MCAR p: _ m } CD F CROSS STREET: _ VERBAL PRIOR: t Q JURIS: 10 City: _` DOCTOR: [?l J Q v •� -- -- - DESTINATION: _._.._. CL/� PT, 92 NAME: DOB: NATURE: � _......-- . �. __- ---------------- CUST. p -- m o _------.------------------_ PT. 113 NAME: DOB: S o TYPE OF CAL . TRANS TIME UNI 2CUST. # n m C 1t CREW: _ _ — WAIT TIME: YES NO REASON: Z UNIT TYPE: ALSBL WC RESPONSE E: 0 1 �? 3 4` REASON FOR 10-22: W a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 103 4 I CANCELLED BY: Q � BY: END MILEAGE: 7' COMMENTS: ` �-��'�'r` p ja Z N TIME: BEG MILEAGE: /►vG• � D DISPATCHER: ► V TOTAL MILES: c XL'01 NOIIVIS 1V 3DNV1f18WV 61-01 `JNINbnIn 3JNV1f18WV 86-01 31OV11VAV 3DNV1f18WV L-01 1V1IdSOH 1V 3DNV1f18Wd � O w EB. 9s [I inn H, Wn sE El snn t ol NO L •` T E , `� r. xY .. �' � �� ^j ••-�,*s�� r.,�.11� �r4•T�r�p,„�•,v, -y�i :w `,� �a �� ;�: ��,?��Vit''�` �r• 4�':�''� " ;:Yj� �.- ` `�, Y'�-ice}�" 1 fr ;rt, wit VAJGJ� f t .,� - - --.� . ;i�` � y ! `�� -�V 21`�L �.' { � �i.i5'C ���'W"""� ���`� I •' sy ,, =•• t l`• t!i N{ _4�.'.� - •t�• T + 1.+- t'�Ket,;� •.-'7 ��.^.{tlrrt + ,�1j'tj, M • { a fi,, ti �►� .tj ,.•.� .�+•-•,,�`.1:r� is• F•^"•�,f r,� k. r , I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK 04 FILL IN APPROPRIATE SPACES DATE: - I• f t� PATIENT'S NAME_ � t } i�Y � �M O ,F� COMPANY N /c) --� OD- ADDRESS .� _( 1 -T AGE��a CITY��j� �t'1YZ�%�STATE� ZIP `I C'-L�— DOB_L?�r�_ SSI O Sn OM OT OW O Th OF �f,s DRIVER'S LICENSE N �____._ ___-_ PHONP -� ,<<� NATURE OF DISPATCH /I(� m tAd TYPE OF TRANSPORT: AMBULANCr THER❑ STATION 1(A)JC1fB)_31C)_4(D)_51E)_ INCIDENT LOCATION: :QUESTED BY: TIME- (24 HOUR COCK) �J I ��{,� �, ' ( S.O. CALL RECEIVED -�' /�I (., � t1 �' P.D. TIME 10-8 ^(JAY _L PATIENT DESTINATION: FIRE TIME 10.97 PSAP TIME 10-49 OTHER/PVT TIME 10-7 � TIME 10-98 DOCTOR1 V G F TIME 10-22 HOW CHOSEN: STANDBY TIME AREST ❑ FAMILY OTA,.,. . _.. WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COliAPN Y: PT. :ES BULATORY? EPATIENT TAKEN TO AMBULANCE: �j CJ RESPONSE ZONE Cl NO WAL 1(ED)KbUERNEY ❑ OTHERy- PATIENT CONDITION: DRIVER` / 1 L `� EMT-IA �L TECHNICIAN PARAMEDIC Hz:TI2\ 4 1 1S ` DISPATCHER: li 6 '7 C-'r CHIEF COMPLAINT: -�' )1�.I DRY RUN: ❑ YES 410 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X— MEDICAL COVERAGE: INDUSTRIAL ❑ YESNO NO.OF PATIENTS: S.S. 1$ C 2 ]y 2 0--3 PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X 1?ro MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �P/PPH N:� 7 � ��l ' � EMERGENCY RUN: •C.`�; M DI-CAL N: CODE 2/3 OTHER:— OXYGEN: (PER TANK) \\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 C DRUGS: (PER ADMIN.) X NAME: J��) U�( S RELATIONSHIP. V vU r E.O.A.: (IF NOT REPLACED) ADDRESS: Z"t 0 'S ORAL AIRWAY: (IF NOT REPLACED) CITY: 1..St'a— STATE COL Z) N C-COLLAR: (IF NOT REPLACED) - PHONE: r A WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIONO OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: ' — \1 PATIENT RECEIVED BY:X •� Provider rrtair• Nhitc r_rd Pira, ,l � 5Vf; — YC ,:c o;: " (SIGNATURE) �S-I �' P. .�hvr hi 2'i n� } ONT A COSTA COUNTY AMBULANCE c :.•!d PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION K OII.,,I IM APPNOPRIA ESPACES ' DATE:._ �S NAMAa/k katto � UT)1• ❑ M F COMPANY a `" HESS �V (_`/� AGE U fin, +�►' H-BMQ J Q STATE - ZIP a _ DOB__J / ❑ Sn ❑ M OT OW O Th OF I S . DRIVER'S LICENSE 8 _ PHONE�o _itS NATURE OF DISPATCH ..:` TYPE OF TRANSPORT: AMBULANCE O OTHER❑ STATION 11A1_2(8)-31C1,41D1_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) S / 1/ TO SCENE- S.O. CALL RECEIVED vA9 !o�$ V 1 Q1� /� ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Cyt C ❑ PSAP TIME 10-49 MILEAGE: r - ❑ OTHER/PVT TIME 10-7 END Q'S TIME 10-98 t"- �.DOCTOR UI P.D(ED START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME �. O NEAREST O FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER �' CALL BACK C AMBULANCE COMPANY: cid PT AMBULATORY? PATIENT TA N TO AMBULANCE: '. RESPONSE ZONE T ' LYES ❑ NO ❑ WALKED GUERNEY ❑ OTHER JJ I PATIENT CONDITION:. DRIVER - EMT-tA r i )' y� TECHNICIAN eta, �' PARAMEDIC Hx: C'A L-U'15,6,J21G.1e__Aa ( :1� DISPATCHER: (�!�! CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN ! lIf AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— r MEDICAL COVERAGE: INDUSTRIAL ❑ YESXNO NO. OF PATIENTS: S.S. K PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X �r `_;U ��• �U I Ly MEDICARE M: 3 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 4: EMERGENCY RUN: MEDICAL F: /JQ �� 7 i� `,'L'• �/r•�.�'�' CODE 2/3 OTHER: OXYGEN: (PER TANK) U P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEARESTRELATIVE/RESPONSIBLE PARTY/: I.V.: (PER ADMIN.) X GAA&t S)-�J� JLQib&� {(DA) DRUGS: (PER ADMIN.) X NAME�� c� CIC ,, �R,E`L�ATIONSHIP:— E.O.A.: (IF NOT REPLACED) ADDRESS: Jcoym-- C��t(W 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:_tZIP: COMMENTS:1�i`_ Waim6� 1'G(1 �A(2Q__ di TOTAL' •- rn III I,r r•I IVI I1,� x( r . 1 ,�'--'.-..- - - ... �:P A "', z 1,#.• �• - .F.• '�}'.d t ."•f!''�•!��,"^ ',T �'g4r+`�R=.�'Vii,: y CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ( AUTHORIZATION r U !?; ., cJ QCT CHECK ON FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME 1 ' ❑IM O F COMPANY N ADDRESS L AGE i Pie y le o l• CITY STATE .r ZIP-------- - DOB O Sn ❑ M OT OW O Th OF OS DRIVER'S LICENSE N ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT::AMBULANCE 0 OTHER❑ STATION 1(A)-_.2(8)_31C)_4(D)_5(E)_- INCIDENT LOCATION: Y ` 31 RES00NSE CODE: REQUESTED BY: TIME- (24 HOUR Cl CK) TO SCENE- 13 S.O. CALL RECEIVED ❑ P.D. TIME 10-8 .L_3 PATI�NT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 s 1T K 'I MILEAGE: ❑ OTHER/PVT TIME 10-7 rr END TIME 10-98 OCTOR t ' '' ,.I ) ( PMD/ER START TIME 10-22 G� HOW CHOSEN: I - TOTAL STANDBY TIME t �.1'. :;❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ,$ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �.r ❑ YES: O NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:: ' ' i DRIVER EMT-lA TECHNICIAN ���� V PARAMEDIC Hx: ; DISPATCHER: v-2_ CHIEF COMPLAINT: DRY RUN: AYES ❑ Ng OREASON FOR DRY RUN Z4 S 5 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) :,:,'PATIENT REFUSED SERVICES: (SIGNATURE)X 95� MEDICAL COVERAGE: - INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: KAISER w: ' MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP CI EMERGENCY RUN: MEOI-CAL N: / / CODE 2/3 1 OTHER: t OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) G-1 _ E.K.G.: (PER EPISODE) " NEAREST RELATIVE7RESPON BLE 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) _�4 PHONE: WORK HONE: DRY RUN: (AUTHORIZED) , EMPLOYER: OCC PATION: OTHER: ADDRESS: CITY: STA ZIP:- "COMMENTS: IP:"COMMENTS: 00 r b l-T CONTRA COSTA COUNTY AMBULANCE p?t� �S' PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION K Q J l • cl CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ' ti ❑ p,f�❑ F COMPANY N (O ADDRESS T + AGE ` pr , CITY_ STATE.ZIP00q _ ❑ Sn OM O T O W O Th OF j DRIVER'S LICENSE N _. 1 PHONE NATURE.OF DISPATCH wK I L1 I TYPE OF TRANSPORT: AMBULANCE OTHER O _ 4(D)-5(E)— INCIDENT I r . STATION 11A)_2SB1_3(C) 4(D)_5lE)_ _. ( [1� E -_`- INCIDENTI OCATION:� -j �. RESPONSE CODE: ; REO TED BY: TIME- (24 HOUR CLOCK) TO SCENE S.O. CALL RECEIVED cs �.JC,�\ �•-� Ll��/� �['1�'l c�(� ❑ P.D. TIME 10-8 PATIENT DE IN14TION:_-._. FROM SCENE- ❑ FIRE TIME 1497 ❑ PSAP TIME 1449 ' tl l T•S;' MILEAGE: ❑ OTHER/PVT TIME 147 END TIME 1498 +' dUCTOR 1::�I�' f PMD/ERS START - TIME 1422 HOW CHOSEN: TOTAL. STANDBY TIME ) .'.. O NEAREST,`7 FAM L� O TRANSFER WAIT TIME _ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULAN E CQMPA Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONS ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' �'�'D C-�S I .d •' PATIENT CONDITION: - - DRIVE SS a�1 MT-tA t TECHNICIAN � ^d PARAMEDIC Hx: DISPATCHER: Ci,A, 2 CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RU rrd �• /Vl 4 -- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES:(SIGNATURE)X ?: MEDICAL COVERAGE- • INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: .•' C_( S.S.M 1 ( ) t PRIVATE INS.CO.: BASE RATE: r rfa°I KAISER Ma �_�_ MULTIPLE PTS.BASE RATE BLUE CROSS N: ' TOTAL MILES: X _'. MEDICARE C' 1 E.O.B.ATT. ROUND TRIP: O YES ❑ NO 13 YES .O'NO NIGHT: (19:00-07:00) - �: CCHP/PPRP 0: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 ^ ` OTHER: I OXYGEN: (PER.TANK) 1.`,-••r., P.O.E. STICKER ❑ YES Q NO " NEONATAL: (INCUBATOR) DATES BILLED: STANDBY; (OVER 15 MIN.) E.K.G.:. (PER EPISODE) 9 -'NEAREST RELATIVE/RESPONSIBLE PARTY: - - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "'NAME-- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - .t• ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) "'CITY: STATE_ ZIP:... C-COLLAR: (IF NOT REPLACED) ./ PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �v -=EMPLOYER: OCCUPATION: OTHER: ADDRESS- ..,l!--CITY:•CITY: STATE: ZIP: -'COMMENTS: TOTAL:----(,�5 C� ) +••-..-- PATIFNT nrrrr%,rr) pv v CONTRA COSTA COUNTY AMBULANCE /_ PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORI TION K _ 6 • CHECK OR FILL IN APPROPRIATE SPACES DATE: )�ATIENT'S NA' --1 O M •❑ F COMPANY f# ADDRESS AGE CITY S ATE ZIP DOB 13Sn ❑ M C3T O W O Th O F DRIVER'S LICENSE N � PHONE _____,_ NATURE OF DISPATCH { TYPE OF TRANSPORT: AMBULANCE OTHER O _ STATION 1(A)_2(9)_31C1_4(D)_5(E)_ t INCIDENT j.00ATION: }t RESPONSE CODE! REQUESTED BY: TIME— (24 HOUR CLOCK) I lNOA) TO SCENE- S.O. CALL RECEIVED �� s D P.D. TIME 10-8 PATIENT DESTINATION:.__._ _ FROM SCENE - ❑ FIRE TIME 10-97 �1 ❑ PSAP TIME 10-49 ; MILEAGE: ❑ OTHER/PVT TIME 10-7 ��•, END TIME 10-98 DOCTOR 7 �L ' -_-� PMD/ER START TIME 10-22 J_L_ : HOW CHOSEN: TOTAL STANDBY TIME _❑ NEAREST:.-, ❑ FAMIL� ❑ TRANSFER WAIT TIME ❑ PATIENT 13 DIRECT .❑ OTHER CALL BACK 4: AMBULANCE COMPANY: c_A 5 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: � RESPONSE ZONE ❑ YES ❑ NO.r. ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: - DRIVER r S � � EMT-1A C2 2 :�-ulsuj 1 " " TECHNICIAN PARAMEDIC I `( l y CHIEF COMPLAINT: 1 DRY RUN:�IR"YES ONO REASON FOR DRY RUN/D Z2 !n�'DJTG N�J1r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 3 ;*,--.,PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE:_. _ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: s.s.# ..,, =' . ... PRIVATE INS.CO.: BASE RATE: ;.'. KAISER R: ` MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X _ MEDICARE N;' ( E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO J ❑ YES •17 NO NIGHT: (19:00-07:00) I -•` r CCHP/PPRP 0:rl ( EMERGENCY RUN: MEDI-CAL M: ' ' 'L 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: - LV.: (PER ADMIN.) X tr` 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� r; __ PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M ?T 31 3 4.19 CHECK OR FILL IN APPROPRIATE SPACES DATE: ��• - i `] yPAtIENT S NAME .I l 1 r + O M- 13 COMPANY M / 7 7'. } ADDRESS,, AGE o r,r to CITY STATE ZIP DOB ❑ Sn O M ❑ T ❑ W ❑ Th [7 F (1 - . DRIVER'S LICENSE M PHONE 'NATURE OF DISPATCH 1.-r Ie Y1^kI ►� ' "^cc` i �... Ia' TYPE OF,TRANSPORT:� AMBULANCE0 OTHER 0 -- STATION 1(A)_2(B)_3(C)-4(D)_5(E); J ; r, INCIDENT LOCATION^ 1 S� .' RESPONSE CODE: R06ESTED BY: TIME- (24 HOUR CLOCK) r, �- TO SCENE- S.O. CALL RECEIVED yJ.J' -,gn. aln111 .-rte^ -- O P.D. TIME 10-8 • : , ',`,':PAT NT DESTINATION:.... FROM SCENE- 0 FIRE TIME 10-97 --- -��. O PSAP TIME 10.49 . ..1 MILEAGE: ( ❑ OTHER/PVT TIME 10-7 + END TIME 10-98 OC70R r' '""a .- PMD/EASTART I TIME 10-22 HOW CHOSEN: -�r. TOTAL STANDBY TIME t ^�❑ NEAREST,-:. ❑ FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT+ 13 DIRECT O OTHER CALL BACK k: AMBULANCE COMPANY: .� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: CP V RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER.- PATIENT THER.PATIENT CONDITION: -- - ) DRIVER J.) ra r le- r'K EMT-tA 2 C TECHNICIAN c PARAMEDIC "Hx: _ - DISPATCHER' '�{ cl-� : . CHIEF COMPLAINT: I -. _ DRY RUN: RYES ❑ NO REASON FOR DRY RUN IQ--Z 7 12 J•O AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (I 7 y �Ar-... 1;,;;PATIENT REFUSED SERVICES: (SIGNATURE)X� 7 ►. MEDICAL COVERAGE;__ INDUSTRIAL ❑ YES 0 NO NO.OF PATIENTS: I 5.y S.S. ' / - I',. PRIVATE INS.CO.: r BASE RATE:-•- `•:f r KAISER C _,: T MULTIPLE PTS. BASE RATE BLUE CROSS 0- " t I ' TOTAL MILES: X i s MEDICARE C, I E.O.B.ATT. ROUND TRIP: .0 YES 0 NO , ' - t 13 YES `DO KNIGHT: (19:00+07:00) ; `.: _ CCHe/PPRP R:1 * I EMERGENCY RUN: r}•i'. MEDT-CAL 0: _ _-- , + .:j CODE 2/3 OTHER:- OXYGENi (PER TANK) P.O.E.STICKER 0 YES 13NO `' NEONATAL: (INCUBATOR) ' + - i is DATES BILLED: STANDBY: (OVER 15 MIN.) " E.K.G.: (PER EPISODE) !""NEAREST—RELATIVE/RESPONSIBLE PARTY: I.V.! (PER ADMIN.) X . . DRUGS: (PER ADMIN.) X 1 AME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) �r • ?! . ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: -- -•,-- STATE.,- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE DRY RUN:•(AUTHORIZED) lm&'EMPLOYER: - -OCCUPATION: OTHER:. 7 :ADDRESS: STATE: ZIP: COMMENTS: �-- - TOTAL: PATIENT RECEIVED BY: X (SIGNATURE, I CONTRA COSTA COUNTY j AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �.� AUTHORIZATION M �G AJ CHECK OR FUL IN APPROPRIATE SPACES ' 1 DATE: PATIENTS NAME ' l I OM ❑ F COMPANY M ADDRESS , (� z f2 14 'K 1 - AGE — ' CITY STATE ZIP DOB - ❑ Sn OM OT OW O Th O F �'$ - DRIVER'�LICENSE 0 ( PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCID NT LOCA ION' + {` RESPONSE CODE; RE UESTED BY: TIME— (24 HOUR CLOCK) ` (— .._ TO SCENE- �-S.O. CALL RECEIVED _/ Z -�� 26 ' P.D.❑ PDTIME 10-8 LZ PATIENT•DE TINAT N:`_- _ FROM SCENE;� O FIRE TIME 10-97 PSAP TIME 10-49 JY 1)'.r' ;'•�"���iCJ w� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR jr': ^rt I r' -� PMD/ER START TIME 10-22 HOW CHOSEN: L " " "" TOTAL STANDBY TIME O NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT r- ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANC COMP NY: c� lz .z PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER , PATIENT CONDITION:,_ DRIVER {•+ t�[./"X �J MT-1A G Z DA1 fj li I A ` .i,( f TECHNICIAN !� PARAMEDIC Hx: DISPATCHER:Ta -e I-AS 077b qO CHIEF COMPLAINT: DRY RUN: �YES ❑ NO REASON FOR DRY RUN -LZ O (� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 10-y q77 ;.I U,, PATIENT REFUSED SERVICES: (SIGNATURE) X �i 5.a- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: # (� PRIVATE INS. CO.. BASE RATE: ! KAISER Ry MULTIPLE PTS. BASE RATE BLUE CROSS M: I TOTAL MILES: X y' MEDICARE M:. ( I E.O.B.ATT. ROUND TRIP:- ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) j CCHP/PPRP 0: ( EMERGENCY RUN: MEDI-CAL#: ' CODE 2/3 OTHER: OXYGEN:,(PER TANK) P.O.E. STICKER ❑ Y ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) !. .._ NEAREST RELATIVE/RESP NSIBLE 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: WOR PHONE: DRY RUN: (AUTHORIZED) .EMPLOYER: OC UPATION: OTHER: ADDRESS: -.CITY: STATE' ZIP' COMMENTS: _. . TOTAL: _ PATIENT RECEIVED BY: X .— hvv(dir retain White ,rI N14 , hat�m rv•I.-,' nf. ham., (SIGNATURE) EMS-I ,m� •r: . r�t ,,, ' CON IRA COSTA COUNTY AMDULANCE /d PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES ,,J^l' DATE: PATIENT'S NAME C � i M D F COMPANY 0 ADDRESS ��---` -.. �'.�5 � �' AGE _ i 1 STATE ( �I ZIP _ DOB r �_IJ ❑ Sn O M O T W ❑Th F S!• DRIVER'S LICENSE# ____--_ _�_ PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ __ —_ STATION 1lA►_2(8)_3(CI_4(D)_5(E)--�.—, —.. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 1TO SCENE- S.O. CALL RECEIVED 4 ❑ P.D. TIME 10-8 �l PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �r 1 ,{� ❑ PSAP -TIME 10-49- 0 0-49 �f MILEAGE: (� ❑ OTHER/PVT TIME 10-7 o�L c v f END�1-L_ TIME 10-98 -"' DOCTOR v_� PMq EF START_ TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME . NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME t - PATIENT O DIRECT 13 OTHER CALL BACK 0: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE. _ RESPONSE ZONE YES •❑ NO ❑ WAUIED t36UERNEY O OTHER } PATIENT CONDITION. DRIVER EMT-tA - `` TECHNICIANARAMEDIC Hx: F T DISPATCHER: J CHIEF COMPLAINT: �S�v �` �- DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 • PATIENT REFUSED SERVICES: (SIGNATURE) X INDUSTRIAL OVERAGE: MEDICAL CIAL ❑ YES �NO NO. OF PATIENTS: S.S, a _1 S PRIVATE INS. CO.: BASE RATE: 0-•� MO KAISER#: MULTIPLE PTS. BASE RATE / C� BLUE CROSS 1t: TOTAL MILES: X •: l MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO , c ; O YES ❑ NO NIGHT: (19:00-07:00) 3�� ��••,� CCHP/PPRP#: EMERGENCY RUN: ��_•��tSG fMEDI-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: , `bA O AP VE- ` RELATI�ONSHIP: V�}� E.O.A.: (IF NOT REPLACED) - - ADDRESS: (\. ORAL AIRWAY: (IF NOT REPLACED) CITY: ISTATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: .. ADDRESS: CITY: STATE: ZIP• COMMENTS: MG J ff_C TOTAL: PATIENT RECEIVED BY: X Provider "tofr White ,xd t*,'e.R corp 5eturn Te':rw - ;-y t LMF when til:inp (SIGNATURE) CIS-1 fp CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: `'!-0 i % -" O--7vPATIENTS NAME -- O M ❑ F COMPANY I ) 0 ADDRESS 1 ( AGES- - / /T i CITY STATE ZIP�� DOB ' 19 Sn O M O T ❑ W O Th ❑ F O S 1 DRIVER'S LICENSE 0 ( 1 PHONE _ NATURE OF DISPATCH 11 -7 I TYPE OF TRANSPORT:, AMBULANCE O OTHER O STATION 1(A)_2(B)_3(C)._4(D)_5(E)_ , INCIDENT LOCATION:, I RESPONSE CODE: REQUESTED BY. TIME- (24 HOUR C,.00K) TO SCENE- © S.O. CALL RECEIVED "' I 0� 1 O P.D. TIME 10-8 G I PATIENT DESTINATION: . J FROM SCENE- � 13 FIRE TIME 10-97 O PSAP TIME 10-49 _t MILEAGE: ❑ OTHER/PVT TIME 10-7 —y END TIME 10-98 FMOCTOR- ` '; ) PMD/ER START TIME TIME 10-22 LL I i i HOW CHOSEN: TOTAL STANDBY TIME i.i 13NEARESj� O FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT O DIRECT O OTHER CALL BACK R: AMBULANCE COMPANY: I EoT AMBULATORY? PATIENT TAKEN TOBULANCE: C. RESPONSE ZONEYES NO 13 WALKED O GUERNEY O OTHER �'�• Q?r` 57- PATIENT rONDITION: • » , DRIVER CydIt a �; EMT-lA TECHNICIAN �� PARAMEDIC -� i l/ Hx: DISPATCHER: U14Ac, In, CHIEF COMPLAINT: 41, DRY RUN:,�D YES ❑ REASON FOR DRY RUN ti/Q/!- ' I _ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 3 Ll ' S.S.8 1 PRIVATE INS. CO.: - BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 8: ' ' TOTAL MILES: X 1 MEDICARE M{ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: I r EMERGENCY RUN: 1 MEDI-CAL 0: I ( 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/RESP NSIBLE PARTY: - I.V.: (PER ADMIN.) X DRUGS: (PER ADM .) X --NAME: RELATIONSHIP: E.O.A.: (IF NOT PLACED) ADDRESS: ORAL AIRWAY (IF NOT REPLACED) -- CITY: STATE-_ZIP: C-COLLAR: IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) J �v r-"EMPLOYER. OCCUPATION: OTHER: ADDRESS: ' - - CITY: STATE- ZIP:— COMMENTS: IP:COMMENTS: TOTAL. '�j J » PATIENT RECEIVED BY:X _ Pn m�dor rYto(• Gn;�,„ ., ... .. (SIGNATURE) (. 11 CONTRA COSTA COUNTY „ AMBULANCE _ PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS- = AGE1 ( J/ h`'11 CITY STATE_ _ .ZIP DOB Sn ❑ M ❑T ❑ W ❑ Th ❑ F ❑S DRIVER'S`LICENSI`N t - PHONE — NAT RE OF DISPATCH D 0 k 1 Ile-1) TYPE OF TRANSPORT:, AMBULANCE❑ OTHER❑ STATION 1(A)!2(8)_3(C)_4(D)_5(E)_ 1 INCIDENTPOCAT!ON� r RESPONSE CODE: ;-Is, UESTED BY: TIME- (24 HOUR CLOCK) '�` --� TO SCENE- O. CALL RECEIVED MOIL/'fG� W� C O,• Lc� ', I ❑ P.D. TIME 10-8 L! PATIENT DESTIN TION: c���(.TD� FROM SCENE- 1 ❑ FIRE TIME 10-97T� ((�� ❑ PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ENDS_ TIME 10-98 - Fb0CTOR T�,'!IL, t _ i PMD/ER START TIME 10.22 t HOW CHOSEN: __� TOTAL. STANDBY TIME 2�j` ,Cl NEAREST 13FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES, ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �ts l►� ��- EMT-1A 1 °vS I 8 _ . . _. 50I TECHNICIAN l PARAMEDIC qqt �— q Hi: DISPATCHER: QL ll (; CHIEF COMPLAINT: DRY RUN: ES•` NO REASON FOR DRY RUN U-Z Z Cfb 1� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j<j l,".1 PATIENT REFUSED SERVICES:(SIGNATURE) X r MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �C� s.s.N � PRIVATE INS.C 1 BASE RATE: KAISER N'. MULTIPLE PTS.BASE RATE BLUE CROSS k: ' ` TOTAL MILES: X MEDICARE N:" E.O:B.ATT. ROUND TRIP: ❑ YES ❑ NO ' CA ❑ YES ❑.NO NIGHT:(19:00-07:00) CCHP/PPRP CaJ EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: I 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) PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) EMPLOYER: - OCCUPATION: OTHER: ADDRESS: -CITY: STATE: ZIP: "'COMMENTS: " TOTAL: __ PATIENT RECEIVED BY: X-- � 1. I : �� I t ► t3� CONTRA COSTA COUNTY AMBULANCE I o PRE-HOSPITAL CARE FORM I UNIT Z� AUTHORIZATION a `63 "I - CHECK OR FILL IN APPROPRIATE SPACES DATE: ..a PATIENT'SNAME— 1(kyO_l...pc9q-�/_.._ __ � 7 F COMPANY# _. �.... 'rr i 1I ADDRESS . lQ—s- -- �T - — AGE_ 1 1 ti. CITY ,1(_HMQno STATE_C—_ ZIP 5y Y01 L1�-__(._JJ- //DOB�.J�J./!/& � Sn ❑ M ❑ T ❑ W ❑Th ❑ F ❑ S R DRIVES LICENSE K ..N.� . . PHONE 23 S W NATURE OF DISPATCH _._•S (�.L �� ___- TYPE OF TRANSPORT AMBULANCEA OTHER❑ INCIDENT LOCATION. RESPONSE CODE. REQUESTED BY TIME — (24 HOUR CFOCK) . TO SCENE ) ❑ so. _____._. -_- CALL RECEIVED ❑ P.L). -- --- TIME 10-8 t PATIENT DESTINATION- FROM SCENE -•� ❑ FIRE ___-___. TIME 10-97 ��`> ___ ❑ PSAP TIME 10-49PUVI �7MA w tA1LEAGE. — ---- OTHERiP�) TIME 10-7 T_ END 2, —_L .I'�%_}.— TIME 10-98 DOCTOR PMD STARTS_-_L_ __ —_-_ TIME 10-22 HOW CHOSEN' I TOTALSTANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER11 WAIT TIME r� ❑ PATIENT ❑ DIRECT ❑ OTHER T CALL BACK R: AMBULANCE COMPANY: _ ear PT AMBULATORY? PATIENT TAKEN TO AMBULANCE L ' RESPONSE ZONE 2 Pr YES ❑ NO ❑ WI`L';ED JS GUERNEY ❑ OTHER j��^ t PATIENT CONDITION. _ DRIVER—__ _!.�f�_�-4�5��_.J�_ _�_— EMT-1A � j� n SEF FO✓M TECHNICIAN _-r�}- L fes-.—.—.:_ _ PARAMEDIC Hx: ?rF-VIOIAS I 5 In -- DISPATCHER'. L� L �5 --- - - L - - CHIEF COMPLAINT: T !_=i�- Tn'�/ �Zl�_Lhs_A-= DRY RUN. ❑ YES �c NO REASON FOR DRY RUN_ - / AUTHORIZATION FOR DRY RUN (EMS USE ONLY). PATIENT REFUSED SERVICES (SIGNATURE) X .___.._... _.. _.—_-____._.___... _-______.______. MEDICAL COVERAGE , ` NDUSTRIAL ❑ YES NO NO. OF PATIENTS: -_ f .,i E S.S K�2 Z7-S L4 5 I `/ wsb _ - - --J //U•(l� PRIVATE IN��n2 L [ lir BASE RATE: KAISER a: _— MULTIPLE PTS. BASE RATE BLUE CROSS 4: TOTAL MILES: — M X (}MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES y NO ��cc ❑ YES ❑ NO NIGHT: (1900- 07:00) CCHP/PPRP 1i: EMERGENCY RUN ' 1 1 40MEDI-CAL#: CODE' 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: IV. (PER ADMIN.)___ _-- X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP:-�LZl� E O.A.: (IF NOT REPLACED) ADDRESS: t___� 7C?_• �_.__—__._ .___ ORAL AIRWAY' (IF NOT REPLACED) CITY: _____._____�.-�. /._-.._.._-_ STATE--------- ZIP__._ -_.- C-COLLAR. (IF NOT REPLACED) PHONE: _.—__--___ WORK PHONE -_.-__._-..._ _.__ DRY RUN. (AUTHORIZED) —_ EMPLOYER: �J'\�_—__-- OCCUPATION:—____ OTHER: CITY STATE:- ZIP: 00 _ :Q�>Q.1 _ b( >4% ! -x Vl L� 1C1T Al. M«_t7,06L„ j�,�n� ir.? �1c,�_�F7 5, ) I AIIENT HECEIVFI) 13Y X :it 11,�6 r IT,n� :.•? n•ta:•: 4h. •, . I•. lSl , i i�ipl fr. i CONTRA COSTA COUNTY AMBULANCE t" PRE-HOSPITAL CARE FORM I `" UNIT AUTHORIZATION M CHECK Oq fILL IN AP'P11gOPg1�'AT[SQPACC,ES DATE: �-7 PATIENTSNAME ,ci1 L�rL/ �— Om •r F COMPANY.r ADDRESS !_ilL L_4 �1 I �� �V AGE t,-) `� ! ► J C� �� CITY STATE ZIP_ _ DOB___ t2 Sn ❑ M ❑ T A❑/W O Th OF OSS DRIVER'S LICENSE N _ PHONE td,T �I - NATURE OF DISPATCH 'V �, 6, —, "'4�: TYPE OF TRANSPORT: AMBULANCE O OTHER❑ _ _-_—,_ STATIO 1(AI (B)_3(CI-4(D)_5(E)_ INCIDENT LOCATION: C N RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- " S:O. CALL RECEIVED P.U. TIME 10-8 PATIENT'DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 O PSAP TIME 10-49 1, MILE GE: O OTHER/PVT TIME 10-7 1 END TIME 10-98 / `'DOCTOR ` PMD/ER START TIME 10-22 i' ✓— i HOW CHOSEN: TOTAL STANDBY TIME :nll O NEAREST O FAMILY O TRANSFER WAIT TIME �— O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: >`�- RESPONSE ZONE O YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ' / /r-1L-� 1 1 ( EMT-tA TECHNICIAN^ .A r�tv^�� �' ���PARAME IC �(�l) HX: (A itiv�r f� Ohs �.wl .�'� DISPATCHE - CHIEF COMPLAINT: 5`� DRY RUN: . YE ❑ NO REASON FOR DRY RUN 0 1 / ) AUTHORIZ N FOR DRY RUN(EMS USE gNgY) J PATIENT REFUSED SERVICES: (SIGNATURE).X • IS MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. # W 3-SO -el go314 PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS K: TOTAL MILES: X 1 MEDICARE C E.O.B. ATT. ROUND TRIP: O YES O NO r O YES O NO NIGHT: (19:00-07:00) /V b CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL M: 0-7677I'eA —_2,,q —z7) CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES 'VNO 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: PATIENT RECEIVED By X ry i CONTRA COSTA COUNTY AMBULANCE prl�� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N S3J� CNfCK OA flLL IN APPROPRIATE 31ACf3 DATE: ►�rls3 "PATIENT'S•NAM ' - I ❑ M ❑ F COMPANYN � ADDRESS ; U 1 AGE + ; CITY STATE ZIP DOB - n Om OT OW ❑ Th OF O S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH j TYPE OF TRANSPORT: AMBULANCE D OTHER 0 STATION 1(A)_2(B)-3(C)_4(0)_5IE), ' INCIDENT LOCATION;I - ; ) 019SPONSE CODE: R UESTED BY: TIME-124 HOUR CLQGK) ,gyp C�II --Ic TO SCENE- O. CALL RECEIVED c�t/j`' �1iCS T Dj IJ/� ❑ P.D. TIME 10-8 ,L� :J ' PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 i T ❑ PSAP TIME 10-49 1 �.' `� G ❑ OTHER/PVT TIME 10-7 ; END TIME 10-98 (DOCTOR PMD/ER " START - ) TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME r i ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBUI-ASE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: -- , c). RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER 1•+' �' PATIENT CONDITION: DRIVER A R�I N s0'J �! EMT-lA CONDITION-; ( p .{- ,, TECHNICIAN �`�NC_,, -7r PARAMEDIC Ir Htt: o-7-L 1\� NO -�J� "fy '-rDISPATC R• o Ali.) Jn I_ CHIEF COMPLAINT: DRY RUN: AYES ❑ NO REASON FOR DRY RUN L'IU AUTHOR ION FOR DRY RUN(EMS USE ONLY) - i (!!A,;;,: .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.B SE RATE I BLUE CROSS N: TI' TOTAL MILES: X MEDICARE C, i E.O.B. ATT. ROUND TRIP: A07:00) YES ONO _ O YES ❑ NO NIGHT: (18:00 CCHP/PPRP N:" EMERGENC RUN: MEDT-CAL N: ' I COD 2/3 T I t OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO ` NEONA AL: (INCUBATOR) DATES BILLED: STAN Y: (OVER 15 MIN.) - E.K. .: PER EPISODE) "-"NEAREST RELATIVE/RESPONSIBLE PARTY: I.V. (PER ADMIN.) X RUGS: (PER ADMIN.) X "' NAME:- - RELATIONSHIP: EVE NOT REPLACED) i ADDRESS: RAL AIRWAY: (IF NOT REPLACED) i. --CITY: STATE- ZIP: C- LLAR: (IF NOT REPLACED) .a1" PHONE: WORK PHONE: DRY R jAUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: i CITY: STATE: ZIP: "- COMMENTS: 201 — �7t TOTAL:6-V PATIENT RECEIVED BY:X of (SIGNATURE) .. t• ��h�n Fil•inp LMS-1 CONTRA COSTA COUNTY AMBULANCE SS7t -��-2J PRE-HOSPITAL CARE FORM L L)NIT AUTHORIZATION#-.D_ CHECK OR FILL IN APPROPRIATE SPACES DATE __..OC�___L4 i PATIENT'S NAME __ _ ..-_...._ n M f COMPANY a ADDRESS -. =sr 0--t_G+�CIi r9 R� .. .� - I .l.! � I 1 M n/ - - AGE - I�- CITY1_.I �_{-- STATE __._ ZIP :/`'1553 DOB -f.�_�J� Sn ❑ F.� D T ❑ W D Th O F D S d �7 DRIVER'S LICENSE# _._ ..__. PHONE 372-9 /Z_ NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE CTHER❑ ....•_.._.....__- .- /} INCIDENT LOCATION: n n RESPONSE CODE: RE UESTED BY. TIME- (24 HOUR CLOCK) C kT E NW TO SCENE S.O. -____ .._._- CALL RECEIVEDIN P.D _-----_-... TIME 10-8 PATIENT DESTINATION: FROM SCENE 2 ❑ FIRE ___ __ __ .. TIME 10-97 I ❑� PSAP TIME 10-49 '--- MILEAGE ❑ OTIiERiPVT TIME 10-7 �1 END_____ -j. ^- TIME 10-98 DOCTOR�P�Y PMD/ER START Z - -__—_ TIME 10-22 HOW CHOSEN: TOTAL -�-� --___ STANDBY TIME D NEAREST V"FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK #: AMBULANCEJJJ(((+++0 1P NY: PT AMBULLTORY? PATIENT TAKE TO AMBULANCE: =j r L RESPONSE ZONE ❑ YES IVO ❑ WA-..--TAKE ❑ OTHER _. PATIENT CONDITION: DRIVERvvlw_IA_ VO.P�- �� LAT-tA TECHNICIAN_. .__ _ _�.�_- AR:A=MED� ( Hx: � �- _ _--_-- DISPATCHER' - L �L. L1U�I� �!__- u 1 ! /�L/c1� A 1 __ CHIEF COMPLAINT: .- K_/ �!V_-_-___. DRY RUN: ❑ YES �O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY)--- PATIENT NLY) _-PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS: .. __ . r.. _.__ ___._ ____. / ��• PRIVATE INS. CO.:____.-- .-_--______._.____-__ BASE RATE: KAISER it -_. -__- MULTIPLE PTS. BASF RATE -• BLUE CROSS#:_. _ _-_ TOTAL MILES: _ __._:____'+ X �''G MEDICARE#:, __ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NICHT (1900-07.00) CCHP,'PPHP# EMERGENCY RUN: _,r •! 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 __-- f� DRUGS: (PER ADMIN.) . .._ .-_..-._- X NAME: CK/1►1__ RELATIONSHIP .J E O.A.. (IF NOT REPLACED) ORAL. AIRWAY (IF NOT REPLACED) CITY _..__ STATE.-_._._._ ZIP:..___-- C-COLLAR: (IF NOT REPLACED) PHONE: ___ _.-_ WORK PHONE:..._.._._-..___._-. DRY RUN. (-AUTHORIZED) ,— EMPLOYER: OCCUPATION:.-_..___.^__ OTHER: ADDRESS: 5• &D CITY: STATE:_ ZIP:— COMMENTS: IP:COMMENTS: r PA 111 141 I+1 i I I V 1 11 11N X - _ V; h) '� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: ✓ _ _ 1 PATIENTS NAME �_`/ �� ❑ M ❑ F COMPANY N ADDRESS AGE { CITY STATE ZIP DOB Sn ❑ M ❑ T OW/ ❑ Th ❑ FD❑ S DRIVER'S LICENSE N _ PHONE_��_��_ NATUR OF DISPATCH A w to TYPE OF TRANSPORT: AMBULANCE OTHER❑ t INCIDENT LOCATIO RESPONSE CODE: REQUESTED BY: TIME—(24 HOURLOCK) ., _ TO SCENE- 3 S.O. CALL RECEIVED t ( t /'ZL�Ct( 1�--�--- 1d–'V4'P, �C�+ P.U. TIME 10-8 ,rte i PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 4 ❑ PSAP TIME 10-49 � 1 MILEA ❑ 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 ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY, PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER— 45Y EY °� )^� EMT-tA TECHNICIAA-r PARAMEDIC q30Hx: __ DISPATCHER: C'CHIEF COMPLAINT: DRY RUN: � YES ❑ NO REASON FOR DRY RUN AUTHORIZRTION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X C!�'� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: \ / 1 S.S. $0 PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHPIPPHP k; 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) _�_7� PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) 5_0 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: r TOTAL: PATIENT RECEIVED BY X Provider retain White artd Pink Copp Rah rn r." CON1tIA COSTA COUNFY AMBULANCE � Z PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATI N J 6 CHECK OR FILL IN APP OPRIATE SPACES DATE: ' •w~ PATIENT'S NAME_. .- L _�� GI- O MIf F COMPANY'p � •�� ADD�6S5. �_ �C� I — / AGE /f�9 f lJ CITY (_NATE ` �� ZIP DO� 7 70 Sn O M 0 T. OW O Th O F O's— //'' 7 DRIVER'S LICENSE q _ .. _..__.... _ .. ._..__ PHONfiQ.Z<__�_��_.I Z>_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEQ-'OTHER❑ ____.. _..____.._—.__ STATION 1(A)._2(8)_3(C)_4(D),5(E)_'��--.'.`� INCIDENT LOCATI0 RESPONSE CODE: REQ)1ESTED BY: TIME— (24 HOUR CI,QCK) f _� A , TO SCENE- F-rS.O. CALL RECEIVED �T ( {( / _� �— ❑ P.D. TIME 10 B PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 C +: MILEA � ❑ OTHER/PVT TIME 10.7 END, _ TIME 10-98 L DOCTOR _ - PM /ER STARTd1 ,r� TIME 10.22 - I I HOW CHOSEN: TOTAL "{i STANDBY TIME ❑ NN AREST O FAMILY ❑ TRANSFER I ` WAIT TIME AQ PATIENT ❑ DIRECT ❑ OTHER l CALL BACK M: AMBULANCE COMPANY: -_ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I �� RESPONSE ZONE 0 YES 0 NO ❑ WAL",ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER._ __ �`x, EK -1A TECHNICIAN P��AMEDIC �+ Hx: fm DISPATCHER: ( � CHI FOMPLAINT: % c J C�/Yi DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 11 PATIENT REFUSED SERVICES: (SIGNATURE) X ( MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: /r S.S. w. PRIVATE INS.CO.:_ BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE - �LUE CROSS�r_ _ �� TOTAL MILES: X MEDICARE u: E.O.B. ATT. ROUND TRIP: DYES 0 NO ' O YES 0 NO NIGHT: (19:00-07:00) i GU 1� CCHP/PPRP q: EMERGENCY RUN:. .� C 1�/a MEDI-CAL N: CODE 2 3 j OTHER: OXYGEN:' (PE�TANK) -- -• j P.O.E. STICKER Cl 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 /� C� DRUGS: (PER ADMIN.) X NAMEaTI �..Y� .:Lz� RELATIONSHIP�LtX 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: ADDRESS: CITY: STATE: ZIP: I COMMENTS: 1 TOTAL:I;w .j PATIENT RECEIVED BY:X (SIGNATURE) . . • ear- :.•71r•. �.:t •h.7 OIS-1 rPATIENTS CONTRA COSTA COUNTY AMBULANCE7/PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#< LI . 'r t- (-CHECK OR FILL INAPPROPRIATE SPACES DATEcA NAME ��t'�\��,�U t=c�(> -� L111-1'_ 15 ❑ Mf COMPANY# ADDRESS �1511 _L� - AGE—LL— - (L C H CITY_ STATE--- ZIP____._ _.. ... DOB�.a�.L�.�/I !p S. ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE # __ .._._ _ �—/J L• ' _ .. _..__ PHONE NATURE OF DISPATCH. .-,.-s—/ TYPE OF TRANSPORT. AMBULANCE OTHER❑ __-. ... INCIDENT LOCATION: RESPONSE CODE: E UESTED BY TIME - (24 HOUR CLOCK))/ TO SCENE O. _.___._.__ CALL RECEIVED �� =.— TIME 10-8 L C ATIENT DESTINATION: FROM SCENE ❑ FIRE ___— TIME 10-97 O PSAP TIME 10-49 ( c-c_ C _— MILEAGE: ❑ OTHER/PVT TIME 10-7 r' h 1' END------.t '� t'C�' ------------ TIME 10-98 DOCTOR 21�Ne S - PMD/ RR START-�-:-�7l._/.. __.____... TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ T ANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT XOTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANC . RESPONSE ZONE YYES ❑ NO WALKED ❑ GUERNEY ❑ OTHER _.._--_.___.. PATIENT CONDITION: DRIVER_. �__ � t EMT-1 r TECHNICIAN PARAMEDIC Hx: _1L LIQ — —. DISPATCHER: 4k i (� ' CHIEF COMP Ai T: 1 __.�,t_ kK _ t-_�`_I ._ DRY RUN: ❑ YES KNO REASON FOR DRY RUN r j Z -��rl _ _�L�r�J`_�� �JS�I./- AUTHORIZATION FOR DRY RUN (EMS USE ONLY) qs� PATIENT REFUSED SERVICES: (SIGNATURE) X-____-_.._____._-_. MEDICAL COVERAGE: INDUSTRIAL ❑ YES LKNO NO. OF PATIENTS: 1 S.S. # \PRIVATE INS. CO.: BASE RATE: Ily•L<� KAISER#: _ MULTIPLE PTS. BASE RATE B UE CROSS#: TOTAL MILES: -: �' X M ICARE#: f 33 LM E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) Y �GHP/PPRP#: EMERGENCY RUN: M DI-CAL#: D b pyo _ COD 2/3 T ER: __ OXYGEN: (PER TANK) P. .E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR) DATES BILLED: - STANDBY: (OVER 15 MIN.) 7 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: - -_ -- PA III NI III (:I IV[ 1) BY X r•.•.ri.(nr• r•rl./h �.'� .. .•. � C�I(RIA'1i111.) • . Irl• I C NTiiA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT Z AUTHORIZATION 1 CHECK Olt FILL IN APPROPRIATE SPACES DATE: v, PATIENT'S NAME L ❑ M ❑ F COMPANY 0 t L U ADDRESS., AGE; CITY - STATE.ZIP DOB O Sn PA ❑T ❑W ❑ Th ❑ F DS DRIVER'S LICENSE N PHONE NATURE OF DISPATCH J`C_("S C A I TYPE OFTRANSPORT:r AMSULANC THER 0 STATION 1(A)L2tf)_•3(C)_4(D),_51E)_ INCIDENT LOCATION 1C RESPONSE CODE: JEOUESTED BY: TIME— (24 HOUR CLACK) LTO SCENE- S.O. CALL RECEIVEDP.D. TIME 10.8 PATIENT DESTINATIO :- FROM SCENE- O FIRE TIME 10-97 N PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10 98 :'.DOCTOR'' J j PMD/ER START_::::�LTIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME �y ❑ NEAREST,:; O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COIxtPAANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: < 1 RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I I � 7 3 EMT-tA x TECHNICIAN MV 0 R-� •-� S� PARAMEDIC Hx: DISPATCHER: 444a e:4 I"� CHIEF COMPLAINT: DRY RUN: WYES NO REASON FOR DRY RUN y qq AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I� 1 PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES El NO NO. OF PATIENTS: `LIq Y 411 S.S.^ /\ PRIVATE INS. CO.: BASE RATE: KAISER«; MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE M, 1 E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) r CCHP/PPRP M:'` I EMERGENCY RUN: MEDT-CAL C 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: IP:COMMENTS: TOTAL uIL PATIENT RECEIVED BY:X + Provider retain, Whit• 4Ad PinK copy Return Ye'lov ••npy t • FIfS vhnn hi 1'i.ar (SIGNATUI,EI rn I+ CONTRA COSTA COUNTY AMBULANCE - /] PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION M o •, CHECK OR FILL INAPPROPRIATE SPACES DATE: /J PATIENTS NAME L�/y��yrl c{ _ ❑ M /ja::P COMPANY N / ', CIS" ADDRESS AGE/_L V ,,k CITY STATE ZIP DOB`-1 _7 ❑ Sn AOM OT OW O Th O F ❑ S Z_1Z-F DRIVER'S LICENSE M _ _ PHONE ._ .� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ S.� INCIDENT LOCATION: I RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K) L j� O� v_r 7 TO SCENE- � � CALL RECEIVED 4 , — P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- (2) ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �' "'2 2 MILEAG ❑ OTHER/PVT TIME 10-74- END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 OW CHOSEN: TOTAL STANDBY TIME 1 ❑ NEAREST- O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: 42!�S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �> RESPONSE ZONE_ -� ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER S T-1 TEC :DIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES 13NO REASON FOR DRY RUN i� AUT R ION FOPIDRY RUN(E U$€ ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ x,577 77� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE $�UE CROSS p: TOTAL MILES: X M (CARE#: 2. — E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) C /PPRP#:' EMERGENCY RUN: e MEDI-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 - Ld y/t- RELATIONSHIP:F2172 [/ 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) alS1__ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL �•- r __. PATIENT RECEIVED BY: X_ — f4.nr,Lr rrta. t9;{.r ,r r• •,r.r r.,, (SIGNATURE) ACNTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT E] AUTHORIZ(��(ATION# �• (' CHECK OR FILL IN APPROPRIATE SPACES DATE: 3 IS-63 PATIENTS NAME13D M F COMPANYIV /.,) 6.17 ADDRESS �\ AGE D� o CITY STATE ZIP DOB ❑ Sn 26 ❑ T/f - Th ❑�W 13 T13h FF 13 S� �/ DRIVER'S LICENSE M _ PHONE__ -- NATURE OF DISPATCH� / 1 r1CK TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL CK) TO SCENE S.O. CALL RECEIVED `3 r D P.D. TIME 10-8 1�-Al -,AOCTOR ATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �) � )f� ' ❑ PSAP TIME 10-49 `< pyQ "IyMILEAGE: ❑ OTHER/PVT TIME 10-7END TIME 10-98 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK s: AMBULANT 3MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: L RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER-IM L(S EMT- _ r TECHNICIAN Z� AMED qoo Hx: UNC DISPATCHER: :dv 11 -n // CHIEF COMPLAINT: K Pte( II� DRY RUN:WYES ❑ NO REASON FOR DRY RUN E L/(�y 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 RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#; EMERGENCY RUN: MEDT-CAL M; CODE 2/3 C� OTHER: OXYGEN: (PER TANK) \1 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) wv EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ( r� oki LSE A Mtn t WC 9 TOTAL PATIENT RECEIVED BY: X -- TMiri,irr• �rt1!c Vl:i f. ! Ji•:� . Jr. 4'•tn•••• :. '! c,. • • • ", (SIGN<.TURE) ,I \\ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 2 CHECK OR FILL.IN APPROPRIATE SPACES DATE:.�� S I PATIENT'S NAME.. _1 I_-).,j-7�:5_ �- 1� D� ��—__1— ❑ F COMPANY# ADDRESS c_ 1 _�_ \ j- t ,_. (( n� AGE _ 7� CITY_ ----------- STATEI_ J—_ ZIPgq&OXY DOB _ `(+�7 n ❑ ❑ / ❑ O ❑ p S T W Th F S DRIVER'S LICENSE M S�(snC_ .__-___. _—_ PHONE. vr�.C- � NATURE OF DISPATCH. c�Z�Te 1 C4 TYPE OF TRANSPORT: AMBULANCE 11K OTHER❑ INC OCA ON: RESPONSE CODE: RRE�STED BY: TIME - (24 HOUR O K) TO SCENE- I�S.O. CALL RECEIVED -� �> c ` \/ :~� �� v �❑ P TIME 10-8 - PATIENTION: FROM SCENE- +'FIRE TIME 10-97 ❑ PSAP TIME 10-49 /•.` MILEAG ❑ OTHER/PVT TIME 10.7 END ' TIME 10-98 DOCTOR �_ PMD START�P" _ TIME 10-22 HOW Ct�OS EN: TOTAL —�, STANDBY TIME 0-NEAREST ❑ FAMILY ❑ TRANSFER !} WAIT TIME ❑ PATIENT Cl DIRECT ❑ OTHER J CALL BACK 4: AMBULAANC`EE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE ❑ YES ❑ NO ❑ WAL:CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIV J 1'pNA Z3z- t,10 EMT-1A • --77 ' �� TECHNICIAN I MC Olt re, RAMEDIC Hx: _.�-.LCA �.._�_ ._\`o. _ DISPATCHER: /\ �(DO CHIEF COMPLAINT: _ 1�..?4 �_ DRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE INDUSTRIAL 0 YES NO NO. OF PATIENTS: rUE - - 1--{,39�-7 7 r t INSY\�.— BASE RATE: MULTIPLE PTS. BASE RATE i ROSS k: TOTAL MILES: X �� '�J MhDICARE b: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO v�. ,O F ❑ YES ❑ NO NIGHT: (19:00-07.00) CCHP,'PPHPEMERGENCY RUN: MEDI-CAL++: _______-__ CODE 2 T 3 OTHER: OXYGEN: (PER TANK) / P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_ STANDBY: (OVER 15 MIN.) 11 .I,�; E.K.G.: (PER EPISODE). . / NEAREST RELATIVE!RESPONSIBLE RTY: I.V.: (PER ADMIN.) X " NAMEow,(� 1z ^„T DRUGS (PER ADMIN.) X ccl A_ ._... —`_(JPE ATIONSHI 'TLV_ E.O.A.: (IF NOT REPLACED) ADDRESS: `11[c�)1 .VQ..r1 LJ+-�11Qj� ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_\?` _ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE:�.�3 j�l�Fi WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: __— STATE: ZIP: CO ENTS� I1LJ A.V TOTAL: P.�� 'JJ _ —_— PATIENT RECEIVED BY:X -- i�wi fcr rrfarr, ihi! ,�:ii ^i.:: (�P� hr!urn Yr'lcm- -1;-y •• n/, b•ilrn bf l'7np (SIGNATURE) D15-1 ryl CONTRA COSTA COUNTY f I, t I AMBULANCE r,7 PRE-HOSPITAL CARE FORM I UNIT �, I AUTHORIZATION MCI CHECK OR FILL IN APPROPRIATE SPACES , I DATE: �` ^ •,� ' PATIENT'S NAME �_'!_ --� COMPANY M / v,", ADDRESS ~ r`I 1 ! I :J ttI AGES ( �D�� / f-•-•+. CITY.._- y �_ 717 STATE__i ZIPtL" L(� O Sn , M O T O W O Th O F $� 1 DRIVER'S LICENSE u __ ___ ___.—.__..-__ PHONE X1.1_`. `) NATURE OF DISPATCH r\� TYPE OF TRANSPORT: AMBULANCE,1� OTHER❑ C :'t: INCIDENT LOCATION: i RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C CK) J ,' TO SCENE- n q S.O. CALL RECEIVED -•-•1 ❑ P.D. TIME 10-8 PATIENT DESTII ATION: I FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 .� � �•�.1(111��I`l��!.� �� �'.��• �1���) .��,- !� •� r .:,.;;:: . \� MILEAGE: 13OTHER/PVT TIME 10-7 Z . �,• END TIME 10-98 . 1ZL�L'1 "•' DOCTOR )11� PMD/gRi START TIME 10-22 u HOW CHOSEN: TOTAL • STANDBY TIME.i. ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT l2k OTHER CALL BACK K: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKE 4 TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL"ED GUERNEY ❑ OTHER ; PATIENT CONDITION: DRIVER-.' v v .je I TECHNICIAN ' PARAMEDIC , r Hx: _?1LPLAINT: '_I �''')_-� _ DISPATCHER: QFVE C� LDRY RUN: ❑ YES &NO REASON FOR DRY RUN r rv; I All-L,-(' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) F';) R( PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIly.. ❑ YES.p NO k NO. OF PATIENTS: f�'S�OCL II' S.S. K- PRIVATE INS. CO.: _ _____ _ dASE RATE: KAISER#: _. _ WIULTIPkE PTS ,BASE.RATIe: BLUE ROSS a; _ __ i C7F?�t"MtLES: _ X _ ' . ` I 'K MED ARE 11` r FA- E.O.B. ATT. ROUND TRIP: ❑ YES O NO ul (LoCYl.2 dt- OYES ❑ NO NIGHT: (19:00-07:00) '. , CCHP/PPRP EMERGENCY RUN: ' MEDICAL� �: 1�1 � //,� _�/ L CODE 2/3 i, ,. ;a E,e�n1, OTHER: OXYGEN: (PER TANK) .E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) to iY, O . l DATES BILLED. STANDBY. (OVER 15-MIN.) _;•,.� s `� E.K.G.: PER EPISODE NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ' NAME: .r�. '..: � .r:'____ RELATIONSHIPI `' E O.A.: (IF NOT REPLACED) ADDRESS::4111 i 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 PATIENT RECEIVED BY:X Provider rrtaic t.'hitc :r.d Itin: , c __ Y•,(SIGNATURE) '•,'2': `•• pp otum Yn ,.- crju ! M.' uArn !*I,i `'�Li d,?Q`q�tw--1'' i ! ►` hL.F.iia` .:' :. CONTRAOSTA COUNTY C COU AMBULANCE PRE-HOSPITAL CARE FORM I UNIT = AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: v v 3] PATIENT'S PATIENTS NAME S1 ti1�] . LciU _.._ ii M ❑ COMPANY p ADDRESS1 "�V J L t —_ AGEG__ CITY STATE—:: i,— ZIP_�/ �Q ._ DOB(ZI.79.-15 ❑ Sn V M OT OW ❑ Th ❑ F ❑ S DRIVER'S LICENSE p ___—____.— PHONE.. 3Z'35�7� NATURE OF DISPATCH_O� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REO ESTED BY: TIME - (24 HOUR CLOCK)? KE5 (� / TO SCENE - �O. .__ .._. _ CALL RECEIVED - �.Do� ✓` / (��> --�--- ❑ P.D. ---_ TIME 10-8 X37 PATIENT DESTINATION: FROM SCENE - ❑ FIRE ____ TIME 10-97 {�0� c f^. - ❑ PSAP TIME 10-49 MILEAGE-.f,-7 ❑ OTHERIPVT TIME 10-7 L_ .►tet END_--(("1 (_!� _-__.__TIME 10-98 DOCTOR ` PMD/ER START-�5'.�- _- TIME 10-22 HOW CHOSEN: TOTAL _ _1- STANDBY TIME -_ ❑ WARIEST ❑ FAMILY ❑ TRANSFER WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER CALL BACK u: AMBULAI'�,CKQMPANY: PT BULATORY? PATIENT TAKEN 0 AMBULANCE: _ - - �'��. RESPONSE ZONE YES •❑ NO ❑ WAL KED GUERNEY 1-1OTHER __ / J _ PATIENT CONDITION: DRIVER N �L. �_ EMT-1A I- TECHNICIAN tj I LAJ\_I_Ll P RAMEDI Hx: �7�/ �— �r'f�/U�Q`-� — DISPATCHER: y�i •'•'J '•_ 1. .7 f !`7 CHIEF COMPLAINT: ,:z, — DRY RUN: ❑ YES CYNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X J MEDICAL COV AGE: DUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: I `� 'KA K: _ MULTIPLE PTS. BASE RATE (BL L L' E CROSS#: uz Z TOTAL MILES:_- -_ X l� 7 DICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) `((.)"CCHP/PPRP#: EMERGENCY RUN: >• ) e.)d to MEDI-CAL#: CODE 2 - 3 U7 OTHER'. OXYGEN: (PER TANK) 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: � � RELATIONSHIP: E O A.: (IF NOT REPLACED) _ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP:--- C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:�f-�-_ DRY RUN: (AUTHORIZED) EMPLOYERu'S.C:.'/L S(!:; CCUPATION I �•� 4 = �� OTHER: ADDRESS:NA V4L «13 d '_1 ', `fJ �,, J /7 CITY: L G' N C° L' r`A STATE' ..ZIP.___ ---- -._-----_ -- COMMENTS: - ---- ------ --- --- 1 d 1[.)TAI -- _. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I < ) UNIT AUTHORIZATION N . CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME-- �5`-�i1�1� "�'a1N �M ❑ F COMPANYN ADDRESS 'M 2 'Llnn�! r5r�� . c Z— AGE \ CITY STATE�_]� ZIP_!�S Z.y DO _L ❑ Sn O M�KT OW O Th OF 1 8 DRIVER'S LICENSE It _ PHONE_!���-[3��_ NATURE OF DISPATCH C42 01 A-r ' •- i TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION 1(A)_2(Bl_3(Cl_4(D) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK ( _ TO SCENE- [}YS.O. CALL RECEIVED Co—k �lks rILR('z s s �+ MT-2 Z 5� ❑ P.D. TIME 10-8 C 8-72--.--} PATIENT DE TINATION: FROM SCENE- ❑ FIRE TIME 10-97 O C13 PSAP TIME 10-49 '- MILEAGE: OTHER/PVT TIME 10.7 88- I �� END �j`{7 TIME 10-98 DOCTOR 163 PMD START r1 c7 TIME 10-22 -- HOW CHOSEN: TOTAL n`� STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT OTHER h I. 700 CALL BACK N: AMBULANCE COMPAV:A --- PT. AMBULATORY? ..PATIENT TAKEN TO AMBULANCE: , RESPONSE ZONE ES ❑ NO ❑ WAL':ED GUERNEY ❑ OTHER ` ( c PATIENT CONDITION: DRIVER (4,, ? J EMT-1A. TECHNICIAN - �S [Q PARAMEDIC _ VI� �' [7 ' Hx: " `S`��- DISPATCHER: _ - .� CF•`IEFPLAINT: !J � G DRY RUN: OYES e- 1�0 REASON FOR DRY RUN '•-"� �-fU�^"'*� ���%I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) , i r PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. a Y 3-" / 3 -39 �' y PRIVATE INS. CO.: rUJ BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE /� rrn� � ��••��^1 BLUE CROSS N: TOTAL MILES: X Sy- - �IiI EDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO - 0i. ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: 430. MEDT-CAL N: CODE 213 " 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 Cr( 1 1 Jt- /305 GO j A RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: ____ STATE-Q-4—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: Lw�ISEI-q S-A OCCUPATION: OTHER: - ADDRESS: CITY: Q- STATE: ZIP: -- COMMENTS: l COLA l'J►� E.ss tf c-lou(A blLf;�_)ujC /)lF TOTAL:",/,4, 0 _ .. PATIENT RECEIVED BY:X ( GNAT Olf 1 1 CONTRA COSTA COUNTY ` AMBULANCE Z rl PRE-HOSPITAL CARE FORM I '� UNIT AUTHORIZATION# {�3 a;. CHECK ON PILL INAPPROPRIATE SPACES DATE: Y��/ PATIENTS NAME L1[Ter—,�I f�j 3 m I✓ PM 13F COMPANY# - C , ADDRESS 3A00 A"7 c,Nlti G� (��AGE �cl )I .' CITY MArel1 ►�1-2- STATESAL( C ZIP_t DOB ❑ Sn ❑ M T O W O Th O F O S DRIVER'S LICENSE# _ + �Ll�_ PHONE?211'v��L. --- NATURE OF DISPATCH /L 7 TYPE OF TRANSPORT: AMBULANCE OTHER❑ — - STATION I(A)_2(B)._3(C)_4(D)-_5(E)_ 7 INCIDENT LOCATI N: RESPONSE CODE: R,.E�ESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ;Is CALL RECEIVED _Ll '2 L f S Q 1 N�-' �-T' �� ❑ P.D. TIME 10-8 C,1 �-1— PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _C4 PZ-- ❑ PSAP TIME 10-49 /---_...� 1 1�Ll i� ��-� MILEAGES g/ .❑ OTHER/PVT TIME 10-7 2,3 ` 1 ENDTIME 10-98 DOCTOR ►J P - PMDCRD STAR TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT 13 DIRECT THER P-l (ANN-12 AP-Si STS/ CALL BACK#: AMBULANCE COMPANN� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES /YNO ❑ WALKED IVGUERNEY ❑ OTHER PATIENT CONDITION: DRIVEREMT-1A I TECHNICIAN0�'Gu 1 PARAMEDIC I / Hx: Pc, ► e _- DISPATCHER: l*Jl 'J')'. CH F COMPLAINT: C4 DRY RUN: ❑ YES�°NO REASON`FOR DRY RUN q 51 / Or— AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAG� r U RIAL 13 YES 13 NO NO. OF PATIENTS: y- S.S. # :, J P NS. CO.: BASE RATE: KAISER#: Q f MULTIPLE PTS. BASE RATE BL OSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO (�✓ vJ, O YES .O NO NIGHT: (19:00-07:00) /� COHP/PPRP#: _ EMERGENCY RUN: "'' C MgDI-CAL#: 0 0 C DL 94 CODE 2/3 OTHER: OXYGEN: (PER TANK) �J P.O.E. STICKER 41fS l � 2384288 NEONATAL: (INCUBATOR) b DATES BILLED: JJ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) JJ `J NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X vvv NAME-' i RELATIONSHIP: E.O.A.: (IF NOT REPLACED) i ORAL AIRWAY: (IF NOT REPLACED) 4 - CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WfRK PHONE: () DRY RUN: (AUTHORIZED) EMPLOYM- OCCUPATION: OTHER: _ ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: 1 C ho LJC�V LJ ---- - TOTAL — Ll'_r' PATIENT RF.rimn DY X � VIII t PATIENT'S N1�^1L': Joe Wallace ; �� . ADDRESS: 22 Ruby ; Richmond,Ca, DATE OF SERVICE: )8-16-83 AUTHORIZATION NUMBER:$ 13$47 1 AMOUNT DUE: 240 INCIDENT LOCATION: 22 w Ruky Richmond ' ' PATIENT DESTINATION: al 'l .rj t M . '•'fit. ;�'� `': �i�. a t: S 1'X'4i s t s� a 3 1 �� '# rOit12 1 1' 2 26 pN '13 Auc 16 2 29 AH 83 Auc 16 2 3i AN '83", L SO NUMBER/1 )��J ���, CAIL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 �t CALLED BY- PATIENT INFORMATION ry _ o _ • _ NAME' ---T -- ---------- -. .---- --- m Cr7 AGENCY: --_-_ --. O --------.------_------ CUSTOMER rr#,(PT�.,1,):' ' DoB7114-41 c DEPT;FLOOR/ROOM tf NAME: 1 .)oe- z 1 V Z m CAILBACKa ._-____.-^ .^..`�<_ .._.__.__ __.____ INS. TYPE: PVT MCAR MCAL KHP PHP VA IND CHAMPUS > V A // �y w Ln INCIDENT IOC: _-.__O`C1__. . .�� '!1 J/ POLICYlMCAL N: N�NC: n a v m a MCAR - ----- --- - ---------- t^ Q VERBAL PRIOR: a m CROSS STREET: --- -:.- �L'4 a IURIS: C iy �'_. /_C/7,--- -- -- DOCTOR: ITL v ----- - - DESTINATION: -__-_- PT. ill NAME: DOB: NATURE: _ ' cI�C INi4/�y / PA -.— —_ CUST. If ; m PT. 43 NAME: DOB: S p D 6 TYPE OF C�LURANS TIME UNIT $1 ,.- CUST. aTVlG•t ., CREW: - - - - -� L � _ WAIT TIME: YES NO REASON: Z •. O UNIT TYPE: At5 WC RESPONSE CODE: 0 1C2/ 3 4 REASON FOR 10-22: 7O O O7 a INCREASE!DECREASE CODE:2 3 10-49 CODE: 0 1 ( 3 4 CANCELLED BY: T v BY: ---___-.- END MILEAGE: —Q�_�— COMMENTS: /1Y�aiCi� Cc✓G 3 ���• O N TIME: .._____- BEG MILEAGE: .- -Q`Ji__ �, • m DISPAI ER: > � TOTAL MILES: XL-0l NOl1v1S iv 3DNvinHwv 61 01 ONIN3DNvinowV 86-01 319V1fVAV 3DNv1T19wv L-OL lV1IdSOH 1V 3:)NV1T19wV. OO 8. Hd 90 91 onn q, SS Z 91 ons. tier:..` ` . - t .• •ql�.y y' � �_� { R � 'N C • ?�"yt JALI ow vft .•."tea-�rq�w....Y .O�rt�`�'�['fw.>.-� ! _ Ol. l r r Ir •7 ! '• >4 S''*�"3 � i 1 .'.�t r +ii[ 3 �„' r � F .L��! i1f 141� CONTRA COSTA COUNTY \ AMBULANCE PRE-HOSPITAL CARE FORM I �� UNIT © AUTHORIZATION a DIM - CHECK OR FILL IN APPROPRIATE SPACES DATE; 16163 L, r1n n P IL _.I PATIENT'S NAMEdC M ❑ F COMPANY M 1Ab ADDRESS 313 _ToLl,_ I9cf_ �n AGE PO � j I CITY! C C�1=1 STATE p ZIP DOB 161 92- ❑ Sn O M T O W O Th O F DRIVER'S LICENSE k ��__. _ PHONENATURE OF DISPATCH A681NS6' _ TYPE OF TRANSPORT:.AMBULANCE Q OTHER❑ _ — STATION 1(A) 2(B)-3(C).:._4(D)_5(E)-t �.- INCIDENT LOCATION: RESPONSE CODE: R OUESTED BY: TIME-- (24 HOUR hcL-O�CKL i J TO SCENE- S.O. CALL RECEIVED vr� Cp 3 D .D. TIME 10-8 ' t �a: lr� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 L� ❑ PSAP TIME 10-491 - ~� MILEAGE: ❑ OTHER/PVT TIME 10-7 END S- TIME 10.98 DOCTOR _ U PMD/ START 50,0 TIME 10-22' I H HOSEN: `/ TOTAL 5 '� STANDBY TIME : NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ^ O PATIENT ❑ DIRECT O OTHER CALL BACK C AMBULANCE COMPANY: :--� CAS P AMBULATORY? PATIENT TAKEP TAKETO AMBULANCE: RESPONSE ZONE_; f _ YES ❑ NO ❑ WAL`:ED V rUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVE RINL EMT-tA 1 TECHNICIAN PARAMEDIC 1 Hx: — DISPATCHER: - CHIEF COMPLAIN DRY RUN: OYES O REASON FOR DRY RUN I�( ) FU 1 1��= �(' t 1 A D AUTHORIZATION R.DRY RUN(EMS USE ONLY) j t � (JC C PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: D�CJD S.S.M h PRIVATE INS. CO.: BASE RATE: KAISER 4: MULTIPLE PTS. BASE RATE BLUE CROSS M _ hl��- TOTAL MILES: S X MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) C CCHP/PPRP M: EMERGENCY RUy: Uk' MEDI-GAL M: CODE 2�3 ) OTHER: OXYGEN: (PEA-TANK) 0-� P.O.E. STICKER D YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X e0 _3.j C DRUGS: (PER ADMIN.) X NAME: S1%20�N ' '(�/)A_%lf E_(- RELATIONSHIP: E.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) IN 1 CITY: 1 1 STATE__ZIP: - C-COLLAR: (IF NOT REPLACED) " PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: J • - - - /_ ADDRESS: /�>�JJ ,ice 3,0•(V A CITY: STATE: ZIP: �l> • 1u In COMMENTS: T+ LJ" Ty -,4jT a_y L TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) Avvider ?wta-r. Whitecr.9 0:.:: r.pp Return Ye';,•,,• -npv t• EN.c when hiI'ing DO-1 CONTRA COSTA COUNTY AMBULANCE fit" PRE-HOSPITAL CARE FORM I UNIT AUT)•IORIZATIO N T CNECK On PILL IN APPROPRIATE SPACES DATE: 'PATIENT'S NAME 1 I O ?JN,O F COMPANY N W ' - ADDRESS,—! t ( { Lam_ AGE- 4 �, I 1) J - •-.• CITY - STATE ZIP DOB ❑ SnO M O (] Th OF O S DRIVER'S LICENSE N - ) PHONE NATURE OF DISPATCH K• n ' TYPE.OF TRANSPORT:+AMBULAN OTHER 0 _ -- STATION 1(A)+2(B)_3(C1,4(D)_5(E►,_ INCIDENT LOCATION:+ ~� f{'• RESPONSE CODEi REO ESTED BY; TIME- (24 HOUR CLOCK)�� i o TO SCENE- S.O. CALL RECEIVED `L. /I/'a''`{` :II): O P.D. TIME 108 PA`{•IENT DESTINATION:.:_.171 fi IDC2- FROM SCENE- O FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: a ❑ OTHER/PVT TIME 1¢7 .1 r' - END TIME 10-98 OGTORLTr"rr? 1 ) pMD/ER START TIME 10-22 ' 0a HOW CHOSEN: TOT STANDBY TIME• y❑ NEAREST,.%❑ FAM 13 TRANSFER WAIT TIME - ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBUI_t4JSMPAP� _. PT. AMBULATORY? I PATIENT TAKEN TO AMBULANCE: I. RESPONSE ZONE ❑YES ❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION:'---- DRIVER f' EMT-1A ' TECHNICIAN PARAMEDIC H, 2 DISPATCHER: CHIEF COMPLAINT: ; ) DRY RUN: , YES ❑ NO REASON FOR DRY RUN i- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 51A.11JOWATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE;_ INDUSTRIAL ❑ `FES ❑ NO NO.OF PATIENTS: S.S.N ` �_� � � • PRI �-` 1 BASE RATE: I i ISER It MULTIPLE PTS. BASE RATE f BLUE CROSS N: ' ' '� I t. ' TOTAL MILES: X MEDICARE N" E.O.B.ATT, ROUND TRIP:• O VES ONO e. O YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N EMERGENCY RUN: MEDI-CAL N: :_.' : .. L _: CODE 2/3 l o� OTHER:'" OXYGEN: (PER TANK) P.O.E.STICKERYES •ONO NEONATAL: (INCUBATOR) i DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.; (PER EPISODE) NFAREST-RELA VE/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) STATE ZIP:----- C-COLLAR: (IF NOT REPLACED) . ;. -PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) r -EMPLOYER: OCCUPATION: OTHER: !1 -ADDRESS: -"'CITY: STATE ZIP. -COMMENTS:- I -:57. TOTAL: ��� a CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z , AUTHORIZATION ar 3 ZE �•)2 __ CHECK OR FILL IN APPROPRIATE.SPACES DATE:— PATIENT'S ATE:PATIENT'S NAME S:1rc:S� �1—L~�_.L1 Ir P(M ❑ F CO MPANY N ADDRESS C r ) a` L r/tic-Ll (111- -��. AGE CITY—- _r 'STATE—C 0 ZIP I DOB t I ❑ Sn ❑ M CKT O W 0Th O F DRIVER'S LICENSE KL._•_ _ PHONE_�'/_-�L'?C c' 1L,.__ NATURE OF DISPATCH 1 TYPE OF TRANSPORT: AMBULANCE. OTHER❑ STATION 1(A)_2(B)_3(C)_4(D)_5(E71 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR Cl CK) TO SCENE - }s S.O. CALL RECEIVED o, I yl JA ❑ P.D. TIME 10-8 1�---1 PATIENT DESTINATION: FROM SCENE - O FIRE TIME 10-97 ❑ PSAP TIME 10-49 - c t� _ MILEAGE: ❑ OTHER/PVT TIME 10.7 _ END r G TIME 10-98 n DOCTOR N 14,'C I L PM ER ' START--)LI-11— TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME O PATIENT ( i( _)DIRECT O OTHER CALL BACK k: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULAN �J ) RESPONSE ZONE 5 YES ❑ NO WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER .;A 1 C7A ,) ✓ � {L MT-1A� 2.C TECHNICIAN : PARAMEDIC Hx: 1. 'AILL J )t' - fit fQ k1(c III/)1.X6IE`PATCHER: f( CHIEF COMPLAINT: DRV RUN: OYES ')D ILIO REASON FOR DRY RUN J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j 1` PATIENT REFUSED SERVICES: (SIGNATURE) X— EDICAL COVERAGE: INDUSTRIAL ❑ YES dNO NO.OF PATIENTS: PRIVATE INS. CO.: BASE RATE: _! ' 1 KAISER 1: I-),.nA r 1( I G ?-,Y 7- MULTIPLE PTS. BASE RATE / BLUE CROSS#: TOTAL MILES: �� X MEDICARE K: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO I�(p O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP p: EMERGENCY RUN: 30. lJ MEDI-CAL a: CODE 2/3 L•_ 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:' O.A.: (IF NOT REPLACED) —� ADDRESS: I ,l 2 7 r' i c I(' n x' M �� RAL AIRWAY: (IF NOT REPLACED) CITY: ( 11 lar d I'11,k STATE—LC3—ZIP: C-COLLAR: (IF NOT REPLACED) -— PHONE: WORK PHONE:•'' DRY RUN: (AUTHORIZED) -EMPLOYER: OCCUPATION: OTHER: -- —" "— ADDRESS: CITY: STATE: ZIP: COMMENTS: y. TOTAL.-"Itl// PATIENT RECEIVED BY:X ` Providrr rrroic Vhitr rd I•Ir: ropy 9ttur+I Yr'lcv -nro r- vW ohrn (SI ATURE) PIS-! CONTRA COSTA COUNTY AMBULANCE 1,�AIZATI PRE-HOSPITAL CARE FORM I UNIT AUNO CHECK OR FILL IN APPROPRIATE SPACES DATE: 61?3 PATIENTS NAME I ❑ M O F COMPANY M ADDRESS AGE1 C (/ A I - CITY STATE ZIP ZIP DOB ❑ Sn ❑ M �T O W 13 Th 13F ❑S bRIVER'S LICENSE N _ -" y PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE❑ OTHER❑ — - STATION 1(A)._.2(B)_3(C)._4(D)_5(E)_ INCIDENT LOCATION: y ;-� RESPONSE CODE': REQUESTED BY: TIME- (24 HOUR CL (rK) (j rnrn 0n ` �- `` TO SCENE- k`S.O. CALL RECEIVED ��� t� 3 S V tl Yr 0(Q •, d L r�i/ ❑ P.D. TIME 10-8 Z. �- ; -sC PATIENT DESTINATION: ._.._.i FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 \ ��• .,� i.11` i �� MILEAGE: ❑ OTHER/PVT TIME 10-7 J ..- . END�� TIME 10.98. <<DOCTOR f�. ' I Y( PMD/ER START TIME 10-22 HOW CHOSEN:. TOTAL STANDBY TIME )_1❑'NEAREST ," FAMILY ❑ TRANSFER WAIT TIME ❑ PATI ❑ DIRECT Cl OTHER CALL BACK M: AMBULANCE CO PANY: PT. AMBULATO PATIENTO AMBULANCE: RESPONSE ZONE ❑ . ( GUERNEY 13 OTHER PATIENT CONDITION: DRIVER A•'Ea I 1 AAT-1A �'11 ` ' __•; TECHNICIAN 1�1 (� V1 ill gf-f� PARAMEDIC Hx: - DISPATCHER: 7Ufo CHIEF COMPLAINT: DAY RUN: K YES ❑ O REASON FOR DRY RUN .147 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) 6�, n F� l(w • f?;1.1 ? PATIENT REFUSED SERVICES: (SIGNATURE) X qsz �/ 1 MEDICAL COVERAGE: .._._ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M PRIVATE INS. CO.: BASE RATE: • KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE 0 E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP CrEMERGENCY RUN: MEDT-CAL M: ' 1' CODE 2/3 OTHER: ) OXYGEN: '(PER TANK) - P.O.E. STICKER ❑ YES ❑ N NEONATAL: '(INCUBATOR) ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) --`-NEAREST-RELATIVE/RESPO ISLE 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: -"CITY: STATE- ZIP: "'COMMENTS: • - TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: X__ r-,.•.i/,- .. , in.:.. .. .. (SIn NA1IMF) .� CONTRA COSTA COUNTY AMBULANCE Q 3 e62 PRE HOSPITAL CARE FORM i UNIT AUTHORIZATION NV CHECK OR FILL INAPPROPRIATE SPAM DATE: J ) PATIENT'S NAM/EL� Gl1t)L� .CU )._�U_�r���_`,�_�� {� M O F COMPANY M ADDRESS �C�1-1—f !) i 1t C!- VQ!/C(p f`�/ / / AG 0,01 13 1 CITY J - C STATE ZIP-J, 1 C� DOB,T^� ss O Sn ❑ M C1 T.O W ❑Th O F D S"' DRIVER'S LICENSE a __. PHONE ^�J _ NATURE OF DISPATCHJ !- TYPE OF TRANSPORT: AMBULANCE OTHER❑ — _ STATION 1(A),2(8)_3(C) 4(D)_5(E)_ INCIDENT LOCATION: j� RESPONSE CODE: REOUESTED BY: TIME– (24 HOUR CLOCK) r _ -� ` y 3 / ' �PvI'z�� -/ � �)l� TO SCENE- S.O. CALL RECEIVED '� �. b LL{ / _ 3 ❑ P.D. TIME 10-8 v v_ PATIENT DESTINATION: FROM SCENE-2) ❑ FIRE TIME 10-97 � : I ,(` O PSAP TIME 10-49 J �- ---1 /+ MILEAGE: ❑ OTHER/PVT TIME 10-7 ILL --� END 03. _. TIME 10-98 DOCTOR __ �VPI PMD/67 START_00 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST O FAMILY ❑ TRANSFER -7— WAIT TIME t ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: I PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON t O YES RNO ❑ WAL"ED q GUERNEY O OTHER PATIENT CONDITION: DRIVER V EMT-lA TECHNICIAN M 1 PARAMEDIC �() Hx: Su� #1 C DISPATCHER: LJ -2 - o I"I 1/ CHIEF COMPLAIN 'JL pRY RUN: ❑ YES (�NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— , r . MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ( J� S.S. a g 51 PRIVATE INS. CO.: BASE RATE: /301cz.-! i KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO { O YES ❑ NO NIGHT: (19:00-07:00) I f1 I I CCHP/PPRP M: EMERGENCY AUN-, MEDT-CAL M: CODE 2/3 r 1,� OTHER: OXYGEN: (PER TANK) Ir� P.O.E. STICKER O 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) _ =�1NI PHONE: WORK PHONE: DRY RUN. '(AUTHORIZED) EMPLOY ER:V _ IV r QCCUPATION: OTHER: -- - Ciay.1 ADDRESS: N pl t Rd - 1 3cITY: STATE: ZIP: TV1C ur4/ , q Y15„Z 0 6T76— bW S COMM ENTS: r y c 1,., _!�I c, kAn1� —AG PATIENT RECEIVED BY:X (SIG AT R ) Pr.^ii.!r- nr'. Fti• n:.. c,- . . ... .>•._ DIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N 1 i CHECK OR FILL IN APPROPRIATE SPACES GATE: U I16�,.]' 7 PATIENT'SNAME -� A>rJ�1.L /)y.�/M O F COMPANY N n^I) L 3I 'L' ADDRESS y i t -j —r"N "AGEb _ `y. ?__ CITY_ 1 SIL \ STATE CA ZIP �� � D,O/B(0_10�tj ❑ Sn O M y0 W O Th OF 0$ DRIVER'S LICENSE a ____ PHONE �� 3� NATURE OF.DISPATCH 35 TYPE OF TRANSPORT: AMBULANCE OTHER❑ —_ STATION 1(A)X,2(B)_3(C)_.4(D)_5(E)_._. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ' TO SCENE- O. CALL RECEIVED _3 O op D. TIME 1" PATIENT DESTINATION: 00 1)1y FROM SCENE - ❑ FIRE — TIME 10.97 oZ / ❑ PSAP TIME 10.49L— �', MILEAGE: O OTHER/PVT TIME 10.7 �..' •:• 17.E 1 END-- -- TIME 10-98 I DOCTOR �:S , Q�)'` L PMD R START J ' 1 TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER (�J WAIT TIME — ❑ PATIENT ❑ DIRECT O OTHER - CALL BACK M: AM�UJ, NCE COMPANY: J PT. AMR U ATORY? PATIENT TA EAkTO AMBULANCE: ��—fl RESPONSE ZONE Cl YESNO O WAL`:ED &ERNEY O OTHER U PATIENT CONDITION: DRIVER L-Ytjcl-• S7 EMT-1A TECHNICIAN P 0`10 2-`7 PARAMEDIC Hx: 1�1V��.N _•�fJ DISPATCHER: R- 9 CHIEF COMPLAINT: L—or U' 12 17E R DRY RUN: ❑ YES O / ASON FOR DRY RUN f i:MP AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE MEDICAL COVERAGE: INDUSTRIAL ❑ YESfij NO NO. OF PATIENTS: -l� S.S. k PRIVATE INS. CO.: BASE RATE: �' L KAISER#: MULTIPLE PTS. BASE RATE BILIFrg ss.#. r TOTAL MILES: X MEDICARE d' '�t=� - �� �- E.O.B. ATT. ROUND TRIP: O YES ❑ NO 1-7/6 A O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CALM CODE 2/3 c. 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: r�1Le•S �5:i: I L RELATIONSHIX.U)FC E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: J = STATE_,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -- TOTAL • -!]— •QQ PATIENT RECEIVED BY:X Provider rer.o r. vhi t,7.•: ••.pi .... (SIGNATURE) 0 CONTRA COSTA COUNTY AMBULANCE #�1 PRE-HOSPITAL CARE FORM IUNIT AU*HORIZATION p -3 79" fit..,. CNECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N l ADDRESSIT' _ C,"' i AGE CITY -•STATE .T,1ZIP DOS - ! ' O Sn OM O T,O W ❑Th ❑ F ❑S 1 DRIVER'S LICENSE N _ - PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE 0 OTHER11 _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INPDENT LOCATION: Hu RESPONSE CODE:- REOPESTED BY: TIME— (24 HOUR CLOCK) yv I_ TO SCENE- Ea S.O. CALL RECEIVED �lQQi 2ssL l��' ;r IA0- O P.D. TIME 1D-8 PATIE�JT REST ATION:" -- FROM SCENE- O FIRE TIME 10-97 V /�J� f, "�"_� _ O PSAP TIME 10-49 I MILEAGE: O OTHER/PVT TIME 10-7 �\ •�• END TIME 10-98 f;00CTOR T Y i•�� -y PMD/ER START TIME 10-22 ! HOW CHOSEN: _ TOTAL, STANDBY TIME t , 2'Ta�13:NEARESTj;; O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT,AMBULATORY? PATIENT TAKEN TO AMBULANCE: �y� RESPONSE ZONE O YES .O NO, , O WALKED O GUERNEY O OTHER " PATIENT CONDITION: DRIVER L-)' �) EMT-tA i ' lie TECHNICIAN PARAMEDIC I Hx: _ ' "' DISPATCHER: A4ZAZ CHIEF COMPLAINT: DRY RUN: OYES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) !� S)ii.i i PATIENT REFUSED SERVICES: (SIGNATURE) X �J MEDICAL COVERAGE: " ." _ O i INDUSTRIAL YES O NO NO. OF PATIENTS: S.S.M _ L - U PRIVATE INS.CO.: BASE RATE: ' KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE M:" E.O.B. ATT. ROUND TRIP: O YES O NO ❑ YES ONO NIGHT: (19:00:07:00) CCHP/PPHP N:r' ' I 1 EMERGENCY RUN: MEDT-CAL 0: r 1^ CODE 2/3 OTHER: OXYGEN:. (PER TANK) P.O.E.STICKER O YES 13 NO V' 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) cdJ EMPLOYER:' OCCUPATION: OTHER: ADDRESS: —CITY: STATE: ZIP* `COMMENTS: TOTAL: PATIFNT nrrri%/rn qY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION NO)Iv a CHECK OR FILL INAPPROPRIATE SPACES DATE 87> PATIENT'S ❑ M RIF COMPA_NJY a ADDR . S -� n1 - �, - --(-]- v----..- AG _ _ — 1_3 Mq CITY 3 C-0 STATE ZIP 1_-1 DOB J� ❑ Sn 11M �/1�O W 13Th 13F ❑$ DRIVER'S LICENSE it _._.___. PHONETlC-f NATURE OF DISPATCEe-At1nQe - TYPE OF TRANSPORT: AMBUtANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOU D BY: TIME- (24 HOUR LOCK n / -A_�-1— .V - - TO SCENE Setl. CALL P _ TIME 0-8 RECEIVED i� 1 PATIENT DESTI TION. FROM SCENE-� ❑ FIRE TIME 10-97 a?�_ L7`- ❑ PSAP TIME 10.49 7s2_ _( _���11,_ -- -- MILEAGE: ❑ OTHER/PVT TIME 10-7 S END_zv_ TIME 10-98 DOCTOR --- PMD/ER STARTnj�l_ TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME Q NEST ❑ FAMILY ❑ TRANSFER WAIT TIME U'PATIENT. ❑ DIRECT ❑ OTHER C69 CALL BACK a: AMBULANQf COMPANY: PTE ATORY') PATIENT TAK;=EY BULANCE: RESPONSE ZONE oe NO ❑ WAL`tED ❑ OTHER PATIENT CONDITION: DRIVER )`��^N C�. � `'EMT-1A T TECHNICIAN Yy<34AL PARAMEDIC l I HX DISPATCHER: - CHIEF COMPLAINT: �`JC'_l�1_ RY RUN: ❑ YES ri O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �/,��•_` PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL CO ERAGE: INDUSTRIAL ❑ YES O NO. OF PATIENTS: S.S. a azw4 PRIVATE INS. CO.: _ - BASE RATE: 10 KAISER MULTIPLE PTS. BASE RATE I BLUE CROSS a: TOTAL MILES: 13 x •50 -►• 5� MEDICARE a: __— E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) C HP q:_ _____.._____-- EMERGENCY RUN: M E D I -C L 4: i CODE 2 31 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 /U- CITY: _- STATE: ZIP: COMMENTS: _— TOTAL: ;9-i PATIENT RECEIVED BY:X (SIGNATURE) \ Pro vi.?rr• rrLai! whir, v..i N,::, r.•N, +rtI,r•, Yr'... eery "C vhe, t:l'ing 11715-1 NQywoo I CONTRA COSTA COUNTY AMBULANCE j PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION If 8313 57-2 «1S _ - CHECK OR FILL INA H APPROPRIATE SPACES � � DATE: 3 PATIENT'S NAME—`_�! �;Yt�� _')w Lrl �M ❑ F COMPANY N ��K7 AD DR SS -C �_5,_ S–f S AGE CITY11 �'+�'Lc_ STATE_._ _ ZIP___ DOB�46Y ❑ Sn ❑ MOW OT OF OS-' '- 1 DRIVER'S LICENSE _ PHONE_ r_�— NATURE OF DISPATCH�_ TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: r RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK�L '' LL TO SCENE- Z S.O. CALL RECEIVED 7 1 p _S_` .� ���7�`� —!— ❑ P.U. TIME 10-8 ; PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 _� �- — ❑ PSAP TIME 10-49 (ly 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 ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. c RESPONSE ZONE ❑ YES ❑ NO ❑ WAL"ED ❑ GUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER__ r�"t'""�'��� _ TECH NICIAl_, — PARAMEDIC Hx: __��-L �_�.-l—=-�-__._.J_c:� :_1t. DISPATCHER: _ CHIEF COMPLAINT DRY RUN: YES ❑ NO REASON FOR DRY RUN ATION F09 DRY �RUN �(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_P , US �-�COVERAGE: INDUSTRIAL __�[� 13 YES ❑ NO NO. OF PATIENTS: �` \ 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: MEDI-CAL it: CODE 2/3 OTHER. OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ( -DATES BALLED STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X A,// DRUGS: (PER ADMIN.) X NAME:�.�L�/_9�_�. �iacQ T.3..—_— RELATIONSHIP:.&--L— 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) �J EMPLOYER: ____--_—_ OCCUPATION: OTHER: ADDRESS: CITY: ___ STATE: ZIP: COMMENTS: _ — TOTAL'��� - -- ------ ... fStGNarUPE1 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M T ' _3 g4 7 • 1 � I I CHECK OR Fll.l IN APPROPRIATE SPACES DATE: –'6 _—K, PATIENT'S NAMES��y_'�= gm ❑ F COMPANY# ( (r `7 ell.V ADDRESS AGE 3 1 I ' ' O/ t ~ CITY STATE �- ZIP DOB_ —_Y OS,, ❑ M 4T OW 07b OF Os -- DRIVER'S LICENSE q _ _ PHONE =4L_3'15!K {NATURE OF DISPATCH 11-71 - - TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ _ STATION 1(A)_2(8)_3(C),44(D)_5(E)_._ ._ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) _ TO SCENE 3 ip S.O. CALL RECEIVED 2-3- 0 ❑ P.D. TIME 10-8 . /"? PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 1 s : 10 - ") ❑ PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 Z/ END S TIME 10-98 DOCTOR PMC START ms`s 7 TIME 10-22 HOW CHOSEN: TOTAL_ % `S STANDBY TIME ----� -$r NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER >> CALL BACK 0: AMBULANCE COMPANY: _ C-,n S 1 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5� RESPONSE ZONE S Cl YES,--9 NO ❑ WAL ,ED,49-GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_FC,_ 77- EMT-1A TECHNICIAN In PARAMEDIC _' J Hx �.T .!. ✓1�.— DISPATCHER: CHIEF COMPLAINT: _-1:=�c_(�_�Jc� L DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X /- /v MEDICAL COVERAGE: INDUSTRIAL ❑ VES NO NO. OF PATIENTS: /J� Y S.S. a '\ PRIVATE INS. CO.: BASE RATE: KAISER p: MULTIPLE PTS. BASE RATE --� BLUE CROSS#: TOTAL MILES' ? X MEDICARE 4; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO - ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: �C,,tp MEDI-CAL a: CODE 2/3 ) 1I� V OTHER: OXYGEN: (PEA 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: ~' If RELATIONSHIP:r'*e'171 E.O.A.: (IF NOT REPLACED) -- ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) 1. PHONE: WORK PHONE: DRY RUN: ,(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: / - ADDRESS: 4, - CITY: STATE: ZIP: 2,UD COMMENTS: - - - - - 2j TOTAL:' PATIENT RECEIVED BY: X (SIGNATURE) - Pn+eider reta:� 61iitr and n=.: 7P� 6rtu* Yr':,_ r;. !M.- when biring O15-1 .I... I •� V-n3 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M(1 `�1�'- -- Q _� I CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME.'__'_._..., = M C] F COMPANY M " ADDRESS s`� 1 , ' - --_----` ��L�)✓ ' AGE CITY.._L_-_ STATE--__ ZIP_ } DOB_�� �_� ❑ Sn O M O T KIN O Th O 1F 138 '- DRIVER'S LICENSE++ ___—.___._--__—___.__--_ PHONE LL(J__�� NATURE OF DISPATCH �/' U TYPE OF TRANSPORT: AMBULANCEK OTHER❑ __ _ -- STATION 1(A)_2(8)_3(C)_4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) _r \ > - INO TO SCENE - O. CALL RECEIVED ❑ P.D. TIME-ID-8 C) n + PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 — O PSAP TIME 10-49 / l MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR � `E 1� PMD/ER START r TIME 10-22 --•+ HOW CHOSEN: TOTAL STANDBY TIME i ❑ NEAREST ❑ FAMILY ❑ TRANSFER p WAIT TIME _ ❑ PATIENT O DIRECT lz OTHER �L;,;j ,;� ` ��7 CALL BACK k AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: J O RESPONSE ZONE YES ❑ NO )2(WAL°;ED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER S `��J EMT-tA � ! TECHNICIAN :I PARAMEDIC + I Hx: J z U I C-Tl_�VA _ DISPATCHER: 1� - _ CHIEF COMPLAINT: —1_iC�_� r ( c� .` }L `-� 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. a PRIVATE INS. CO.: BASE RATE: - KAISER.#: MULTIPLE PTS. BASE RATE �� 1 BLUE CROSS N: TOTAL MILES: / X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO // ❑ YES ❑ NO NIGHT: (19:00-07:00) CCFre/p" 1 EMERGENCY RUN: vU ejd" ( I MEDI-CAL k: CODE 2/3 - ' l I OTHER: OXYGEN: (PER TANK)- �!() P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ,l e•r 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` COMMENT ) (� l� • TOTAL sG- __ PATIENT RECEIVED BY: X (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT 7 AUTHORIZATION N ✓ /f CHECK OR FILL INAPPROPRIATE SPACES DATE: 13 •,�� PATIENT'S NAME_1 ^�1'f l_LL,11`\�(l (A flN / �Gjq b — ( -1._l Q M ❑ F COMPANY N I • ADDRESS _P2_3 I))! �)L)S 1 AGE SLL_ C -7 STATE ZIP DOB ❑ Sn O Irl O T.ofW .�.Th• O F p$'" I1 DRIVER'S LICENSE qPHONE--- -- L ��L,�t'C�_�i.:S.�_... _.. ._____ ���f,.._LI,� NATURE OF DISPATCH � TYPE OF TRANSPORT: AMBULANCE'g OTHER❑ __ STATION 1(A)._218)_31C)_41D)_61E .��._. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) MF_o\l STC C-� TO SCENE - S.O. CALL RECEIVED J" 7_ �1[.L �.� P.D. TIME 10-8 ' s 1 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 2- O PSAP TIME 10-49. ) E MILEAGE: ` L ` ❑ OTHER/PVT TIME 10-7 b ---1 END �..�� TIME 10.98, DOCTOR �h�� PMD/tj STARTS TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ~:_.4�_•, ❑ PATIENT O DIRECT 9 OTHER SPEC S=RVIC� I U CALL BACK N: AMBULANCE COMPANY: A` Cd PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: :G�O RESPONSE ZONE 2 AYES ❑ NO 32 WALED ❑ GUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER /_ I C4 T-A a) I) EMT-tA ll/ w f TECHNICIANPARAMEDIC "1 Hx - E l'r *� ��T� -� DISPATCHER: IO 14-z c.Iato I OC) CHIEF COMPLAINT: - ���se DRY RUN: OYES IRNO REASON FOR DRY RUN (w/�+-]Tr D �, 1•c�"_C�1�P( r , AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES X NO NO. OF PATIENTS: 12� Z I PRIVATE INS. CO.: BASE RATE: LC.�IV. KAISER C MULTIPLE PTS. BASE RATE t BLUE CROSS C TOTAL MILES: f� X 6 3 J MEDICARE X: E.O.B. ATT. ROUND TRIP: ❑ YES A'NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ✓5y w , �� EMERGENCY RUN: -u I CCHP/PPRP p: 7_7 r� MEDI-CAL C CODE(D 3 I �. .. OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES hr 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: `� �l SLC RELATIONSHIP: )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: (AUTHORIZEO) EMPLOYER: %"x OCCUPATION: OTHER: -- - - - - ADDRESS: CITY: STATE: nn ZIP: COMMENTSVP. (x 1 11)rc , P+ :_ IOy�L,> (fib C TOTAL: - 1nrn C 1 1n� U! I C _ PATIENT RECEIVED BY: CONTRA COSTA COUNTY AMBULANCE /1 PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION N CHECK OR nLL IN APPROPRIATt SPACES DATE: a Yf ATIEN' NAME O M Ll F COMPANY N i 'J ADDRESS. ( AGE p� C / _ CITY -2 USI $TATV rrca CoSfA 114f",� R7 -i)6OB - O Sn O 1�1 O T ©W O Th 0 F CIS• DRIVER'S LICENSE N ' PHONE NATURE OF DISPATCH t I,) TYPE OF TRANSPORT: AMBULANCE OTHER -.;-STATION 11A1_2181_31C1_41DI_5(E) INCIDENT LOCATION: - I RESPONSE CODE: REgWESTED BY: TIME— (24 HOUR CLOCK) p j 1 TO SCENE- S.O. CALL RECEIVED C Y ' C�� �� k�ls.M — _��_. ❑ P.D. 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 F-DOCTOR -' ,1 PMD/ER START TIME 10.22 HOW CHOSEN: 1 TOTAL STANDBY TIME .,-,,O NEAREST,"2 O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULA11 C COMPANY: L T��• , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I RESPONSEZONE ZNE O,YES ❑ NO O WALKED O GUERNEY ❑ OTHER +' PATIENT CONDITIONr ) DRIVER J C,,-,EMT-IA TECHNICIANS - ' LA-10 �l - .PARAMEDIC Hx: - DISPATCHER: Ittc lbw 1 > - NuT CHIEF COMPLAINT: fs5EQi. DRY RUN: ❑ YES ONO REASON FOR DRY R AUTHORIZAT N FO DRY RUN(EMS USE ONLY) Yl�l ,• /(,{y; F`.,j; PATIENT REFUSED SERVICES: (SIGNATURE) X. - �7 q MEDICAL COVERAGE. . INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: f) 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: O YES ❑ NO ` O YES "D NO NIGHT: (19:00-07:00) CCHP/PPRP N:^ E ( EMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: LI OXYGEN:, (PER TANK) P.O.E. STICKER OYES 13 NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'NEAREST RELATIVE/RESPONSIBLE RTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 7—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) —EMPLOYM OCCUPATION: OTHER: ADDRESS: —CITY:---." STATE: ZIP: " COMMENTS: - TOTAL< C PAT lEN'1'S NAME': Aileen Lamson ADDRESS: 2117 Barrett Ave, ' Richmond-, Ca. DATE OF SERVLCE: 08-17-83 i AUTHOR17.nT.UN NW-jjt ER:8313931 ° { AMOUNT DUE: $iQ3-nn INCIDENT LOCATIO14: 2547 Barrett Ave. Richmond PATIENT DESTINATION: Brookside HoSoital •J • sus . .; yyy{��l�ss . `. - � �-''�.:•.. ,. ...;i°A'1 �;r. ,uteaa .c�...�,tj*V' yy,,���� ''{siy ! )l.•j��Y-t ( SSS l' AUG I 5 17 AM X83 auc 17 5 18 AM 183 AUG 11 519 AN '83 i �?(11')(i11) 50 rUf' T ,BF.R Pr a, r i CAU RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 r1 CALLED BY— PATIENT INFORMATION oNAME: '\ ... -- ---- ------------- C "� AGENCY .--..-- ... -'--- '� _... ---.__�__ CUSTOMER sl(P, . 1) DOB.�?� r r� w / z / D vDEPT.'FLOORiROOM a: ..._ NAME: Igyt.�( �D,.•�� m a CALLBACK p -___—.___._ __- - _ INS, TYPE: PVT MCAR ® KHP PHP VA IND CHAMPUS > N v I INCIDENT LOC —L.5`L .. ?�rLF_L_ /� POLICY/MCAL 4: 1J u:Oc -�y 13D`� YY1 n b Z m MCAR p: m m � • f- CROSS STREET; _ -_. _._ VERBAL PRIOj; timet cXTv 10 4 �1 a JURIS _._ ,t h C�1_I,r)�%�1 {.-_-__._____—__ DOCTOR: _ ti ---- - DESTINATION: l,J r1 _ `.I1. PT. #2 NAME: 'DOB: a . I NATURE: _—__.....-.. �C�O�L1 _. ._.i f.Kms___---- COST. p . PT. aJ NAME: DOB: c o TYPE OF CALL.. 7�'G IRANS TIME UNIT 4 CUST. P w CREW: �._ . — WALT TIME: VES NO REASON: Z ;� A O UNIT TYPE:QA BLS. WC RESPONSE CODE: 0 1 2 (3 4 REASON FOR 10-22: p c a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 O2 3 4 CANCELLED BY: m CA ii BY: END MILEAGE: COMMENTS: p Ln aTIME: BEG MILEAGE: ( �•((� _� ^(•d _ DPA CHER: TOTAL MILES: '� a L cowtXL- OI1V1S lV 3DNVinevwv 61-01 ONINLI6Td/3JNvV18Wv 86'01, 31SV11VAV 3DNVif18Wv L-01 1VlIdSOH IV 3�Nvi118WV E�s 9 t� tfi E H7 th �n� Htl zo � 9 l f end l� v 'i' 7PIT NEW tti` '., ;'`P`:i -•6. �. c t 40 ll� . �� s� ...�' •�� `- s�1 7 is „r-� �,• - s. r �. •.•fie ° � �} •�' .r-rl 6 s Iii. e. Y. _ . tea, � ••- ..-. ti: •- a.; a * �' h ,�. r.rt�'f1 • Ii.A i "•(11.!7�.ti�. ♦`i'.'..��F:'!�'.�1'' 1 it- • P;Al,zp�-± .'�•. 11� CONTRA COSTA COUNTY � AMBULANCE V` PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N,:,q / I ,C...3 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME Om ❑ F COMPANY#' ! _ - ADDRESSAGE~ C r) CITY STATE ZIP DOB - ❑ Sn OM O T OW O Th OF OS DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A)_2(8),3(C)_4(D)_5(E)_ INCIDENT LOCATION:. w �~ RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) / TO SCENE- {{ © S.O. CALL RECEIVED 3 O P.D. TIME 10-8 ` PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 _r ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 �T END TIME 10-98 DOCTOR'_ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK k: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Cl YES, ❑ NO ❑ WALKED ❑ GUERNEY O OTHER U PATIENT CONDITION: DRIVER(_ Lt L U EMT-1A TECHNICIAN-0Z C`'t :n PARAMEDIC Hx: DISPATCHER: E L." .f r (Y)L4 Lf, q CHIEF COMPLAINT: DRY RUN: O YES ❑ NO REASON FOR DRY RUN -^• 'O'� N AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1 r. MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO.OF PATIENTS: t, ' S.S. K PRIVATE INS.CO.: BASE RATE: KAISER It: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X / MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ONO ( ❑ YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPHP0:� I EMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) `NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: WER 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: IP:-COMMENTS: TOTAL: _ PATIENT RECEIVED BY: X. _ I'n•ni fnr r�r.r •. LA- .. , , (SIONA111RE) / CONTRA COSTA COUNTY AMDULANCE p PRE-HOSPITAL CARE FORM I UNIT Z1 AUTHORIZATION M — fir CNECK ON FILL IN APPROPRIATESPACES j� GATE: PATIENT'S NAME ��� .1.\Z��_[_� �hA ❑ F COMPANY K AD ESS �1r�-- --1-` �. �Ls —7)�`" AGE L f o 1-�15 "_11_LSTATErn ZIP DOB 00450 O Sn O M O T D W O Th O F O S-" DRIVER'S LICENSE a _-_ J_. PHON l✓> 7 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEtW OTHER O __ _—_. STATION I W_2(B)_31C 410)_5(E)_� INCIDENT LOCATION: RESPONSE CODE REOUESTED BY: TIME- (24 HOUR CLOCK) ! <CIL r TO SCENE- S.O.— CALL RECEIVED f� :3`��i' `�� �� O P.D. TIME 10 8 L3.f:•._�...- , PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 / f ' �j o� h y �-/ ❑ PSAP TIME 1G-49.. MILEAGE: ❑ OTHER/PVT TIME 10-7 (} END �� �'� TIME 10-98 1 DOCTOR __, ^ 1 PMD® START—P7_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME -•-►l ❑ NEAREST O FAMILY ❑ TRANSFER _ WAIT TIME ,J A PATIENT O DIRECT O OTHER ��C1 CALL BACK a: AMBULANCE COMPANY/lq� P AMBULATORY? PATIENT TAKEN TO AMBULANCE: Q ' RESPONSE ZONE YES ONO ❑ ,AL'CED WGUERNEY O OTHER - PATIENT CONDITION: DRIVERI ' 1 lio 44 58V EMT-1A ,�/�. {� TECHNICIA 1 y bO PARAMEDICS Hx:! '"l �LC��C-. '\OC( /U DISPATCHER: C 011) CHIEF COMPLAINT:�_!U, ( �� V F~14M� DRY RUN: ❑ YES O NO REASON FOR DRY RUN J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - '/ PATIENT REFUSED SERVICES: (SIGNATURE) X _ r MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: �`5- S.s a FEZ �!Z"q 7 PRIVATE INS. CO.: BASE RATE: _- KAISER a: MULTIPLE PTS. BASE RATE , BLUE CROSS a: TOTAL MILES: i X 11-='� �.._� MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES O NO -^ O YES ❑ NO NIGHT: (19:00-07:00) -D/ CCHP,'PPRP a: EMERGENCY RUN: `•.v MEDI-CAL a: CODE 2/3 I OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) - f DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) y 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: CITY: \/ STATE: ZIP:— CO IP:COF�7 • - ( I,L�JA YSL c 1�G 1 QrI�L U .` �E�►� TOTAL:�3�J PATIENT RECEIVED BY: X _ Pmvidrr rrto-r iAt •r.' P .:: pp 4rt�r^ Ii",:�• •���. t !ASuhtn b{i inp (SIGNATURE) DIf-1 I ITRA COSTA COUNTY AMBULANCE C : P E-HOSPITAL CARE FORM I UNIT —T AUTHORIZATION N s CNECK ON FILL IN./APPJRO/PRIATE SPACES �I ,�/ DATE: PATIENTS NAME ' /�/�7�T E ► A/u N1 O M F COMPANY N K% C `-�� �'L- ADDRREESSSS - (L�-`7 (�t / '/(�C I.CSYt Ci IC: AGE�� CITY_ 1'1LSTATE- �'a ZIP L� DOB��� ❑ Sn 13M O T ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ _ PHONE 23 f,.1/ZZv NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ — -- STATION 1(A) 2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: OUESTED BY: TIME- (24 HOUR C OCK) C� TO SCENE - S.O. CALL RECEIVED �LL_ Res ❑ P.U. TIME 10-8 y _ PATIENT DESTINATION: FROM SCENE ❑ FIRE —, TIME 10-97 ❑ PSAP TIME 10-49 ` ��- ���� ^ MILEAGE: ❑ OTHER/PVT TIME 10-7 �j �- ENO '•�- TIME 10-98 ' I DOCTOR k!I d !' S PM /ER STAR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- � a PATIENT ❑ DIRECT ❑ OTHER 0-) CALL BACK N: AMBUf C COMPANY: PT. AM ULA RY? PATIENT TZENG AMBULANCE: ��, RESPONSE ZONE ❑ YES NO O WALKRNEY ❑ OTHER C� r PATIENT CONDITION: DRIVER / 1 f ( L r E T EMT-IA 1"�'` TECHNICIAN S�� "�(:���+VALL-11l`. t4j PARAMEDIC Hx: /Z � s DISPATCHER: R0k2N.Ld CHIEF COMPLAINT: DRY RUN: ❑ YES I 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: NATE CO.. CC- F`��`� ������-� BASE RATE: KAISER R: �J �g�''J f)IJ� MULTIPLE PTS. BASE RATE BLUE CROSS N: %�L��'/ 4 TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: G 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: 1-QWORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: T OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: -COMMENTS: ul o U- rL-�l S 04 --- - ri TOTAL' i.. PAI tI N I IIL(A IVI 1)BY, X --. �� 1'.1r.NA 1.nn 1— 6 � r CONTRA COSTA COUNTY AMBULANCE IVAPRE-HOSPITAL CARE FORM I UNIT P.7 AUTHORIZATION N 53- 1 3 7 CHECK OR FILL IM APPROPRIATE SPACES DATE: ` f J l gATIENT'S;NAME, !DA 1 ❑ M 13F COMPANY N /�+� ADDRESS; � `� �.` � AGE~ CITY STATE ZIP DOB O Sn OM OT CKW O Th ❑ F O S DRIVER'S LICENSE 01_ PHONE NATURE OF DISPATCH 1179 TYPE OF TRANSPORT: AMBULANCE IX OTHER 0 STATION 1(A)_2(B)_3(C)-4(D)_5(E) INC IDENT;LOCATION- N j .•:'. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 7 1 �� �••y `.�.J�/� TO SCENE- � j�S.O. CALL RECEIVED 1� . —'� Gu'y l 1�FL-. Tz; O P.D. TIME 10.8 ( / PATIENT DESTINATION: r FROM SCENE- O FIRE TIME 10.97 Z� q ' �rVw O PSAP TIME 10.49�D.�J� fz7 MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10.98 DOCfOA ' I RT TIME 10 2 PMD/ER STA2 ' HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST, ❑ FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK><: AMBULANCE COMPANY: [PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SC) RESPONSE ZONE O YES ❑ NO - O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER mr rna(a.nDA t"'C �'GEMT-IA: TECHNICIAN - PARAMED 0� Hx: DISPATCHER C� CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AIDZ&l JURY AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S.k i PRIVATE INS.CO.: BASE RATE: KAISER C ` MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M:^ 1 EMERGENCY RUN: MEDT-CAL 0: I 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) EMPLOYM-- - OCCUPATION: OTHER: ADDRESS: CITY: STATE:—ZIP:- -COMMENTS: TATE: ZIP:—"COMMENTS: TOTAL: L' ' - PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT IM AUTHORIZATION N ISS 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: g r�1 Y3 PATIENT'S NAME `N N�S,_________c, ' ' `�"'^�� �+ ❑ na COMPANY N I A-7 O v ADDRESS 1���- -'- 1 t�(��•/��4 �/ AG 19 3 2--: CITY� �1�r,0 STATE L Z DO ❑ SI, O M ❑ T C) Th O F O:S ' ? DRIVER'S LICENSE 4 1 3- � 1 .__-_ PHONE �-2.. �_.��1VATURE OF DISPATCH TYPE OF TRANSPORT: AMBULA HER T INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �C U ^, TO SCENE CALL RECEIVED —_ ❑ P.U. TIME 10-8 PATIENT DESTINATION: F;V 0 FROM SCENE- ❑ FIRE __ TIME 10-97 / ^6 fir• �t 'I gC )A ❑ PSAP TIME 10-49 SdSL `� a __— MILEA ❑-OTHER/PVT TIME 10-7 END _ TIME 10-98 ^ ' y'" DOCTOR PMD/ER STAR___. TIME 10 22 �L HOW CHOSEN: TOTAL — STANDBY TIME ❑ NEAREST ,,�IILY ❑ TRANSFER WAIT TIME c:�::�TIENT ❑ DIRECT ❑ OTHER CALL BACK it: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEEN� AMBULANCE. J RESPONSE ZONE S ❑ NO ❑ WAL':ED L�UERNEY ❑ OTHER PATIENT CONDITION: DRIVER_w���o V 3rt� r.►� T-�e 1 TECHNICIANr;U PARAMEDIC Hx: .__ __ _ DISPATCHER:_. ��.I)F� b J ' L� CHIi OMPLAINT: -?.`J�Z �r—v DRY RUN: 13 YES ¢7 NO REASON FOR DRY RUN ` �G AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL CO� DU T IAL 11 YES ❑ NO NO. OF PATIENTS: PRIVATE INS.CO.:— _ BASE RATE: �r ) KAISER k: __ MULTIPLE PTS. BASE RATE r BLUE CROSS a: TOTAL MILES: =r X ;•, .� > �� . MEDICARE q: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPHPN: EMERGENCY RUN: ok 1 I I 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.: fPER ADMIN.) X \/ S DRUGS: (PER ADMIN.) X NAME:._-`�'[t�__ RELATIONSHIF� in 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:- --v TOTAL: IP:COMMENTS:- TOTAL: �n . •.Jr� PATIENT RECEIVED BY: RE) Frwidrr rrtci Ol;itr r.d f`in: .•�Tp Sct:.ri Y.'. .-^�•: ^t5 _hca n� Pil: t71S-1 45-753 rl�i0—g3 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT P-T AUTHORIZATION 8 3139 yS CHECK OR FILL IN APPROPRIATE SPACES ,„ , , DATE: PATIENTS NAME_ / f �U� <�/��/�,2� 1 f /_r—f 9"M. ❑ F COMPANY 1 ADDRESS I64 7I ••vl40 1�/-1 C7LC)AVr. 3�1 AGE 55 �Jf� lei CITY 4- STATE klc-o ZIP 4$D DOB 11 F.•, •9f"VE43=S LICENSE# _162006_7 PHONE (.262— NATURE OF DISPATCH 6-14L TYPE OF TRANSPORT: AMBULANCE IVOTHER❑ _ I STATION 1(A)_2(B)_3(C),d(0)_26(E) INCIDENT LOCATION: RESPONSE CODE`. RE�U£STED BY: TIME—(24 HOUR ) / \ �+�-^ /1�}�� v TO SCENE- 2 , 1 S.O. CALL RECEIVED [c ����y Jl tls�'H/ 1/Kf-tI� J ❑ P.D. TIME 10$ _Tk 1: `7' PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 yI 0 PSAP -TIME 10-49v AO l ���•r 1 • MILEAGE;• 0 OTHER/PVT TIME 10-7 , END TIME 10-98. DOCTOR _ E N Q2, PMD/ER START S21S TIME 10.22.4 HOW�HOSEN: TOTAL STANDBY TIME 'G0. NEAREST / WAIT TIME 13 PATIENT PATIENT DIRECT ❑ OTHER CALL' M .BACK III: AMBULANCE COMPANY: ❑ FAMILY ❑ TRANSFER , 1 4'x'1 4: PT. AMBUVTORY? PATIENT TAKEN TO AMBULANCE: ,-- U RESPONSE ZON 11 YES yV NO 0 WAL'<ED O�GUERNEY ❑ OTHER I i PATIENT CONDITION: + DRIVER w� (�_ EMT-1A -7 TECHNICIAN P AMEDI 7 Hx: _ �. F-AUDISPATCHER: v ;1. T CHIEF COMPLAINT: �_A'C, b NCps ItS7 DRY RUN: ❑ YES NO REASON FOR DRY RUN I ', AUTHORIZATION FOR DRY RUN(EMS USE ONLJ, PATIENT REFUSED SERVICES:(SIGNATURE) X 1•. ! zlo MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: '��;� r•'`; S.S. « -114A -- 1. PRIVATE INS.CO.: r BASE RATE: 31 A.* ' KAISER k: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: / 1 fivr.,".., Xyea MEDICARE N: E.O.B. ATT. ROUND TRIP:-'0 YES 0 NOV. 0 YES -0 NO NIGHT: (19:00•07:00) I�i'.8 I "M3 �! I CCHP/PPRP#: EMERGENCY R WpA �• '\MEDT—CAL#: CODE 2 3 , c OTHER OXYGEN: (P -LANK) \\ �.: ,7. V.-QETICKER ❑ YES 0 NO NEONATAL: (INCUBATOR)Tt?;'I3W 3V �)xJ `'• �I�\v DATES BILLED: STANDBY: (OVER 15 MIN.) si{ L 1` E.K.O.: (PER EPISODE) ------. XMI " 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) dk EMPLOYER: OCCUPATION: - OTHER.- ADDRESS: THER:••. -- —•-'ADDRESS: CITY: STATE' -ZIP: � 7 O COMMENTS: o 4 - - - - - - TOTAL: PATIENT RECEIVED BY P>"vider rft : L'I;:Ir .�+ n:.1 ^I� c •r_ .. I$IONA URE) t►Ie-1: CONTRA COSTA COUNTY AMBULANCE l D PRE-HOSPITAL CARE FORM I UNIT 1/ AUTHORIZATION N ,y• 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: /'•�� 'PATIENTS NAME OM OF COMPANY N ADDRESS p - AGE 1' DR CITY STATE ZIP ZIP�_ DOB - ❑ Sn OM OT OW ❑ Th O F OS I 1 - DRIVER'S LICENSE N _ _ PHONE NATURE OF DISPATCH n•'� l r,�c_�c TYPE OF TRANSPORT:. AMBULANCE Q OTHER❑ — STATION 1(A)_2(8)_3(C)_4(D)_5(E)a- INCIDENT LOCATION' '% �� RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) \ m S.O. CALL RECEIVED l.2- QL _L��, 3/ •�� �{�n f L� 15" TO SCENE- - D 2, •-D O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - O FIRE TIME 10-97 U O PSAP TIME 10-49 DR Y'- �� /'? I MILEAGE: ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 'DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: ,._ TOTAL STANDBY TIME ';• .❑ NEAREST ❑ FAMILY O TRANSFER I WAIT TIME D PATIENT D DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO . ❑ WALKED 0 GUERNEY O OTHER :ter. PATIENT CONDITION: DRIVER,-.J: EMT-1A u;4 T(' _. TECHNICIAN PARAMEDIC Hx: DISPATCHER: RN,e E.'A C (` ` do CHIEF COMPLAINT: DRY RUN: d YES 13 NO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 95y MEDICAL COVERAGE: INDUSTRIAL D YES D NO NO. OF PATIENTS: L/ S.S. N PRI TE INS. CO.. BASE RATE: K ISER K: MULTIPLE PTS.BASE RATE BLUE CROSS K: TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: O YES D 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 D YES NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '- NEAREST RELATIVE/RES ONSIBLE 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) SNs� -" EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE# ZIP: COMMENTS: - TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: X (SIGNAIURF) i 1 CONTRA COSTA COUNTY AMBULANCE �/�/� vM PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION OK 7 CHECK OR FILL INAPPROPRIATE SPACES DATE:`� '/ �] b �+ �• 1 PATIENT'S NAME ' �'`l`� �CTTI1 �U—Llq� yin ❑ f COMPANY M r_ ADDRESS (_�� / `V1 AGE I CITY_2±L ffL/±JlJ > STATE_ C ZIP___ DOB O Sn ❑ M 0 T 0 W kTh O F 8— DRIVER'S LICENSE a ____ PHONE .—_ NATURE OF DISPATCH e .�. TYPE OF TRANSPORT: AMBULANCEOTHER❑ _ STATION 1(A)_2(8)_3(C)_4(D)_5(E)_- --•- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) , `fo c' ATO SCENE- CALL 13P.D. TIME 10-8 RECEIVED PATIENT DESTINATION: `t FROM SCENE- 0 FIRE TIME 10-97 !�2_ :-•L-�LZ_ ❑ PSAP TIME 10-494_ t ` " N "& MILEAGE: ❑ OTHER/PVT TIME 10-7 , I END -- TIME 10-96 ,• � 7 DOCTOR _ PMD/ER START TIME 10-22 / -- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY 0 TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: , PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 0 YES 0 NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER O PATIENT CONDITION: DRIVER '_zoo EMT 1 TECHNICIAN L 3 s PARAMEDIC Hx:•N DISPATCHER: 5 P e •C r CHIEF COMPLAINT: DRY RUN:0-YES 0 NO REASON FOR DRY RUN i A THORIZA ION FOR RY RU EMS E ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X Ll J I � 1 IW MEDICAL COVERAGE: INDUSTRIAL ❑ YES ;d-NO INO.OF PATIENT ,+�•! '4i".«� K...� I •� IVATE INS. CO.: BASE RATE: - KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r ❑ 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 ❑ 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: 'I'C�I� c� S NL Dols rg01 5�>; F 7 vL s /,Ila i 7�ilc N/f .tiC V, TOTAL• '- O TT1 I ui l •r_ wAf iIrl U:aT> STRrt Ofr MiAlD PATIENT RECEIVED BY: X Provider retain shite v i 1•i..% -or? Fet.r Ye'1••a (SIGNATURE) 015-1 CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CN[CK 011 FILL INAPPROPRIATE SPACES DATE: 9 /X3 `PATIENTS NAME I ❑ M ❑ F COMPANYO- /O - O ,, ADDRESS AGE �N CITY I STATE • ZIP DOB O Sn ❑ M OT O W / Th ❑ F CTS DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:. AMBULANCE OTHER — STATION 1(A)•_2(8)_3(C)_4(D)_5(E)_ <co! INCIDENT LOCATION." - rr � ' RESPONSE CODE! RE UESTED BY: TIME- (24 HOUR C K) JACK InJ IK- (16X P,rJri��J j�/ /� TO SCENE- S.O. CALL RECEIVEDJ± T_l - < ' ❑ P.D. TIME 10-8 PATIENT DESTINATION: .. I FRO CENE - ❑ FIRE TIME 10-97 n1 13PSAP TIME 10-49 f� (zy_T t A"'CE L_-� 1 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 0OCTOR I'" 1 PMD/ER r START TIME 10-22 c - HOW CHOSEN: TOTAL STANDBY TIME `'•: ❑ NEAREST 13 FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `jU RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' PATIENT CONDITION: DRIVER'_ L� � U C) EMT-IA ')bR Fj I TECHNICIAN �7 /� 5 PARAMEDIC Y ` Hx: DISPATCHER: /'i P C. CHIEF COMPLAINT: 62DRY RUNES ONO REASON FOR DRY RUN 10-11 ZAJAVL-M AUTHORI TION FOR DRY RUN(EMS USE ONLY) ;'. PATIENT REFUSED SERVICES: (SIGNATURE)X� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: l S.S. M 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 ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: 1 --- - EMERGENCY RUN: MEDI-CAL N: , CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) OATES 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: 000C LE- 4 I.1 ROw� IxY P f[[ 1�l /1- f C_�IY12 0 L TOTAL 1 , PATIFNT RFCFIVFn Rv X __. CONTRA COSTA COUNTY AMBULANCE �� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M 7 cHrctt or+rci i IN AnnannAce t[sn�crs DATE: PATIENT'S NAME.- _-, - � WJA ❑ F COMPANY M ADDRESS rJ:_�_S h'i/c� C /� /�/���� AGE ' r7 -7 { CITY_ `�r Y C c_' STATE_C___�— ZIP S2�J DOB_/ ,Z❑ Sn OM OT ❑W OF .O$` - — _< < DRIVER'S LICENSE q ___ PHONE %�� � _ NATURE OF DISPATCH n� �S. t• 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 ❑ P.D. TIME 10-8 �'' PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 '7— 13 / �PSAP TIME 10-49 MILEAGE: .1 i I ` ❑ OTHER/PVT TIME 10-7 7 ;.LI:a 1 END TIME 16-98 DOCTOR PMD/ER START X ,3 ' U TIME 10 22 HOW CHOSEN: TOTAL I STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER - WAIT TIME O PATIENT IRECT ❑ OTHER } CALL BACK c AMBULANCE COMPANY: ti . ' C. ,ArS• I PT. AMBU TORY? PATIENT TA EN TO AMBULANCE: So RESPONSE ZONE 2 ❑ YES' O 13WAL'CED UERNEY ❑ OTHER —� PATIENT CONDITION: DRIVER •Vu's L42 ' ( 1 0 EML T-tA 1 ( i TECHNICIAN ///��/�/�r I�t4. 1 D PARAMEDIC Hx: J� � ' DISPATCHER: CHIEF COMPLAINT: e'—oz I>A G k, DRY RUN: ❑ YES KNO REASON FOR DRY RUN Z AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: _ INDUSTRIAL ❑ YES V_-N_0 NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: �� , X —! MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL k: CODE,2 1 3 i OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) ►�iL=.:.�r� % E.K.G.: (PER EPISODE) y 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' PATIENT RECEIVED BY:X (SIGNATURE) Provider mar.. whir, ,..! n:": .,, c,.r.,.+ � r+•- .r.. r: MS-1 t CONTRA COSTA COUNTY AMBULANCE I 3 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: - PATIENTS ATE:PATIENTS NAME I ❑ M ❑ F COMPANY M a ADDRESS V AGE f V CITY STATE ZIP DOB— ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE —__ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑/OOTHER❑ f INCIDENT LOCATION: G '��. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C O K) TO SCENE- 3S.O. CALL RECEIVED ❑ P.U. TIME 10-8 • i/- ,,PATIENT DESTINATION: �v U FROM SCEN D� - ❑ FIRE __ TIME 1D-97 ❑ PSAP TIME 10-49 - MILEAGE:^ ❑ OTHER/PVT TIME 10-7 END TIME 10-98 c DOCTOR - PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME `^ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE CO PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j L� RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I'�`. EMT-1A TECHNICIAN PARAMEDIC L� Hx: _ DISPATCHER: k-) CHIEF COMPLAINT: u DRY RUN:�YES ❑ NO REASON FOR DRY RUN /I,'(r' AUTHORI ATION FOR DRY RUN (EMS USE.ONLY) `1'1'1 PATIENT REFUSED SERVICES: (SIGNATURE) X— �,/Of, MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: KAISER c MULTIPLE PTS. BASE RATE BLUE CROSS M: -_ TOTAL MILES: X MEDICARE It: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: 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: 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: �SjT,ATE: ZIP: COMMENTS: .moi p r w r O TOTAL. PATIENT RECEIVED BY: X (SIGNAL URE) CONTRA COSTA COUNTY AMBULANCE 0(j) PRE-HOSPITAL CARE FORM 1 UNIT /� AUTHORIZATION N 13' CHECK OR FILL IN APPROPRIATE SPACES DATE: d / - 'PATIENTS NAME r'• ' l L` L D I / ❑ M O F COMPANY N v 0 ADDRESS - AGE f /), i ow1 CITY STATE ZIP DOB ❑ Sn OM OT Ow O Th ❑ F O S DRIVER'S LICENSE N _ PHONE _ NATURE OF DISPATCH I TYPE OF TRANSPORT. AMBULANCE OTHER❑ - STATION-1(A)_2(8)_3(C)_4(D)`5(E)_ n � i INCIDENT LOCATION: f RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 1�� TO SCENE- ❑TS.O. CALL RECEIVED 5 I S" � f� O P.D. TIME 10-8 QV PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 :•'� ( ; (�'` ` - ;'��yrJ G-/ •'�_. C:- C.- C" � ❑ PSAP TIME 70-49 MILEAGE ' : ❑ OTHER/PVT TIME 10.7 : I END TIME 10.98 �— ' DOCTOR' ' - PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I RESPONSE ZONE I O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER �) ' i PATIENT CONDITION: DRIVER '��-��� "'� EMT-1A TECHNICIAN — PARAMEDIC Hx, DISPATCHER: j.� CHIEF COMPLAINT: DRY RUN: © YES ❑ NO REASON FOR DRY RUN PATIENT REFUSED SERVICES: (SIGNATURE) X AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ,. ._. i MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO 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;-& 1�`1 - �� ��' E.O.B. ATT. ROUND TRIP: ❑ 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) f 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• I I PATIENT RECEIVED BY: X i ' CONTRA COSTA COUNTY . AMBULANCE I'f I ��� �►+�� PRE-HOSPITAL CARE FORM I UNIT ��( / AUTHORIZATIONN CHECK OR FILL IN APPROPRIATE SPACES DATE: 0 .� PATIENT'S NAME.-�`�crL_ J� Rte- ❑ M CF COMPANY N _ ADDRESS — /� ] AGE CITY-1�`�►{rL1 L) Lr STATE— 0 ZIP U t D0B`J-1 L � S ❑ M O T Ow ❑ Th � O S' DRIVER'S LICENSE e __ _ PHONE_;%-_ 06 NATURE OF DISPATCH12 I -- t TYPE OF TRANSPORT: AMBULANCE D -OTHER❑ -__ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE - S O. < CALL RECEIVED P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE --1FIRE TIME 10.97 /J OPSAP TIME 1049 MILEAGE:_ ❑ OTHER/PVT TIME 10.7 END TIME 10-98 1 DOCTOR __._ v�� PM /ER START i TIME 1022 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPANY: PT AMBULATORY? PATIENT T E O AMBULANCE: RESPONSE ZONE_ YES Cl NO ❑ WAL"ED AGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER .Me-Iefel ? � ` I�nEMT-tA 1 TECHNICIAN_ - PARAMEDIC Hx: 1Z ,(hl) %N DISPATCHER: 'r - � I CHIEF COMPLAINT: �!�<<�_�Q� — DRY RUN: D VES O REASON FOR DRY RUN _-- AUTHORIZATION FOA DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ tt MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. N �-- j.� ^ ,, PRIVATE INS.CO.:-LS<<� i 1 1 i 'PL -1 L) BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE _ BLUE CROSS If: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO Cl YES ❑ NO NIGHT: (19:00-07:00) o ` CCHP/PPRP N: EMERGENCY RUN: J MEDT-CAL It. 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: 0. 3 Z TOTAL: c � - •'c. PATIENT RECEIVED BY: X rp,,t,:(rte rrt. L7,( ...{ n:.: ,�� irr, vr•r..,,. r'•_ r (GNAT E) tr. i n DK-1 CONTRA COSTA COUNTY AMBULANCE �� PRE-HOSPITAL CARE FORM I UNIT `,/ AUTHORIZATION N CHECK OR PRL IN APPROPRIATE SPACES •�- DATE: PL PATIENTS NAMEJh eC , &-1'`I 10M OFF COMPANY# ADDRESS AGE 3 CITY STATE ZIP DOB O Sn OM OT OW O Th OF OS DRIVER'S LICENSE N j - PHONE NATURE OF DISPATCH ^4AW,LA[ TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 1(A) ,X2(8)_3(C)_.4(D)_5(E)_ INCIDENT LOCATION:, RESPONSE RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) ✓ C ' 11 TO SCENE- OO P.D. TIME 0-8 CALL RECEIVE � PP_ PATIEN DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 D11 f - a 11PSAP TIME 10-49 �1 ` �Q --ZZ 1 MILEAG ❑ OTHER/PVT TIME 10.7 END TIME 10-98 ` DOCTOR_'�' i PMD/ER START TIME 10.22 _ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER 00 T-1 TECHNICIAN PARAMEDIC Hx: DISPATCHER: 'f /qq CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DAY RUN t (� AUT IZ NF RY UN(EMS USE ONLY) I 7 9 PATIENT REFUSED SERVICES: (SIGNATURE) 6� �- 15 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. 0 PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS.BASE RATE . r BLUE CROSS M: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: O YES ❑ NO DYES ONO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL K: CODE 2/3 OTHER: OXYGEN: (PER TANK) ` 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 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: , I TOTAL: ! (. - nn�ir�1T nrl^rlrn r • v CONTRA COSTA COUNTY AMBULANCE n PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION NV �•,• CHECK OR FILL INAPPROPRIATE SPACES DATE: I 'PATIENTS NAME 2 � ❑ M ❑ F COMPANY N ADDRESSAGE"\ t/ 1� J. CITY STATE ZIP DOB ' ❑ Sn OMOT ❑ W a❑ Th F O$ DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:I AMBULANCE D OTHER❑ _ -_ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) a� , �f G TO SCENE- XS.O. CALL RECEIVED 4 T [/i1 ` G O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 / Q ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME r� ?'i :• O NEAREST: ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: I^� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: .510 RESPONSE ZONE ❑ YES 11 NO ❑ WALKED O GUERNEY ❑ OTHER 1 i 1 t PATIENT CONDITION: DRIVERLA ( ` e _ d�� EMT-1A J�1 h_j. TECHNICIAN PARAMEDIC C S<_ Hx: DISPATCHER Ji L-1 '�,Al, !Or) CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN q,I � !, y y `�' � . PATIENT REFUSED SERVICES:(SIGNATURE) X AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Oe-1 MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N L 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 ❑ NO O YES ❑ NO NIGHT: (19:00•07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: 'T 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) C EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: �,C PATIENT RECEIVED BY:X 1 CONTRA COSTA COUNTY AMBULANCE I G PRE-HOSPITAL CARE FORM I UNITM AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: ' `G (93 PATIENTS NAME nE NV (Ns �; ThC mL W . U'M ❑ F COMPANY R ADDRESS Lt` -- — AGE TU CITY m� �• STATE ZIP�L11 5�_�-_ DOB,A143 O Sn OM OT OW O Th F O S DRIVER'S LICENSE M ________L _ � �_ PHONE NATURE OF DISPATCH 'V - TYPE OF TRANSPORT: AMBULANCE OTHER _..__-__ .._ _._-_ - STATION I(A),20,_3(C)_41[13)_51E),_ INCIDENT LOCATION: RESPONSE CODE: REO JESTED BY: TIME- (24 HOUR CLOCK) TO SCENE S.O. CALL RECEIVED O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - O FIRE TIME 10-97 ll1 O PSAP TIME 10.49 l4 -c-q , f C -c -c-t'R - C- `Q�• MILEAG O OTHER/PVT TIME 10.7 r -, END TIME 10-98 Lk DOCTOR �_ 1 MOt� PMD R START TIME 10-22 HOW gKOSEN: TOTAL r- STANDBY TIME -- CNEAREST ❑ FAMILY O TRANSFER WAIT TIME D PATIENT O DIRECT ❑ OTHER i S / CALL BACK«: AMBULANCE eD iTAnm j�IY: PT. AMBU,�LA�RY? PATIENT TAK�E,NN AMBULANCE: j'r RESPONSE ZONE//TT SS O YES l NO O WALKED P GUERNEY O OTHER PATIENT CONDITION. DRIVER rtf 45�►" I r! aT-1A ) TECHNICIAN ��C �� `� PARAMEDIC lHx: �AS co P _ e vll t't5e Ih A DISPATCHER: CHIEF COMPLAINT: W '0.k�leSS IS. DRY RUN: OYES NO 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: t' S.S. PRIVATE INS. CO.: BASE RATE: �i KAISER C MULTIPLE PTS. BASE RATE r TOTAL MILES: X r CMED=ICARE#. �y-G� -• 97(, E.O.B. ATT. ROUND TRIP: OYES ❑ NO. O YES O NO NIGHT: (19:00-07:00) C ' J CCHP/PPRP 4: EMERGENCY RUN: CA 00r MEDT-CAL«: CODE 2/3 OTHER: OXYGEN: (PER TANK) ✓'_ ' J P.O.E. STICKER O 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 1f DRUGS: (PER ADMIN.) X NAME: ENV' N tC,ciD RELATIONS `'uT-IA,`1 E.O.A.: (IF NOT REPLACED) ADDRESS: er ' nS ORAL AIRWAY: (IF NOT REPLACED) CITY: Q d STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: g34 -�)yy WORK PHONE: DRY RUN: (AUTHORIZED) -. EMPLOYER: OCCUPATION: OTHER: ADDRESS: I CITY: STATE: ZIP: MMTTS:}�� il ✓10: �' �U .Sirltl t7 C� 0 k vt es-3 _ - TOTAL:—L +�-' - — --j- -- r • — ---_�^---_ PATIENT RECEIVED BY- X t, � c ` � _.._-_---��-.__ • PR?vidfr rftair, White .xd Pi.: r 5.rt�rn 7,•' w. 1."l ilill (316 AT RE) EMS-1 CONTRA COSTA COUNTY AMBULANCE `'�!•I PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N > CHECK OR FILL IN APPROPRIATE SPACES DATE: 7, /`f - J -S _ •" PATIENT'S NAME M PF COMPANY N ` ADDRESS / 7�_(�j LJ.1tLL1L.-_L'r.r ctc . AGE ;rte �: ! i��) j CITY- e,'f STATE ZIP c11�`J DOBr1L ❑ Sn ❑ M ❑ T ❑W C3Th ❑S 1 I DRIVER'S LICENSE p _t.•__� __S_ .iir _ PHONE Y32 NATURE OF DISPATCH M P r 1 C R l TR HILM TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A)_2(8)_3(C)_4(D)_5(E7 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ,)f RU TO SCENE- _ S.O. CALL RECEIVED RU- I r ��, t. c Qom— ❑ P.D. TIME 10-8 •; 7 .� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 L �v O PSAP TIME 10-49 H TJ MILEAGE: ❑ OTHER/PVT TIME 10-7 ' END 7• TIME 10-98 za ,: 3 DOCTOR i�r' L rr•�•: !'� M/ER START �� TIME 10-22 - HOW CHOSEN: ITOTAL `I• 3 STANDBY TIME ❑ NEARESTFAMILY O TRANSFER WAIT TIME ' ❑ PATIENT ❑ DIRECT O OTHER rj) CALL BACK 0: AMBULANCE COMPANY:P N , •— ti PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: -5/0 RESPONSE ZONE tl ❑ YES NO ❑ WAUIED GUERNEY O OTHER QQ -^, PATIENT CONDITION: DRIVER_ 4-Jo A (k c-4 3BOE::MT-A 77 TECHNICIAN R ( h et-4-, 130 PARAMEDIC Hx DISPATCHER: HQ'Q LGAM 100 (f I CHIEF COMPLAINT: %/�• DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: ct PRIVATE INS. CO.: BASE RATE: - I KAISER#: MULTIPLE PTS. BASE RATE �BBLUE CROSS N: _ TOTAL MILES: �� X �o �J —� - •' (MEDIC' E's; c� C( •� L) / J E.O.B.ATT. ROUND TRIP: 11 YES ❑ NO �~ ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: �� �t ' MEDT-CAL a: CODE 2/3 J r/ �(t OTHER: OXYGEN: (PER TANK) 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 DRUGS: (PER ADMIN.) X NAMEvt-91 M�? �i // RELATIONSHIP:- /��/�w E.O.A.: (IF NOT REPLACED) ADDRESS:1 / 7`� f)(rr �,-t. It: Ll Rd.. / ORAL AIRWAY: (IF NOT REPLACED) CITY:-J��—_ �___ STATE_CIP0 ZIP: C-COLLAR: (IF NOT REPLACED) - - PHONE: l j Y" rr T WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - 7 ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: Z r S'R TOTAL: ��...: ' ___•__ Y. `7yc, '/4l. I04�I rf r-(—,,C i.�of m YY � — PATIENT RECEIVED BY: n•^ni dr- •� . Vh•• ..i . (SIGNATURE) -r� 4rtar• Yr" .. - �+• vhln Pilin; OIS-1 CONTRA COSTA COUNTY AMBULANCE 3 vi PRE-HOSPITAL CARE FORM I UNIT ` Aur ORIZATION N_ CHECK OR FILL IN APPROPRIATE SPACES DATE:1— 147- o 3 j 7 J 'PATIENT'S NAME ❑ M O F COMPANYN /+ I ADDRESS:. ^"'�' AGE1 C �� CITY STATE_ ZIP DOB ❑ Sn O M ❑ T ❑ W ❑ Th F ❑ S DRIVER'S LICENSE N � - � PHONE NATURE OF DISPATCH�T— • TYPE OF TRANSPORT:] AMBULANCE O OTHER❑ _ STATION 1(A)_2(8)-3(C)-4(D)_5(E)._ s t 1 ' RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) iNCIDENT�LOCATiON:; J e 11 I.. TO SCENE- X S.O. CALL RECEIVED Do(..c.. (L- ) GL�.� ❑ P.O. TIME 10-8 PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10-97 ' ❑ PSAP TIME 10-49 CRY zznr; n )`) MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 •DOCTOR LLLL PMD/ER START TIME 10-22 HOW CHOSEN: _ TOTAL STANDBY TIME .❑ NEAREST •n. ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANn- /� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ HH ❑ YES ❑ NO .� O WALKED ❑ GUERNEY O OTHER s PATIENT CONDITION: DRIVER 2 L-2 EMT-IA • ) TECHNICIAN �CeqI (DSS_ PARAMEDIC Hx: SQA � ?S. DISPATCHER: AT LY EOOP, ZHf? CHIEF COMPLAINT: Q Z �� C DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 853THOR T N F R 0,E �Y RUtJ•(E USE ONLY) , P .i�J;� PATIENT REFUSED SERVICES: (SIGNATURE) X T MEDICAL COVERAGE:. . . . I 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 N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#:;' f I EMERGENCY RUN: MEDI-CAL N: ' CODE 2/3 OTHER: t' 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) Gv �-EMPLOYER: OCCUPATION: OTHER: j' ADDRESS: lr CITY: STATE: ZIP: t� "'COMMENTS: TOTAL: �Z f 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME LLr._/_/JYI-n7/?/;� FL�oi�/ 'M ❑ F COMPANY/# ADDRESS --b4'� (�1_�� �/, � AGE / CITY A STATE/_11_±_ ZIP�'(_ DOB/_': ❑ Sn ❑ M ❑ T ❑ W ❑ Th !s F Os- DRIVER'S LICENSE ft _�.4 L� / PHONE J35--5_. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ --.__ STATIO 1(A) 2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: (,) I. `� RESPONSE CODE: ED BY: TIME– (24 HOUR CIL K) TO SCENE- S.O CALL RECEIVED TIME 1G-8 PATIENT DESTINATION: FROM SCENE FIRE TIME 10-97 n3 C ❑ PSAP TIME 10-49 p� MILEAGE: ❑ OTHER/PVT TIME 10-747 END _ TIME 10-98 DOCTOR _ �_�� PMD/ER START I TIME 10-22 r HOW CHOSEN: TOTAL STANDBY TIME ❑ AREST ❑ FAMILY ❑ TRANSFER / WAIT TIME __ + PATIENT ❑ DIRECT ❑ OTHER �') CALL BACK#: AMBULANCE C M ANY: 1 ..1 PT. AM TORY? PATIENT TAK N 0 AMBULANC IO RESPONSE ZONE---(,,±' ❑ YES NO ❑ WAL`,ED GUERNEY 13 OTHER J 9Q PATIENT CONDITION: DRIVER. �Dm ill? TECHNICIAN I � �/1� PARAMEDIC 1 Hx:'f ok I`k-A,_ �l/C�/`✓J C/PiYt� DISPATCHER: loo 1CHIEF COMPLAINT: DRY RUN: ❑ YESXNO REASON FOR DRY RUN � AUTHORIZATION FDRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES' (SIGNATURE) X— - MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAIS9R K: MULTIPLE PTS. BASE RATE 1 BLUE CROSS#' TOTAL MILES: X MEDI�ARE#: I E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �6—����� CCHP/7HP#: EMERGENCY RUN: sw•w Q I MEDI-CA4#T CODE 2/3 1 Ir 1 OTHER: OXYGEN: (PER TANK) G7 I !! P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) (!:lid 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: OTH15R: r ADDRESS: _ s ,-•, i. . /pf /I CITY: STATE: ZIP: -- COMMENTS: AJ ,�c� ,Fyfe:!? E!(�. ✓ TOTAL:C`�Y. D _ PATIENT RECEIVED BY:X Prnr•idrr rv•.a - V4••, c vr• •, �� (SIGNATURE) -y J� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: •� /_ PATIENTS NAME K ff Tnl iH F 5 JrM ❑ F COMPANY 10 <I ADDRESS QAGE CITY yf"' /.s -,10►J STATE C ZIP j S 9—� DOB (_'- 140 Sn O M ❑ T O W O Th CXF ❑ S DRIVER'S LICENSE N ___ _______._ PHONE;5 - 5Y S_Y 3 1-7 NATURE OF DISPATCH L 'h IC L' TYPE OF TRANSPORT: AMBULANCE THER❑ STATION 1(A)_2(B)_3(C)_41D)_5f0A_ INCIDENT LOCATION: - - RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE - KZS.O. CALL RECEIVED dfwr ❑ P.U. TIME 10-8 PATIENT DESTINATION: All FROM SCENE- ❑ FIRE __ TIME 10-97 IPAL/' 2— 13PSAP TIME 10-49 r---- '1`T I �'7 { �] MILEAGE: ❑ OTHER/PVT TIME 10-7 END ' TIME 10.98 DOCTOR ��°`v t' IZ N PMD ER START 7 a . TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT XDIRECT ❑ OTHER L` ' CALL BACK N: AMBULANCE OMPANY: PT,�AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE '~ YES ❑ NOW ALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER TECHNICIAN��i1 ���� r PARAMEDIC Hz: Awa !�-�� • DISPATCHER: 7 ? CHIEF COMPLAINT: rl�h i LLL ' OS DRY RUN: ❑ YES )VNO REASON FOR DRY RUN L�!'1,.� ni P ( -r �= U� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED S VICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES k'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 N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 45 O YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN: ? , J 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 (r'cf DRUGS: (PER ADMIN.) X NAME: G Q `leT RIC 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: G !W r t /• .�CJ~` Z i Y TOTAL: -----� -�7O PATIENT RECEIVED BY: X �t,��� _ (SIGN!TUBE) P CONTRA COSTA COUNTY AMB AN`�E- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION I qt oz CNECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME � ❑ M �F COMPANY N ADDRESS 6 AGE CITY TATE C� ZIP DOB3 2 ❑ Sn ❑ M OT OW O Th OF OS DRIVER'S LICENSE N ___..__.-_� PHONE933-�3.6.� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER STATION I(A),2(B)_3(G) 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOU� D BY: TIME- (24 HOUR CLOCK) TO SCENE �Q'S O. -_ CALL RECEIVED l uYI�-1 O P.U. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ` ❑ PSAP TIME 10-49 MILEAGE: 13OTHER/PVT TIME 10-7 END,rzo, � TIME 10-98 e" i DOCTOR PMD6) START TIME 10-22 HOW CHOSEN: / TOTAL A STANDBY TIME . 0 NEAREST -_ FAMILY O TRANSFER ( ( _ WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER `= CALL BACK N: AMBULANCE COMPANY:^ PT. AMBU ORY? PATIENT TAKEN T AMBULANCE: RESPONSE ZONE ❑ YES L NO ❑ WAl'<ED d ""�RNEY ❑ OTHER r PATIENT CONDITION: DRIVER I' EMT-1A " + TECHNICIAN Y PARAMEDIC Hz: DISPATCHER: CHIEF MPAINT: I r DRY RUN: ❑ YES 11 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SER ICES: (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 ME ICA E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES .O NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: �(J./ MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) n•a l•J P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) r \ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 3.3 / DRUGS: (PER ADMIN-) X NAME: IM /� �1,L'L� RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) 7 57 CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) �( PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: el NITS: h o C E J Q TOTAL: ss c � PATIENT RECEIVED BY X _ _....1L^' v !'f•rrridor• tvrui.: Whit, r! +' .q,I, 4alr.r• :. .. �L .,J 1�! rn� (SIRN,#TURE) LRS•1 Y�JC I r � • � Y CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N / J 77 DATE: OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME`' / l ❑ M O F COMPANY M Z O ADDRESS - ' S YAGE4\ U. ole 'l, CITY t -STATE ZIP DOB ❑ Sn ❑ M O T OW ❑ Th OF KS'" DRIVER'S LICENSE M ) PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:. AMBULANCEOTHER 0 4STATION I(A)_2(B)_3(C)_4(D)_5(E)_ - INCIDENT LOCATION: RESPONSE CODE a REOUESTED BY: TIME- (24 HOUR CLOCK) I l, l -� TO SCENE- PkS.0, CALL RECEIVED _ :3 ZL ❑ P.D. TIME 10-8 `2 PATIENT DESTINATION: ! , FROM SCENE- ❑ FIRE _ TIME 10-97 A ) , ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 I ,,• END TIME 10-88 R"06CTOR I-- ` `1 I PMD/ER START ' TIME 10-22- 4 0-22:e ` HOW CHOSEN: TOTAL STANDBY TIME �. : D NEAREST--r ❑ FAMILYO TRANSFER ' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J RESPONSE ZONE _ ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: y DRIVER CFfAT=T7t� TECHNICIAN �p ` "/0 PARAMEDIC Hx: DISPATCHER: & CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ 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: _ S.S.« '` I PRIVATE INS.CO.: BASE RATE: KAISER R: I MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE C. E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP C11 I I- ' EMERGENCY RUN: MEDI-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: - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: r 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: t �co/ PATIENT RECEIVED BY:X Pr+uf,�rrr lvtif� �4it• ,-d r•.,, ,r.,, p,,,, ISIGNAIIIRE) s f CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 [--CHECK OR FILL IN APPROPRUtf SPA CFS DATE: PATIENTS NAME to �� � � �� ' ❑ M ❑ F COMPANY 0 ADDRESS LL'S f, S e2 � ) C AGE — U 1 i CITY STATE ZIP ZIP T---T— DOB ❑ Sn ❑ M ❑ T ❑ W O Th ❑ F ❑S I c DRIVER'S 06ENSE M (- r PHONE NATURE OF DISPATCH ��'+��• - TYPE OF TRANSPORT:t AMBULANCE OTHER 0 STATION 1(A)-._2(8)_3(C)_4(D)-5(E)_ INCIDENT LOCATION' S,` RESPONSE CODE: RE06ESTED BY: TIME— (24 HOUR CLOCK) I C V 7 I 0 w� /f� � TO SCENE- 'l S.O. CALL RECEIVED �_ 1.3 A Y •.r, tc( , ( /L� P.D. TIME 10-8 PATIENT DESTINATION: .... FROM SCENE:& ❑ FIRE TIME 10.97 l; Jp ❑ PSAP TIME 10-49 Q P I``��'��t•,y - �i%� �� t+ �,•� 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 1 i END TIME 10-98 :1.DOCTOFkl -2 " 3 �) PMD/ER START TIME 10-22 L HOW CHOSEN: _ TOTAL: STANDBY TIME j ❑ NEAREST;- O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCCOMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1( RESPONSE ZONE- ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER I i PATIENT CONDITION: I DRIVER YL ' n I iy AT- `1I`{ r- TECHNICIAN _—�4 ✓4 y/7 '1 J r PARAMEDIC Hx: DISPATCHER: /" T If (' ��� CHIEF COMPLAINT: G DRY RUN: 13 YES ❑ NO REASON FOR DRY RUN UTHORIZATIO F R DRY UN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATyIRE) X40-6 t I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO.OF PATIENTS; S.S. N ( ; PRIVATE INS.CO.: BASE RATE: E KAISER M: , MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE 0; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#:r' EMERGENCY RUN: MEDI-CAL N; CODE 2/3 C 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) q PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) w EMPLOYER: OCCUPATION: OTHER: ADDRESS: t CITY: STATE: ZIP: COMMENTS: TOTAL: D PATIENT RECEIVED BY:X Provider tvtnih Vho. .f Pi.:: (SIGNAruAE) Inti-� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ,-7 AUTHORIZATION M (Y I CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME�'lJ'�` �� DI�( O M F COMPANY M ADDRESS � ( �' _—� AGE ZI Cr, /,3 .:P9 D CITY_-0r / G�IL) STATE Cf, ZIP 00R 13❑ Sn ❑ M ❑.T ❑ W ❑Th OF PN DRIVER'S LICENSE a _ _ PHONE_ `�_�—� NATURE OF DISPATCH' ���� It-(1$ ('Q('• TYPE OF TRANSPORT: AMBULANCE O OTHER❑ .__ — STATION }(A)_2183_3(Cy-4(D)_5(Ey INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCE E- S.O. CALL RECEIVED J ❑ P.D. TIME 168 PATIENT DESTINATION: FROM $ ENE- ❑ FIRETIME 10 97 tI v ❑ PSAP TIME 10-49 L MILEAGE: ❑ OTHERIPVT TIME 10-7 END� TIME 10.98 DOCTOR <i' PMD/ER START TIME 1D-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER — WAIT TIME _ ❑ PATIENT ❑ DIRECT 17 OTHER 7 l CALL BACK p: AM ULA ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ �'jC� RESPONSE ZONE + YES ❑ NO ❑ WAL KED UERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER EMT-IA TECHNICIAN L C. / PARAMEDIC ( Hx: DISPATCHER: i`i r / ( i If '' • CHIEF O LAINT: ' 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.R Kd PRIVATE INS. CO.: BASE RATE: r> KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: — X MEDICARE tt: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ' ❑ YES ❑ NO NIGHT: (19:00-07:00) � �� CCHP/PPRP#: _ EMERGENCY RUN: `,1 MED(-CAL a:__�o LCL., CODE 2/3 l OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO ' BILLED CO. NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) APR 4 5 d E.K.G.: (PER EPISODE) NEAREST FLAT VE/RESPONSIBLE PARTY: // I.V.: (PER ADMIN.) X ��I �.. DRUGS: (PER ADMIN.) X NAME: LJ RFI TIONSHIPQJV E E-O.A.: (IF NOT REPLACED) - ADDRESS: ' h 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: L Ll ` TOTAL:— -s --- - " c. PATIENT RECEIVED BY:X Provider reta-'r. White -r.1 M-: "Pi, -Srfum Yf:tuw Mp. t• RIS whin bit i•ip (SIGNATURE) UIS-i CONTRA COSTA COUNTY AMBU_LLAN_C_E_ PRE-HOSPITAL CARE FORM I UNIT I {�� ) AUTHORIZATION N 3 LI J .1• -., . .. I .. .t' _ CHECK OR FILL IN APPROPRIATE SPACES DATE: ._�r I PATIENTS NAME , ,r y' lJ O M ❑ F COMPANY 0 ADDRESS • ! AGE1 I L) :L/ CITY STATE ZIPS_. DOBE_ - ❑ Sn ❑ M OT ❑ IN E3 3]Th ❑ F ❑ S - DRIVER'S LICENSE M PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCETHER 1) �� _ STATION 1(A)_2(B)_3(C)_4(D)_5(E CNI- INCIDENT LOCATION:' ( RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- �S.O. CALL RECEIVED 41 10'*P.D. TIME 10-8 PATIENT DESTINATION: - FROM SCE E - ❑ FIRE TIME 10-97 " ) ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 T . r - END TIME 10-98 � PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ''^_r•❑ NEAREST,'D ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER Li CALL BACK 0: AMBULANCE COMPANY: C'J4 S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO.., ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER L'�' EMT-1A ')d116t' _� TECHNICIAN <l i' PARAMEDIC Hx: _ - DISPATCHER: (. q q CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN (II�p 7 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 R: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE R: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES •❑ NO NIGHT: (19:00-07:00) CCHOIPPHP N:" ► EMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) C P.O.E. STICKER 11YES 13NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RES ONSIBLE PARTY: — LV.: '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: -- PATIENT RECEIVED BY:X ISIONAT(JRE) CONTRA COSTA COUNTY AMBULANCE r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# r A v1 CHECK OR Flll INAPPROPRIATE SPACES DATE:._ PATIENTS NAME I�f��- �///L Z)A �/9 ❑ M t(F COMPANY# / =% ADDRESS f ,ZI AGE`` l CITY STATE— ZIP ' DOB L'�v J ❑ Sn 13M ❑ T ❑ W,❑ Th O F XS DRIVER'S LICENSE# �_`___._�...___�_. PHONEr �> 1. /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) n TO SCENE- _ ❑ S.O. CALL RECEIVED ❑ P.U. TIME 10-8 / PATIENT DESTINATION: FROM SCENE- ❑ FIRE — TIME 10-97 :1 ❑ PSAP TIME 10-49 MILEAGE: �'VOTHER/PVT/ TIME 104 /J END s J rl c .n TIME 10-98 DOCTOR /jL`L V PM ER START TIME 10-22 HOW CHOSEN: TOTAL �, STANDBY TIME ❑ NEAREST ❑ FAMILY 'TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER I CALL BACK#: AMBULANCE C MPANY: PT. AMB TORY? PATIENT TAKETC,AMBULANCE: 1 I I RESPONSE ZONE , . ❑ YES�NO ❑ WALKEDERNEY ❑ OTHER PATIENT CONDITION: DRIVER �1/�/y2 ,� •f L / +� TECHNICIAN /2,0 PARAMEDIC j Hx: INA SOL-f'S DISPATCHER: I = /J CHIEF COMPLAINT: oZ c/Il SQA/.J DRY RUN: 13YES ) NO REASON FOR DRY RUN L'v7 4-,f ��`�LL'/0 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: /lJ•C d KAISER#: MULTIPLE PTS. BASE RATE 'T BLUE CROSS# TOTAL MILES: Y7 ME �2 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) I CCHP/PPRP#: EMERGENCY RUN: MEOI-CAL#:L',�'' �' C-'� ` f `� CODE 2/3 -� OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES. ❑ NO NEONATAL: (INCUBATOR)' 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: �OMMENTS: TOTAL: fes. I I PATIENT RkCEIVED bY: X hvvidor rlta:r, White r.n-7 I i•.• pp yol,,,", I. •• „ (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION • ,b !7. CHECK ON llll IN APPROPRIATE SPACES ) OATE: }PATIENTS NAME Y f �/ O "1, ❑ F COMPANY N ADDRESS- ' AGE— CITY GE i U/V CITY V -STATE�T�-���ZIP DOB ❑ Sn, O M OT OW O Th OF DRIVER'S LICENSE N _ • I ' - PHONE �--r NATURE OF DISPATCH A6-lz! Lg = _ i TYPE OF TRANSPORT:)AMBULANCE 0 OTHER❑ STATION 1(A)_2(B)_3(C).-4(D)_5(E)_ ' INCIDENT,LOCATIOW: fi:.. RESPONSE CODE REQUESTED BY: TIME- (24 HOUR CLOCK)/ TOE S.O. CALL RECEIVED O P.D. TIME 10-8 PENT DESTINATION: . __1 FROM NE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10 49 a, Z:�r� r1 i ,+ MILEAGE: ❑ OTHER/PVT TIME 10-7 :T_ END TIME 10-98 / U 1 DOCTOR '7 %' f- ~- PMD/ERI START TIME 10.22 �- HOW CHOSEN: TOTAL STANDBY TIME 2T.A_ 13 NEAREST-,.;iO FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: l;l RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-tA _ TECHNICIAN �� �� PARAMEDIC �-�- Hz: - DISPATCHER: q"" CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN SS AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUS SERVICES: (SIGNATURE)'X n,- 9Sa'' MEDICAL COVERAGE: .- 1 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 N: E.O.B.ATT. ROUND TRIP: ❑ YES t7 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 '❑ YES ❑ 0 NEONATAL: (INCUBATOR) C DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) `-"NEAREST RELATIVE/RESPON IBLE 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) L� Cil EMPLOYER: OCCUPATION: OTHER: ADDRESS: - CITY: STATE' ZIP: ---'COMMENTS: TOTAL: ` '�� 1V / CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FO I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY M ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F e S DRIVER'S LICENSE# _ PHONE ____-- NATURE OF DISPATCH l 1 9 - TYPE OF TRANSPORT: AM13ULA}N�CE OTHER❑ _ INCIDENT LOCATION: C '-C RESPONSE CODE: REOUESTED BY: TIME — (24 HOURCL CK)� I 7) TO SCENE- op S.O. __ CALL RECEIVED (L 1 /_','41,42act.Y j slU c&-Pi1�_ ❑ P.U. TIME 10-8 t PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ��— ❑ PSAP TIME 10-49 'n �,,- 6 MILEAGN ❑ OTHER/PVT TIME 10-7 � V �' END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE CO PY: " PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 7 V RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERI EMT-tA S TECHNICIAN— 1 C� PA MEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY I ASON FOR DRY RUN,(D-Z2 / / AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: _s 9l� S.S. # 1 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/PPHP N: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 C-1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER 13 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 PATIENT RECEIVED BY:X_ 1 i'r•r,l,{nr r,.._:.. :a:... (SIGNATURE) F_• I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION Op_ •I I CHECK OR'F/LL IN APPROPRIATE SPACES DATE: `O •� ,-,- :? ATIEfJ7'S'NAME_ "� � c_9!=If- M ❑ F COMPANYp __.cL I cy ADD9ESS — ---- — 1 -- AGE — O 1 CITY._. � _ STATE_C A_ ZIP_— DOBO Sn Ofd{ OT ❑ W O TTh OF .Ir$' DRIVER'S LICENSE d _-. PHONE_.—__.` KTP NATURE OF DISPATCHZLv� TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CI,#CK) TO SCENE S.O. CALL RECEIVED "f/— / O P.D. TIME 10-8 i PATIENT DESTINAT N: FROM SCENE- ❑ FIRE TIME 10-97 " _ T ❑ PSAP TIME 10-49 .;�._._-- O `_ MILEAG . ❑ OTHER/PVT TIME 10-7 END _ _. TIME 10-98 ` DOCTOR _ _. PMD/ER START TIME 10-22 T HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCY: ) PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL°:ED ❑ GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER-7�-A/ t C EMT-1A TECHNICIAN c PARAMEDIC Fix ._—_-�--___--_-- DISPATCHER: C CHIEF COMPLAINT: ___-__.__.___ ____ _ DRYRU 6 YES NO REASON FOR DRY RUN Pr!;—. ±a Rr T�T AUTH ZklT bC N F DRY�IJN(E�jO Y) PATIENT REFUSED SERVICES: (SIGNATURE) X'< - -- c�l; MEDICAL COVERAGE: INDUSTRIAL 0 YES ❑ NO NO. OF PATIENTS: S.S. a I PRIVATE INS. CO.:— _ BASE RATE: _..! KAISER It: ____ MULTIPLE PTS.BASE RATE - 1 BLUE CROSS t7 _. —__-- TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: D YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) { CCHP/PPRP a: _—^ EMERGENCY RUN: MEDT-GAL#: -- 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) J .NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X V 1h' - RUGS: (PEA ADMIN.) X •:. NAME - ��-2 L-� __.__ ._— ATIONSHIP: __ 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:- r t COMMENTS: �✓ _ TOTALcl Q Q(� -• PATIENT RECEIVED BY:X . .. providrr rrtar� wh:t, ,.rd pini. rCJL Fxrtuf+' lv';.;r p:' t n!." ��han t'1'ina (SIGNATURE" as-I CONTRA COSTA COUNTY AMBULANCE , 1 PRE-HOSPITAL CARE FORM I UNIT Z ' AUTHORIZATION N 1 1 CHECK OR fill INAPPROPRIATE SPACES DATE: l , 'PATIENTS NAME O M 13F COMPANY N _ ADDRESS.- � I - AGE CITY r- STATE__.. ZIP DOB O Sn O M ❑ T O W O Th OF L7 S DRIVER'S LICENSE 0 PHONE _ NATURE OF DISPATCH TYPEOFTRANSPORT:1 AMBULANCE OTHER 0 _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)-._ INCIDENT LOCATION:{ RESPONSE CODE: REOIJfSTED BY: TIME— (24.HOUR CLOCK) 7 0 TO SCENE- CALL RECEIVED No ❑ P.D. TIME 10-8 PATIENT DESTINATION:_ ; T� FAL, FROM SCENE O ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 (,I An-fil•7 ?�= =�? _ MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10-98 t` PbOCTOR'15; r PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME e i.,❑ NEARESTI ,� O FAMILtY ❑ TRANSFER ` WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY:�� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J U RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A_ , DA 18 _ TECHNICIAN ��" ® "` � PARAMEDIC Hx: - DISPATCHER: • CHIEF COMPL�INT: I DRY RUN: ES ❑ NO REASON FOR DRY RUN h O 1 h\J•-1 AUTHO A ON FOR DRY RUN (EMS USE ONLY) ii,:it PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE- .. INDUSTRIAL O YES'O NO NO.OF PATIENTS: 9C l/ I S.S. N I J PRIVATE INS.CO.: I BASE RATE: KAISER 0. MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: j E.O.B.ATT. ROUND TRIP: ❑ YES O NO ❑ YES .fl NO NIGHT: (19:00-07:00) CCHP/PPRP 4:1` EMERGENCY RUN: MEDT-CAL N: ) I I ' 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: PATIENT RECEIVED BY:X (SIGNATURE) LMS-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION x U J CHECK ORME IN APPROPRIATE SPACES GATE: � I PATIENTS NAME 1 n 2 ❑ M ❑ F COMPANY N ADDRESS AGE / o CITY STATE ZIP DOB 0 Sn 0 M O T O W O Th O� O S DRIVER'S LICENSE M _ _ PHONE __ _ NATURE OF DISPATCH— TYPE ISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ __ STATION 1(A) 2(B)_3(C)_41D)_5(E)_ IL INCIDENT LOCATION-. I D �(,5yt'r RESPONSE CODE: RSUESTED BY: TIME- (24 HOUR CLACK) f� TO SCENE - .O. CALL RECEIVED V Y_-7 NnM67Gt 3 ❑ P.D. TIME 10-8 I PATIENT DESTINATION: FROM CENE -v 0 FIRE TIME 10-97 0 PSAP TIME 10-49 I t MILEAGE: ❑ OTHER/PVT TIME 10-7 1 END TIME 10.98 'DOCTOR I PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY ❑ TRANSFER WAIT TIME 0 PATIENT ❑ DIRECT 0 OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE------- 0 0 YES O 0 WALKED 0 GUERNEY 0 OTHER � '1 ' _ PATIENT CONDITION: DRIVER Gu (.`� IEMT-tA 1 I"T '°'' TECHNICIAN /, M'`� ARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: t DRY RUN/ATION YES 13 NO REASON FOR DRY RUN ' - q'I / AUTHORI FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ,( MEDICAL COVERAGE: INDUSTRIAL 0 YES W NO NO. OF PATIENTS: S.S.M PRIVATE INS.CO.: BASE RATE: I KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES 0 NO ❑ YES ONO NIGHT:(19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 0 NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) cl 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) O PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) ` EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: a STATE: ZIP: COMMENTS: A)O A-inn A AJ TOTAL: �✓ PATIENT RECEIVED BY:X (SIGNA URE) Pmoider rvrr.'� L'hitr «a n:.:1 .••.r. c,.•.,._, v. " ,. . r„- ,..:-.. ... [Mc- CONTRA COSTA COUNTY AMBULANCE '� PRE-HOSPITAL CARE FORM I UNIT ( p� AUTHORIZATION#3�\ CHECK Op FILL IH AP/Pp1'OPR1AiE SPACES DATE: l /1 PATIENT'S NAME O M ( F COMPANY N ADDRESS �/[---_y\l \f` 06-10 r AGE CITY.__��U�VLC `STATE�-- ZIP OB�� 5 Sn ❑ M O T ❑ W ❑ Th ❑ F 19(s DRIVER'S LICENSE# _�.2_U �. UPHON61!��� NATURE OF DISPATCH'�� TYPE OF TRANSPORT: AMBULANC E11 OTHER❑ __ _ STATION 1(AY—'\2(B)-3(C)-4(D)-5(E)— 1 INCIDENT LOCATION: N 1 ( RESPONSE CODE: RE UESTEO BY: TIME— (24 HOUR C K) —56 �C�� 7 r� TO SCENE- .0. CALL RECEIVED -J ` `�( ❑ P.D. TIME 10-8 PATIENT DESTINATION: / FROM SCENE-/� ❑ FIRE TIME 10-97 !! O PSAP TIME 10-49 -5 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR -- �' PMD/Io START TIME 10-22 HOW HOSEN: TOTAL STANDBY TIME EAREST ❑ FAMILY ❑ TRANSFER / WAIT TIME /////Q PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE�CObAP!ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `> RESPONSE ZONE IV YES ❑ NO ❑ WAL ICED P GUERNEY ❑ OTHER 4D PATIENT CONDITION: DRIVER t `�Eh� -tA TECHNICIAN ' PA MEDIC Hx: —��l_�� DISPATCHER: � Ly CHIEF COMPLAINT: V-"LC_=SL1 l DRY RUN: O YES WNO REASON FOR DRY RUN - t'� -`�L\ I AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL O YES10 NO. OF PATIENTS: S.S. #_ c) - PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE _ \BLUE CROSS#: TOTAL MILES: X �0 MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO `• ❑ YES .O NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: ;O•Gc� 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 ''`` I % DRUGS: (PER ADMIN.) X NAME:l,o Z" 1 A- -a-?'JELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:1_ .T `�J_��' ) ORAL AIRWAY: (IF NOT REPLACED) CITY: N(�ll �[� '_ STAT �—( ZIRPL3yy C-COLLAR: (IF NOT REPLACED) - PHONE:' F�7 6 S6 WORK PHONE: DRY RUN:. (AUTHORIZED) EMPLOYER: () F OCCUPATION: �' OTHER: r CITY: N(�) F�-� STATE: �I 'ZIP: �J - COMMENTS:__—; ,\ L TOTAL: 6v ol PATIENT RECEIVED G AT RE) Provt:dr,r Ntu[r, White rrd 1'iri ropy 4c•>a+i YF:i„�� rnpp t "Cohen bf1'ina CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITAUTHORIZATION M�-s DATE: A-"ao- �3 { CHECK OR FILL IN APPROPRIATE SPACES PATIENTS NAME �M, ❑ F COMPANY M ADDRESS• AGE ", CITY STATE zip.ZIP DOB O Sn OM OT OW O Th ❑ F XS DRIVER'S LICENSE 1I _ PHONE _— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ STATION 1(A)_2(B)-3(C)_4(D)_5(E)_ INCIDENT;LOCATION:. - 4- RESPONSE CODE: �REQUESTED BY: TIME- (24 HOUR CLOCK) -17 1� ' TO SCENE- CALL RECEIVED Yl/ool O P.O. 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 P DOCTOR +' ' ~�� PMD/ER START TIME 10-22 HOW CHOSEN: 1� TOTAL STANDBY TIME ?1► D NEARESTr:. 4 FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE C MP Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �(7 RESPONSE ZONE_�� ❑ YES El NO_ ❑ WALKED 13 GUERNEY ❑ OTHER PATIENT CONDITION: - DRIVER I 1 eT' !�YG�17 PARAMEDIC TECHNICIAN ,,�_— ' Hx: / l� DISPATCH 0 0 C F COMPLAINT: A i �G DRY RUN: ES ❑ NO REASON FOR DRY RUN 7.23 T, "9 d C F/a �l HORIZ TION�OR D RU (EM USE ONLY) �� nu A� PATIENT REFUSED SERVJCES: (SIGNATURE) f f�� /r �c� MEDICAL COVERAGE.. INDUSTRIAL ❑ YESt9alO NO. OF PATIENTS: S.S. N 1 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: D YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N:` ' I EMERGENCY RUN: MEDT-CAL 8: CODE 2/3 { OTHER: I OXYGEN: (PER TANK) P.O.E.STICKER D YES_13 NO NEONATAL: (INCUBATOR) DATES BILLED: 1 STANDBY: (OVER 15 MIN.) f 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) tZL�'Ll EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X `•- r�1�r.;;i�=11Rn i \ ( |' 73CONTRA COSTA COUNTY AMBULAN(;Z INCIDENT LOCATION. RESPONSE CODE. REOUESTED BY: TIME- (24 HOUR CLOCK) PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIA TE SPACES DATE: C-D DRIVER'S LICENSE PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC��THERCI TO SCENE )!j's.o. CALL RECEIVED C�/ 0 P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10-97 .-g PSAP TIME 10-49 ___G_ s H. 1(, 0 OTHER/PVT TIME 10-7 MILEAGE: 5 El ID TIME 10-98 (Zr NEAREST 0 FAMILY 0 TRANSFER WAIT TIME PATIENT DIRECT 13 OTHER CALL BACK AMBULANCE COMPA" PT AMBNL�,:;ORY,7 PATIENT �EN T�AMBULANCE RESPONSE ZONE n 0 YES 0 WAL!,E�D PINEY 0 OTHER PATIENT CONDITION: DRIVER CHII M DRY RUN: .0 YES REASON FOR DRY RUN AUTHORIZATION FOORIDRY R4N 1EIMS llEolLY L COVERAGE: INDUSTRIAL YE NO. OF PATIENTS: ^+~�_ � rsws co BASE RATE: -_-_-_ �u���u� ' . KAISER MULTIPLE PTS. BASE RATE BLUE CROSS# TOTAL MILES: x ` ROUND TRIP: Ovsa [] mo u ,sn uwo NIGHT: nyoo'orom -_-__- ^-.40-0 L ( / ~. sMsnoswcvnuw�� : ... �. . ... ' �-.._--- rl CODE o/o � oxvosm: (PER TANK) IrFa u YES u NO NEONATAL: (/wooaAron) DATES BILLED: erAwoav: (OVER 1om/m) ---_--- --_-__ sxo' (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: /v.: (PER ADMIN.) x onuoo: (PER ADMIN.) x __-__- ----_-- NAME:_ RELATIONSHIP:- soA,: (IF NOT REPLACED) onAL AIRWAY: (IF NOT REPLACED) --_---' ___--- c'oouxn: (IF NOT REPLACED) DRY RUN:PHONE: WORK PHONE: (Aur*On/Zso)EMPLOYER: OCCUPATION:-- or*sn: rorAL: ~~/ ��( '-'-�������� _�~�' pxr/swTnsoswsoe� *\��_ _ � , � �^ ^»,�,_ ~����'.� .' ,, �,` `'',_ ~_ ��mA/v°E/ ox�� CONTRA COSTA COUNTY AMBULANCE 'Pit PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION .• CHECK OR FILL!M APPR PRIATE SPA s , � DATE: PATIENTS-NAME OM O F COMPANY# ADDRESS I AGE — (� 2 V 1 CITY STATE ZIP DOB - ❑ Sn OM OT OW ❑ Th OF OS DRIVER'S LICENSE# PHONE NATURE OF DISPATCH - TYPEOFTRANSPORT: AMBULANCE 0 OTHER 0 STATION I(A)_2(B)_31C)_4(D)_5(E)_ INCIDENT L CATION::' RESPONSE CODE' REQUESTED BY: TIME— (24 HOUR CLOCK) / TO SCENE- .0. CALL RECEIVED ;._ 0y P.D. TIME 1D-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 ' r MILEAGE: ❑ OTHER/PVT TIME 10-7 y END TIME 10-98 DOCTOR ' PMD/ER START TIME 10-22 " HOW CHOSEN: 1 TOTAL STANDBY TIME i ❑ NEAREST 13 FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT O DIRECT O OTHER CALL BACK C AMBULANCE COMPANY,L, PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 7 RESPONSE ZONE .�. ❑ YES ❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION:. DRIVER s EMT-1A ' _ .. . i , TECHNICIAN u PARAMEDIC Hx: DISPATCHER: — Z' u CHIEF COMPLAINT: DRY RUN: OYES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4 l 5 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: J . S.S.# 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: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP%PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) 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 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: 12F1 rs PATIENT RECEIVED BY: X C, (SIGNATURE) ►hc CONTRA COSTA COUNTY AMBULANCE ° PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION K I CHECK OR FILL INAPPROPRIATE PTCES DATE: � 1 PATIENTS NAME_�-- n zM �J F COMPANY M ADDRESS I Ldp /`` CITY �5 73 STATE ZIP-CL Y DOI31Q+Lv ❑ Sn ❑ M ❑ T.❑ W ❑ Th ❑ F DRIVER'S LICENSE N __V .lL�-. lIP ..__ PHONE 3 5-E l G v NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANr'c'FI OTHER❑ _.-. --_---_.._. STATION 1(A)_2(8)___.3(C)_4(D)_5(E)_ 77 INCIDENT LOCATION: G RESPONSE CODE: RES O STED BY: TIME-CALL RECCE VEDR CLOCK) w y � /_' = ^! 7- � f��� TO SCENE ❑ P.U. TIME 10-8 PATIENT DESTINATION: (/ C F/ FROM SCENE - ❑ FIRE TIME 10-97 : y� I•��� /� � � _ ❑ PSAP TIME 10-49 ' MILEAG� 5 ❑ OTHER/PVT TIME 10 7 A �� / , END TIME 10-98 DOCTOR T /I PMD(ER / STA RT TIME 10-22 HOW CHOSEN: �`� TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT 61k OTHER I C 14� CALL BACK M: AMBULANCE COMPANY: PT. MBULATORY? PATIENT TAKEN O AMBULANCE: RESPONSE ZONE ES ❑ NO ❑ WAL!<ED UERNEY O OTHER PATIENT CONDITION: DRIVER ,�' '�"' 3 EMT-1A TECHNICIAN -�? ~ S PARAMEDIC Hz: ;C DISPATCHER: 7s CHIEF MPLAINT: v�- DRY RUN: ❑ YES " NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YESNO NO. OF PATIENTS: S.S. M x J PRIVATE INS.CO.: V K���^ �' `� BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: 1 X ell ✓� �' Sri MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 3y r ❑ YES "❑ NO NIGHT: (19:00-07:00) 7 �^ CCHP/PPRP R: EMERGENCY RUN: MEDT-CAL N: L/h 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 G ? DRUGS: (PER ADMIN.) X NAM a Iti'C h RELAT10NSHIR � E.Q.A.: (IF NOT REPLACED) ADDRESS: ���Ilb f I;? ORAL AIRWAY: (IF NOT REPLACED) - CITY: STATE-,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _Jb.,g2 h Q OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: `�� J* T� -- - TOTALrfil[l - 1 PATIENT RECEIVED BY. X — ✓ CONTRA COSTA COUNTY AMBULANCE I PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR rftt INAPPROPRIATE SPACES DATE: ^� _ PATIENT'SNAME._L.CI�_/ / /� M ^!� ^ 0 F COMPANY ADDRESS �-_ �-_(7 `-" n/7E-� 1-,/Z (4 AGES_ r ! / J__31 I CITY!�tll'JylL L�= STATE `—�/� ZIP DOB91-� 31 'Sn O M O T ❑ W O Th 13 F Q S ^. DRIVER'S LICENSE u _• _��._-�!_}_`_..' PHONE __-�__ NATURE OF DISPATCH h -' .. _ TYPE OF TRANSPORT: AMBULANCE OTHER❑ _____ STATION 1(A)_2(B)._3(CI__4(0)_5(E)_ INCIDENT LOCAT RESPONSE CODE: RE STIED BY: TIME- (24 HOUR CLOCK) ( ~ TO SCENE- ig S.O._ CALL RECEIVED L, ~••• P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1 ❑ PSAP TIME 10-49 Dr2 �I MILEAG�j� ❑ OTHER/PVT TIME 10-7 1� ENDTIME 10-98 -.: DOCTOR PMD/ER START-7q TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST' O FAMILY O TRANSFER l WAIT TIME I jt3,.pATIENT ❑ DIRECT O OTHER CALL BACK k: AMBULANCE COMPANY - PT VAMBULATORY? PATIENT TAKEN TO AMBULANCE: 5'0 RESPONSE ZONE YES ❑ NO WAL'<ED ❑ GUERNEY O OTHER ll } PATIENT CONDITION: DRIVER `� - EMT-1A TECHNICIAN C-�^S �InO PARAMEDIC _- Hx: -_ DISPATCHER: ►d°r r+ 00 CHIEF COMPLAINT: 1—�1' r 1 Q-1 DRY RUN: ❑ YESNO REASON FOR DRY RUN AUTHORIZATION OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ C. MEDICA.�Cp RAGE: INDUSTRIAL 11 YES NO NO. OF PATIENTS: S.S. # ( PRIVATE INS. CO.. BASE RATE: KAISER c nc �`IL= MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: __A �__, _ •• ( MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES . ❑ NO - O YES ❑ NO NIGHT: (19:00-07:00) J C% rj CCHP/PPHP#: EMERGENCY RUN: qo,Gv AC,d I MEDT-CAL#: CODE 2/3 �?. 00 ' OTHER' OXYGEN: (PER TANK_ P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ! L NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.)- r - DRUGS: (PER ADMIN.) 195.F-C 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: -YZsJ-�Q OCCUPATION: OTHER: - ADDRESS: CITY: STATE: ZIP: COMMENTS: -- \f TOTAL: PATIENT RECEIVED BY: X SL Pmvidrr rrta-• o-ir, .+•I ' � �rt•,r 7• ..- ..► � ►:t ",? (SIGNATURE) OSS-1 l t CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL,IN APPROPRIATE SPACES DATE:.' `�T3 _-,- PATIENTS NAME ) ! L.L'�.! r 1 0 M /F COMPANY# 4� ^, ^, C-0 1- ADDRESS ZZ b.� _ —S!_�1� 1�_S T _ AGE-_! 2 1 f CITY `a ZV STATE�~�` ZIP y S��_ DOB 1q7Z-S_y-JI(Sn Cl M ❑ T OW O Th O-F O S DRIVER'S LICENSE# ______— __.. __..._. _. PHONE . .7 J 7 NATURE OF DISPATCH..�_�—��,� TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ . _______.. .___. _ STATION I(A)_218)_31C)_4(D)_51E)_ INCIDENT LOCATI RESPONSE CODE: REpd'ESTED BY TIME— (24 HOUR CLOCK) N , M / �7 TO SCENE S.O. — CALL RECEIVED > o ❑ P.U. TIME 10-8 y I PATIENT DESTINATION: FROM SCENE - ❑ FIRE —__ _ TIME 10-97 r u ❑ PSAP TIME 10-49 I 1 �7 U L i 1 I _ MILEAGE:/► ❑ OTHER/PVT TIME 10-7 ' D --�� END—`� I TIME 10 98 ' DOCTOR �L�- I /--• PMD/6? START 7 -0 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ CNEAREST Cl FAMILY ❑ TRANSFER i WAIT TIME -- F ATIENT ❑ DIRECT Cl OTHER I., .t. i CALL BACK#: AMBULANCE COMPANY: 155 EABULATORY? RIENT TAKEN TO AMBULANCE: - RESPONSE ZONE 11 NO AL'(ED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVERS "-71 �= �^'j EMT-1A ` TECHNICIAN — PARAMEDIC — Hx: DISPATCHER: h CHIEF COMPLAINT: f-- A r� ('30 11 DRY RUN: ❑ YESNO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN (EMS USE ONLY) C' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL C VERAG INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S # '-�- - 6 -2. Z 1-f5` PRIVATE INS.CO.: BASE RATE: KAISER#: _ MULTIPLE PTS. BASE RATE �3J BLUE CROSS �� �,.�(� TOTAL MILES: X ARE#: 1 E.O.B. ATT. ROUND TRIP: O YES Cl NO A / t ❑ YES ❑ NO NIGHT: (19:00-07:00) r' t 1 CCRPPHP#: ' P7EMERGENCY 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 NAME:�� Cr C/ t� RELATIONSHIP/"" E O.A: (IF NOT REPLACED) ADDRESS/ Z 7 4:� 16 Ie 1�� Il 3 % ORAL AIRWAY: (IF NOT REPLACED) CITY:/Iq , A��n STATE_-A_ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE: — WORK fHON _ DRY RUN: (AUTHORIZED) EMPLOYER:,L 46AtIPA ON.-C` Rt 1 OTHER: ADDRESS: 6YclA7- C y' _- CITY: n`���-/ N STATE:—zip:—.- COMMENTS: IP: ..COMMENTS: -------- - - TOTAL:. . t_:�. - -- --- -- PATIENT RECEIVED BY: X 1.17, eder rat I (SIGNA,LIRE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORI7ATI�O7N CJ �T.. r"MEciK ON FILL INAPPROPRIATE SPACES DATE: ` PATIENTS NAME ❑'M ❑ F COMPANY N ) %� 3 ` �1 ADDRESS I AGE Lfo CITY r.STATE_ _ ZIPDOB ,WSn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE 4 ! t PHONE NATURE OF DISPATCH { . TYPE OF TRANSPORT:, AMBULANCE?Z OTHER 0 _ — STATION I(A)_2(B)._3(C) (D)_5(E) _ INCIDENT LOCATION:( Q�l RESPONSE CODE: tEQUESTED BY: TIME- 124 HOUR CLOCK) G',�� /-,� •' TO SCENE- .0. CALL RECEIVED ❑ P.D. TIME 10-8 _1 } l PATIENT DESTINATION: -`-'.� FROM SCE ❑ FIRE TIME 14.97 �J ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 AbOCTOR l I PMD/ER START TIME 10-22 Sr HOW CHOSEN: _ TOTAL STANDBY TIME ❑ NEARESTI� ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK It: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �j C� RESPONSE ZONE PPTT ❑ YES Cl NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION; 1 ORtVER` << '� C'� MT-tA TECHNICIAN PARAMEDIC Hz: ____ DISPATCHER: CHIEF COMPLAINT: DRY RUN: IRIYES ❑ NO REASON FOR DRY RUNj ZZ7 yyyAUTHORIZATION FOR DRY RUN(EMS USE ONLY) �S S?•i...:' : PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 'c�' y S.S.11 1 PRIVATE INS. CO.: BASE RATE: KAISER*: MULTIPLE PTS..BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO . ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C"I EMERGENCY RUN: MEDI-CAL N: I 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 - 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: PATIENT RECEIVED BY: X IMS CONTRA COSTA COUNTY AMBULANCE - PRE-HOSPITAL CARE FORM I UNIT L 1 AUTHORIZATION K C CHECK OR FILL IN APPROPRIATE SPACES _ DATE: PATIENTS NAME GIM ❑ F COMPANY M ADDRESS AGES i CITY STATE Q\ ZIP ��( 1 DOB �� Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M �_—_._ PHONE��- MATURE OF DISPATCH ( M kLvu v_,, i11 t TYPE OF TRANSPORT: AMBULANCE)< OTHER❑ ____.___. ... STATION I(A) L 2(B)_31C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY. TIME- (24 HOUR COCK) �v 11 TO SCENE - �S.O. CALL RECEIVED CS ) (pI lir cc L�►t,!»A --- ❑ P.U._ _ TIME 10-8 PATIENT DESTINATI N'. FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 iZL } 0� Az MILEAGE: ❑ OTHER/PVT TIME 10-7 S.�_ 1 ' END �1L�.<` TIME 10-98 1! DOCTOR Y 1)e S PMD/CR START S 7 . TIME 10-22 HOW CHOSEN: TOTAL ` L STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME l(PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C /A ', KT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZQNE YES ❑ NO ❑ WAL'<ED AGUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER _ _ EMT-1A TECHNICIAN Lt C C I 'f h$ L. _I PARAMEDIC Y' Hx: DISPATCHER: CHIEF COMPLAINT: 14 L i0f AL11101DRY RUN: ❑ YES NO REASON FOR DRY RUN � lot/ PATIENT REFUSED SERVICES: (SIGNATURE) X AUTHORIZATION FOR DRY RUN(EMS USE ONLY) MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: j S.S. # ��7 n?,-l1 cl - - PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE r,�LUE CROSS#: TOTAL MILES: X r '» MtDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO (� (/ 11 YES ❑ NO NIGHT: (19:00-07:00) CCHFh(PPHP N: SCC k F G1J eA_ - - - EMERGENCY RUN: MEDT-�AL M: CODE 2/3 OTHE : OXYGEN: (PER TANK) O.E. TICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) /I DATES BILLED: STANDBY: (OVER 15 MIN.) J` E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X _C'�Lxn DRUGS: (PER ADMIN.) X NAME:�l) S � RELATIONSHIP:1u Lf k E.O.A.: (IF NOT REPLACED) ADDRESS: vr,>< c'u ORAL AIRWAY: (IF NOT REPLACED) - -' CITY: - �I.ICZ,Ir�, STATE_C4 ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:(we In Ii IQrC J OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ - -- T0TAL.__o&_.00 - -- _ PATIENT RECEIVED BY. X _—_- rr".r.(.., (!;I('.NA 1,IM') _ - ^"°.TEA COSTA COUNTY AMBULANCE �) UNIT AUTHORIZATION PrIE-HOSPITAL --'^ FORM ' " CfIECK ORFIL: 114 APPROPRIATE SPACES DATE: PATIENT'S NA ADDRESS AGE L r) e/p�_ OSn OM OT OW 0 Th Ell F EIS STAT Zj E ZIP DO on/vsprounswss* pHow NATURE npDISPATCHTO SCENE- CALL RECEIVED - TYPE OF TRANSPORT� AMBULANCE OTHER 0 STATION l(A)_2(B)_' 3(C)_4(D)_5(��) INCIDENT LOCAT;ON: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ell 13 OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN TOTAL STANDBY TIME 0 NEAREST 0 FAM:LY 0 TRANSFER WAIT TIME - , . ~ ( [,> PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE PATIENT CONDIT;ON: DRIVER -1A EIVIT TECHNICIAN PARAMEDIC_A' '. *,. o�pArc*sn � ` CHIEF COMPLAINT: 42 DRY RUN: O YES O NO nEAaow FOR DRY RUN — ^ AUTHORIZATION FOR DRY RUN �avnUSE ONLY) ' ' pAr/st�rREFUSED asnv/Css� (s/nmATuns) x_ � ' MEDICAL COVERAGE: INDUSTRIAL OYEu ONO NO. OF PATIENTS: s.o. w PRIVATE INS. oo.:___--__ BASE RATE: KAISER#: '-_ MULTIPLE PTS. BASE RATE _--_--- ' ' TOTAL MILES: e�oa� ATT ROUND TRIP: o vso O NO . . . Ovsu ONO NIGHT: (19:oo-m:0N .. ocxr/ppHp*. EMERGENCY RUN: / wso/'n^L#: CODE o/o or�sn oxvoem (psnr�mx) ' --- . ' - ' ------ -' P.O.E. r/cxsq O ,sa Owo wsowArAL� UwouoAron) x� DATES BILLED: orAwoev: (OVER mw/w.) / s.x.a.: (PER EPISODE) ` NEAREST RELATIVE/RESPONSIBLE PARTY: /v.. (PER ADMIN.) x _::`06 co_� onuoo: (PER ADMIN) ' u wAMs� '___-__--_ PsLArmmsmp:-__-_-- E0.A.: (IF NOT REPLACED) Aoonsss: -_...._ _-__ ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE___-_- orArE-___Z/p:-_--__ c'oouAn: (IF NOT REPLACED) pHowc: __ WORK PHONE. DRY RUN: (AuT*on/ZEo) swpLovc9: OCCUPATION OTHER: Os AoonsSa:-_-_-___-_-_' - CITY: orxrE:-___-Z/p:__-_-- ~. oomwswrn: ' TOTAL: ------------ ----' | PATIENT RECEIVED BY: u ~� ~ SIGNATURE) ''` �'`� ,/ ".-' ',r, '^^��,�� .� ' � "' . - ��/ `, ' ~ w., CONTRA COSTA COUNTY AMBULANCE -)3, J y 2 3(o PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N CHECK OR/ILL IN APP PRIATE SPACES DATE: V l 'pATIENrs'NAME ❑ M ❑ F COMPANY N ADDRESS AGE\ �Jw CITY STATE ZIP DOB O M O T OW O Th OF O S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE nOTHER❑ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)._. INCIDENT LOCATION:, - S'1� ` RESPONSE CODE: TED BY: TIME- 124 HOUR CLOCK) LbTO SCENE-. CALL RECEIVED _ ❑ P.D. TIME 10-8 ` (> PATIENT DES. INATION: FROM SCEN ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 �j• � MILEAGE: ❑ OTHER/PVT TIME 10-7 I t END TIME 10-98 S;DOCTOR ` r PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ZI-a_0 NEAREST, ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE E��_O :YES 13 NO 13WALKED 13GUERNEY ❑ OTHER ' PATIENT CONDITION:, 1 DRIVER MT-1A 7�f I TECHNICIAN `' PARAMEDIC Hx: DISPATCHER: AA'jL� 85/ CHIEF COMPLAINT: DRY RUN: YE ❑ NO REASON FOR DRY RUN z z S IIII . AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4`1�. A A.10,-:PATIENT REFUSED SERVICES:(SIGNATURE) X �S1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES 11NO NO. OF PATIENTS: 77 --//' S.S.N 1 PRIVATE INS.CO.: BASE RATE: J KAISER it: 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 N:^ ' EMERGENCY RUN: MEDI-CAL N: 1 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: - 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: PATIENT RECFIVFD BY' X CONTRA COSTA COUNTY AMBULANCE/G/ !!! PRE-HOSPITAL CARE FORM I, ) - UNIT AUTHORIZATION N ' CHECK OR FILL IN APPROPRIATE SPACES DATE:_ _•< —� �6� PATIENTS NAME N NJ) M ❑ F COMPANY N ADDRESS -rf-A/��.JAGE ������ �J • � � ^'� CITY L - STATE �M`/ ZIP DOB .l" Sn ❑ M ❑ Tr ❑ W ❑ Th O F ❑ S DRIVER'S LICENSE It _ __ PHONE J2 7122 Z NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ STATION 1(A)_2(B)_3(C)-4(D)_5(E)ll �1INCI•DENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) � �✓✓ / / G 4 /¢l(J TO SCENE- S.O. CALL RECEIVED ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ✓ lc/ �L ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END ) %- ��I TIME 10-98 y.DOCTOR `�- ' � MD R START TIME 10.22 HOW CHOSEN: TOTAL L STANDBY TIME ❑ NEAREST` O FAMILY ❑ TRANSFER l4 WAIT TIME —� ❑ PATIENT ❑ DIRECT /761 OTHERl ry, / CALL BACK N: AMBU NCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBU NCE: I RESPONSE ZONE J ❑ YES t9 NO O WALKED GUERNEY OTHER L PATIENT CONDITION: DRIVER I ^1 EMT-tA / 7 ' TECHNICIAN 1^I PARAMEDIC Hz: IAC. `u L S DISPATCHER: l r A �j CHIEF COMPLAINT: r Ll �� �;t� DRY RUN: ❑ YES PNO REASON FOR DRY RUN c, \� ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 5� PATIENT REFUSE SER (SIG TURE) X— MEDICALOVERAGE: INDUSTRIAL ❑ YES�;NO NO. OF PATIENTS: PRIVATE INS, CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: ` X - �!!,CIG MEDICAR E.O.B. ATT. ROUND TRIP: ❑ YES 11 NO 11 Cl YES ❑ NO NIGHT: (19:00-07:00) _ CCHP/PPRP N: EMERGENCY RUN: C1 MEDI-CAL N: CODE 2/3 T OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/ ESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �� DRUGS: (PER ADMIN.) X NAME - 601-7- RELATIONSHIP:yy � • ,11 E.O.A.: (IF NOT REPLACED) ADDRESS:3 ORAL AIRWAY: (IF NOT REPLACED) CITY: 1_41M71" STATE— ZIP: - C-COLLAR: (IF NOT REPLACED) PH( RK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS -CITY: STATE: ZIP: �C• G2J ' / 0 COMMENTS: �, Cy ' 8 116D TOTAL. 1 I PATIENT RECEIVED BY X + Provider retcir, Ai to end I'in: ,.'I•l, �.•... Y: �• ,•„ (SIGTURI) ►.M' 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT .7 AUTHORIZATION# !� C•• CHECK OR Flll INAPPROPRIATE SPACES DATE: PATIENT'S NA MEM 13 F COMPANY N 2 _ ADDRESS I C'� rr ( ✓I L� T + AGUE Z'z- (i. J CITY�-- ' �-�''� 1 STATE __�:� ZIP ��(LL�// DOB1-13� Jj Sn ❑ M ❑ T ❑ w O Th O F 0 8- DRIVER'S LICENSE K __ PHONE "�L - �� Z NATURE OF DISPATCH Sh OcJT� ✓� - , TYPE OF TRANSPORT: AMBULANEEP OTHER❑ _ - STATION 1(A)`2(B)_3(CI_4(D)_5(E)_ -:•••' INCIDENT LOCATION: RESPONSE CODE: R�E�STED BY: TIME- (24 HOUR C/LOcC_K) '5i L �;G,2 �n`� TO SCENE- IQ S.O. CALL RECEIVED 1� _ \ — ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- -Z ❑ FIRE TIME 10-97 / ❑ PSAP TIME 10.49 MILEAGE:�� O 13 OTHER/PVT TIME 10-7 14Vn 71 r END TIME 10-98 1. DOCTOR PMD(O START 7. TIME 10-22 I - HOW CHOSEN: TOTAL • STANDBY TIME I ^❑ NEAREST ❑ FAMILY 13 TRANSFER WAIT TIME 'CI PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: • i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE _ YES ❑ NO ❑ WAL'CED ICS GUERNEY ❑ OTHER �I� ! PATIENT CONDITION: DRIVER �' S ILQ EMT-1A f , TECHNICIAN 22 �' yt .-1 �o�� PARAMEDIC-_�_- Hx: �- DISPATCHER: HoL-; 100 t I CHIEF COMPLAINT: --!;a.5 L/ L DRY RUN: ❑ YES O10 REASON FOR DRY RUN ' et AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ' 1 -q MEDICAL C VERAGE: INDUSTRIAL ❑ YESNO NO. OF PATIENTS: S.S. « �{ Z--_/ PRIVATE INS. CO.: h fL BASE RATE: 1 KAISER It: MULTIPLE PTS.BASE RATE ' BLUE CROSS q: TOTAL MILES: X 1 MEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES O NO t ❑ YES ❑ NO NIGHT: (19:00-07:00) �/ 1 CCHP/PPRP#: EMERGENCY RUN: 4' v U� MEDI-CAL#: h O h CODE 2/3 ! ��•- - r ( OTHER: OXYGEN: (PER TANK) r P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) ` t�l) 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 O'(-�%6' 1 QRELATIONSHIP:N 7M E O.A.: (IF NOT REPLACED) ADDRESS�!r'�' 1 L r_E��S n ORAL AIRWAY: (IF NOT REPLACED) CITY:R ., '� c1T __ STATE_L_L!ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: W RONE DRY RUN: (AUTHORIZED) EMPLOYER: N O TP/i�-(T N U ATISSJN: OTHER: ADDRESS: V` (�c i- /- /,- - y' CITY: �-`� e- STATE:e-�A ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X ......: !-^ (SIGNATURE) rCO RA COSTA COUNTY AMBULANCE UNIT AU PRE-HOSPITAL CARE FORM I THORIZATI N a.►, CNECR OR FILL IM OPgIATE CES DATE: 61 ' fi ti taAT1ENTSNAME � At OAA O F COMPANY N to ' ADDRESS" • ' ' AGES CITY ' j - STATE—.ZIP DOB Sn ❑ M ❑ T OW O Th O F OS DRIVER'S LICENSE N ' PHONE - NATURE OF DISPATCH a i TYPE OF TRANSPORT: AMBULANC OTHER❑ _ - STATION 1(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOCATION i RESPONSE CODE: REUESTED BY: TIME- (24 HOUR CLOCK) j J TO SCENE- ' 1�S.O. CALL RECEIVED —�J rC— ❑ P.D. TIME 10-8 !`i I PATIENT DESTINATI FROM SCE 11 FIRE TIME 10-97 :T— i O PSAP TIME 10-49 ` MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 DOCTOR". 1� PMD/ER START TIME 10-22 HOW CHOSEN: .. TOTAL STANDBY TIME LrIi„.❑ NEAREST--'-' O FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP PT. AMBULATORI.Y? PATIENT TAKEN TO AMBULANCE: r [RESPONSE ZONE ❑ YES Cl NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' T PATIENT CONDITION: DRIVER—' `� EMT-IA TECHNICIAN 2 nJPARAMEDIC r Hx: DISPATC 111 CHIEF COMPLAINT: DRY ES NO REASON FOR DRY RU AUTH OR DRY RUN(EMS USE ONLY) (l (/l' S?:•. ''i. 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 N: I E.O.B. ATT. ROUND TRIP: ❑ 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 ❑ 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 -2211, _ Q _ TOTAL: PATIENT RECEIVED BY X ,,..,.,.,-.. ... . _ (sInNA11.IAF) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 3 CHFCM OR FILL IN APPROPRIATE SPACES DATE: _ r' / " l' rPATIENT S NAME, C C r) P iL-A n i" ❑ MC� F COMPANY N I J ADDRESS-1-2 fQ- �A L. LFN i) �c X: k^- t AGE T" J 3 Lf CITY G STATE �' ZIP DOEI_ ��_ O Sn OM OT OW 0Th OF DS DRIVER'S LICENSE N ^ I _ PHONE 1/ 1 _L _�NATURE OF DISPATCH NSA 2 t TYPE OF TRANSPORT: AMBULANC OTHER❑ _._ _ ____ - —_ .. STATION 1(A)_2(B)_3(C)_._.4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REO STED BY: TIME- (24 HOUR CLOCK) ` ` TO SCENE- S.O. CALL RECEIVED ' I�� CN� i'`' V N f O P.D.— TIME 10-8 ;, .- PATIENT DESTINATION: r1l FROM SCENE -Z O FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE:, ❑ OTHER/PVT TIME 10-7 �,��� END /.-L— TIME 10-98 ' DOCTOR ( I - 61 tl PM / START_ L— i TIME 10-22 HOW CHOSEN: TOTAL J` STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER (�. WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER \.I CALL BACK#: AMBULANCE COMPANY: ��S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO O WAL'<ED ❑ GUERNEY 13OTHER PATIENT CONDITION: DRIVEF<74_1-. Ll�' ' ^ EMT-1A TECHNICIAN Cc-`Z PARAMEDIC N_ Hx: DISPATCHER: Nnl•._L_1'_; A ' - / CHIEF COMPLAINT: DRY RUN: ❑ YES ZNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) )�f PATIENT REFUSED SERVICES (SIGNATURE) X.- r 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES"p•NO NO. OF,PATIENTS: 11 S.S. # "h C C L_ , PRIVATE INS.CO.:"IIE:7112C 1V(lT�ti �-l�'c BASE RATE: ) KAISER M: MULTIPLE PTS. BASE RATE I BLUE CROSS C TOTAL MILES: X ?'✓J �`� MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) r \v\ CCHP/PPRP C EMERGENCY RUN: , Y 1 MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) A L RO.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: ~ 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: �; •r A COMMENTS:C'l�ctj ACC!. T h��3 Z TOTAL: _. n • Z-n f d PATIENT RECEIVED BY. X . T -T--- (SIGNATUHF) Yrovidor retain L�hitr cril PI,:� ,'.F.L 4UL4nt i, ': •��,, t ' �.rr.; uh,n 1 i( .,.i UFS•1 f i CONTRA COSTA COUNTY AMBULANCE ' v PRE-HOSPITAL CARE FORM I UNIT � cl AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 PATIENT'S NAME. L_r�. �.Ll,..r.1�11y���( Y��y M 13F COMPANY Of 1011. 6 ADDRESS J����� `S:L_L1.��� �C"�` ,LAS AGE IC � o 13 3 C . CITY .� ��' I�C STATE ZIP 9-<c)to DOBSn ❑ M O T ❑W O Th,O F O S ' DRIVER'S LICENSE a ___ PHONE ?3 7"�9 _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O _ STATION 1(A)_2(8)_3(C)_4(D)_5(EI_ «. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C OCK) _ TO SCENE- ,123S.O. CALL RECEIVED _ ❑ P.D. TIME 10-8 / :�, + PATIENT DESTINATION: FROM SCENE - Z ❑ FIRE TIME 10-97 l J I ��• ❑ PSAP TIME 10-49 '�— •: i ��}• �S ''� MILEAGE: ❑ OTHER/PVT TIME 10-7 END 2 `-. -c TIME 10-98 �: DOCTOR S<TC C PMDAo START L(�T' TIME 10-22 HOW CHOSEN: TOTAL / n STANDBY TIME RI NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME Cl PATIENT ❑ DIRECT ❑ OTHER / CALL BACK N: AMBUL/NCE COMPANY: r----- Q_A 5 _ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 �� RESPONSE 2 NE OYES ❑ NO ❑ WAL'<ED &GUERNEY ❑ OTHER f Q PATIENT CONDITION: DRIVER,_��-�C�� c�� 5O0 EMT-tA 1 ` TECHNICIAN9C� �� r PARAMEDIC Hx: c�:� lg L C DISPATCHER: CHIEF COMPLAINT: L_� DRY RUN: ❑ YES X NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X J MEDICAL COVERAGE: INDUSTRIAL ❑ YES XNO NO. OF PATIENTS: S.S. 0�T�- 17—` �((� t_.._. PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE -v' • �J . BLUE CROSS M TOTAL MILES: � X � --• - MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES Cl NO NIGHT:(19:00-07:00) CCHPIPPHP p: EMERGENCY RUN: ` MEDI-CAL a: CODE 2/3 -- - OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) II i DATES BILLED: STANDBY: (OVER 15 MIN.) i� E.K.G.. (PER EPISODE) X NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) / l 1 DRUGS: (PER ADMIN.) Z X .'v NAME: 1" r`S[-.�1L RELATIONSHIP:W _ E.O.A.:(IF NOT REPLACED) ADDRESS: �� A • ORAL AIRWAY: (IF NOT REPLACED) CITY:_ _____ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: I OCCUPATION: OTHER: ADDRESS: CITY: STATE: Z(IP: C MMENTS: I ` TOTAL,--,— PATIENT RECEIVED BY:X (SIGNATURE) Proui,frr rrtoic :ryitr .Tf T �: rorl .hat"r• re'low Mpy t• rWs when biI"ing CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: 'J `PATIENT'S NAME �M/O F COMPANY IV l� .; ADDRESS ' AGE* w CITY- _.4=.==-STATE ZIP DOB Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S i ORIVER'$'UCENSE N !• -1 PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 13 STATION I(A)_2(B)_3(C)_4(D)`5(E)_ le INCIDENT LOCATION:: 51-A W L //O` ESPONSE.CODE: R�EMTED BY: TIME— (24 HOUR CLOCK) L7 TO SCENE- S.O. CALL RECEIVED /'^ /( -�SS r•l pQ jt O P.D. TIME 10-8 S`rte PATIENT DESTINATION: FROM SCENE -O ❑ FIRE TIME 10-97 - -o ❑ PSAP TIME 10-49 •' �' :��}. 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 ::TDOCtOR 1' PMD/ER START TIME 10-22 ' HOW CHOSEN: TOTAL STANDBY TIME i ter: ;;❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK 8: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j" ; RESPONSE ZONE �_TT�� Q YES ONO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER / ( 1 EMT-1A ' ��•i� TECHNICIAN L-1 64' PARAMEDIC Hx: ___ DISPATCHER*. CHIEF COMPLAINT: 1 DRY RU O N EA O DRY RUM YC�" A t I I y UTHO 12ATI FOR Y RU X� C NLY) 9q9 !' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 7: 5� S.S.(r PRIVATE INS.CO.: v BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS K: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: ` ' EMERGENCY RUN: MEDI-CAL K: ' CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPON IBLE 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 HONE: DRY RUN: (AUTHORIZED) - " EMPLOYER: OC PATION: OTHER: ADDRESS: ,---CITY:-- STATE: ZIP: COMMENTS* - TOTAL: r� +� PATIENT RECEIVED BY. X_ (SIGNATUREI �.,, - 1 CONTRA COSTA COUNTY AMBULANCE !� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION OL-> r Z 3 CN[CK OR Flll IN AMMOIIIIAtE SFACfS DATE: 2 PT c AV— " ❑' . � F COMPANY M � d "• 1 'PATIENTS NAME O �� ADDRESS).,pp_1 V,E= i/fV T--o AGE- CITY GE CITY STATE ZIP____T�r,DOB gSn ❑ M O T ❑ W' ❑ Th ❑ F ❑ S ; i 'DRIVER'S LICENSE N - PHONE _ NATURE OF DISPATCH ' T TYPE OF TRANSPORT: AMBULANCEOTHER 0 STATION 1(A)_2(8)-31C)._4(D)_5(E)_ INCIDENT LOCATION:: 1 � RESPOWSE CODEF REQUESTED BY: TIME- (24 HOUR CLO K) r� r 1 TO SCENE- j �O. CALL RECEIVED :Q Lar V-4 LL / C! IVyoui j I,R E �y 2 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ) '� I r^ ❑ PSAP TIME 10-49o MILEA ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 ?�j7 i?'00CTOR ( PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑,NEAREST;: ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: v L7 RESPONSE ZONE X31': ❑ YES ❑ NO 0 WALKED 13GUERNEY ❑ OTHER i ' ' _ • PATIENT CONDITION: DRIVER rEMT-1A ; TECHNICIAN ��L^ SO -Z a PARAMEDIC Hx: tJ GI DISPATCHER: 11 Lf Q 0 . CHIEF COMPLAINT: DRY UN: AYES ❑ NO REASO FOR DRY RUN!-T• Ca:�►t /'�7•iQON HQ T,�IO��F'�O-�R DR U (EMS USE ONLY) L ( PATIENT REFUSED SERVICES: (SIGNATURE) G �L�✓C/`��"" lly MEDICAL COVERAGE: . . 1 INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: 1 KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS N: I TOTAL MILES: X MEDICARE M: E.O.B, ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#:-; EMERGENCY RUN: 17 MEDT-CAL M: 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: , , t o a S Lir-4g- `7 P- rofv 1 S TOTAL PATIENT RECEIVED BY:X ISIGNA TURE) Of C:1 �' S1 CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT / AUTHORIZATION N <> >� CHECK OR flLl/N APPROPRIATE SPACES DATE: .gl PATIENTS NAME r ❑ M Z F COMPANY N - ' ADDR SS9SE AGE !CI STATE ZIP.— ___- DOB' 2p _/ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S 11 DRIVER'S PHONE - �� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE•eOTHER❑ _- STATION 1(A)__,_.2(B)_3(C�4(13)_5(EI_ INCIDENT LOCATION: RESPONSE CODE: REgUESTED BY: TIME- (24 HOUR CLOCK) •? CTO SCENE !J p"S.O. CALL RECEIVED 1� ❑ P.O. TIME 10-8 PATIENT DESTINATION: ` FROM SCENE.) ❑ FIRE _ ___ TIME 10-97 � ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 END J TIME 10-98 :.DOCTORS�- t PI�nR START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER t' I. CALL BACK N: AMBULANCE COMPANY: PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: . RESPONSE ZONE C ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN k INK kc� -J �-t Y �'"L PARAMEDIC L�l Hx: (- t J DISPATCHER: CHIEF COMPLAI - DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN )�'(M - - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) C PATIENT REFU SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: i S.S. N PRIVATE INS. CO.: BASE RATE: y r,' MULTIPLE PTS. BASE RATE � TOTAL MILES: X ✓U MEDI J_ SE.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHPIPPHP C EMERGENCY RUN: MED17CAL N: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) l 1 D P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) �� _ f'1• 1 1 l E.K.G.: (PER EPISODE) NEAREST RELATIVEIRESPP14SIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS. (PER ADMIN.) X NAME: -S' Y�/ ATIONSHIP: E.O.A.:_(IF NOT REPLACED) Wit= 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:_� �!T� "tC_ / j� vv,\ PQj- so . c, NAble To Joco.� 'tel � V'eh : cue �1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 1442– S CNECK OK RLL IN APPROPIUATE SPACES DATE: Z — �3 PATIENTS NAME 0-M ❑ F COMPANY N / ✓ r ADDRESSOf AGE C CITY - STATE +ZIP DOB— - VSn ❑ M ❑ T ❑W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH 4 - TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ — STATION 1(A)_2(B)_3(C)�4(D)_5(E)_ INCIDENT LOCATION:I { RESPONSE CODE: REE ESTED BY: TIME— (24 HOUR CLOCK) ' `� �- TO SCENE- v S.O. CALL RECEIVED �1Fws�c Uri ❑ P.D. TIME 10-8 PATIET DESTINATI N:. FROM SCENE- O FIRE —� TIME 10-97 – ' ❑ PSAP TIME 10-49 ' II - "•• MILEAGE: D OTHER/PVT TIME 14.7 S� END TIME 10-98 I DOCTOA 1__ Li' T' _ PMD/ER START TIME 10.22 HOW CHOSEN: .. .__. TOTAL STANDBY TIME ❑ NEAREST.4 ❑ FAMILY ❑ TRANSFER - -- WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE OMP Y: S 2 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i` RESPONSE ZONE ❑ YES D NO .. D WAL!<ED ❑ GUERNEY ❑ OTHER `al PATIENT CONDITION: DRIVER rXSSO ` –�`/ EMT-IA -:"61I& .. . e . . i.• TECHNICIAN ne(, c-bv\ 1R `, PARAMEDIC ✓� Hx: DISPATCHER:: L p, l CHIEF COMPLAINT: -�`— DRY RUN: _IES D NO REASON FOR DRY RUNLl AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �� ' S: I ►" PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M 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: OYES ❑ NO ❑ YES 0 NO NIGHT: (19:00-07:00) t CCHP/PPHP N;^ ' 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 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< <�✓ — � C. PATIENT RECEIVED BY:X aiNIFIA COSTA COUNTY AMBULANCE FAE-HOSPITAL CARE FORM il I UNIT AUTHORIZATION a • 1I / �I � CHECK OR FILL IN APPROPRIATE SPACES DATE: - 77- `` _ / J/• /1 1 PATIENT'S NAME (-�'_ �CJ�-�I��_z ti���L Om �f COMPANY ADDRESS 'S�' 4•"�tl.s 7 1 AGE / - - CITY. STATE- ZIP DOB i jY 5YL O Sn )Z yA O T ❑ W O Th O F CIS DRIVER'S LICENSE q PHONE7.7 GG=?�j — NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE7 OTHER❑ STATION 1(A)_2181_31C1_4(0)_51E1_. INCI ENT LOC6rTION: ^ R �RESPONSE CODE: QUESTED BY: TIME–(24 HOUR CL CK) 1�.��t.�� �✓���:�Z TO-SCENE ,/ RECEIVED 7) 0 P.D. TIME a8 •` PATIENT DESTINATION: FROM SCE! - ❑ FIRE TIME 10-97 �/ C]MILEAGE: •` TIME 10-49 1; - MILEAGE:1G i O OTHER/PVT TIME 10-7 END TIME 10-98 _ DOCTOR Sly of PM /ER START- TIME /0 22 HOW CHOSEN: TOTAL STANDBY TIME �--1 O NEAREST O FAMILY O TRANSFER WAIT TIME �. I PATIENT ❑ DIRECT O OTHER S CALL BACK M: AMBULANCE Q ,NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 Q RESPONSE ZONE-�� I?qES O NO O WALl<ED.Qb5UERNEY O OTHER PATIENT CONDITION: DRIVER o EMT-1A ( _a TECHNICIAN - I PARAMEDIC Hx: DISPATCHER: - CHIEF COM AINT: .(�_ 0�4 �pRY RUN: ❑ YES /eNO REASON FOR DRY RUN �iC( '/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) _ PATIENT REFUSED SERVICES: (SIGNATURE) X_ ` MEDICAL C V E: INDUSTRIAL O YESANO NO.OF PATIENTS: �•�+ �� S.S. K 3 ! PRIVATE INS. CO.: BASE RATE: �SQ•�•.! KAISER R: MULTIPLE PTS.BASE RATE BLUE CROSS p: TOTAL MILES: X MEDICARE tt: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) .,�'S/.�-.c/6n�1. CCHP/PPHP a: EMERGENCY RUN:. C MEDT-CAL tt: CODE 2/3 -� OTHERC�/44 it QU S �,f__ /=� G 7 OXYGEN: (PER TANK) P.O.E. STI KER ❑ YES O NO NEONATAL: (INCUBATOR) /�Y beTES BLED: STANDBY; (OVER 15 MIN.) E.K.W (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ?CJ'L1J � 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: �f OCCUPATION: - OTHER: ADDRESS: ,f(� CITY: / STATE: ZIP: COMMENTS: i _ q(0 - S TOTAL: �fi i,• .�.. PATIENT RECEIVED BY:X - Provider rrto:r "ito rd r r., ,-opt, 4ttur+ Yp:Ira wpy t• ENS when !il•inp (SIGNATURE) D16-1 CONIRA COSTA COUNTY AMBULANCE 7 / PPE-'"!'"^ITAL CART FnE`'0 UNIT AUTHORIZATION A4 _ _ CHECK OR FILL IN APPROPRIA iE SPACES ,. DATE:�,SL ■ *� i PATIENT'S NAME r� ��- ❑ M COMPANYN - An ADDREV: ooB�-AGE CITUSTATE ZIP E l3❑ Sn ❑ T; O W .Q Th ,O F $' DRIVER'S LICENSE# i� --_ PHONE NATURE OF DISPATCH .c TYPE OF TRANSPORT: AMBULANCE THER❑ _ STATION 1(A)-2(8)-3(C)-_4(D)-51E)t INCIDENT LOCATION: ^ `-4 RESPONSE C E: REQUESTED BY: TIME- (24 HOUR C CK) ( C� TO SCENE- S.O. CALL RECEIVED '�� ❑ P.D. TIME 10-8 ' I? PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O 1) 91 PSAP TIME 10-4 6 , ❑ OTHER/PVT TIME 10-7 + MILEAGE: n - END v TIME 10-98, C DOCTOR PM ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME�_�_.T. y ❑ NEAREST %'�y6AMILY ❑ TRANSFER WAIT TIME :-. j ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPAAt C PT. AMBULATORY? PATIENT T KEN TO AMBULANCE: j;' RESPONSE ZONE YES ❑ N ❑ WAL!<Eb'?4,7UERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1 TECHNICIAN u PARAMEDIC DISPATCHER: rr Q I qr HI F COMPL T: DRY RUN: 11YES NO REASON FOR DRY RUN L AUTHORIZATION F R DRY RUN(EMS USE ONLY) �- PATIENT REFUSED SERVICES: (SIGNATURE) X` h(1 ,Mft-TqAL COVERAGE,-, 0 STRIAL ❑ YE O NO.OF PATIENTS: _r . : PRIVATE INS.CO.: BASE RATE: " KAISER 4: MULTIPLE PTS.BASE RATE ^- BLUE CROSS p TOTAL MILES: X MEDICARE N, E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT:(19:00-07:00) � CCHP/PPRP p: EMERGENCY RUN: r, ,.; MEDT-CAL M d - Q `� CODE 2/3 --. . ,,. �tY. i OTHER: OXYGEN: (PER TANK) t P.O.E. STICKERYES 13 No NEONATAL: (INCUBATOR) " " _L....�..J Z DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSI@LE PARTY: LV.: (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 PHON DRY RUN:. (AUTHORIZED) EMPLOYER: OCCUP ION: OTHER: ---�- - -' -�- •'�`�`•" � " ADDRESS: , CITY: STATE: ZIP: COMMENT TOTAL: • L/z PATIENT RECEIVED BY: Provider retain, White cnd Nn: copy A°turn Yr:tcv -net, t+ Ems when bit"inp-„IGNATURE) z"S_I i CONTRA COSTA COUNTY AMBULANCES/ y3a y PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OA FILL IN APPROPRIATE SPACES DATE: C' '63 PATIENTS NAME 4 D a''' ❑ M ❑ F COMPANY N t ADDRESS ( AGE (J CITY STATE ZIP DOB O Srt Et M ❑ T 0 W 0 Th O F 0 S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH (46C)l< ^'IE TYPE OF TRANSPORT: AMBULANCE 13 OTHER 0 -- STATION 1(A) 2(B)_3(C)_4(D)_5(E)_ r INCIDENT LOCATION: I RESPONSE CODE: R�OUESTED BY: TIME— (24 HOUR CLgCK) , TO SCENE- ` ' S.O. CALL RECEIVED ! I.t�i s ❑ P.D. TIME 10-8 I PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10-97 Cl PSAP TIME 10••49 MILEAGE: ❑ OTHER/PVT TIME 10.7 j END TIME 10-98 n ` DOCTOR '' PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME 13NEAREST 13FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT 0 OTHER CALL BACK N: AMBULANCE COMPANY: S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE / Cl YES ❑ NO ❑ WALKED 0 GUERNEY O OTHER PATIENT CONDITION: DRIVER l�6 EMT-tA TECHNICIAN �/���- �, PARAMEDIC Hx: ^ DISPATCHER: CHIEF COMPLAINT: DRY RUN: -YES ❑ NO REASON FOR DRY RUN 1�`2�� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -,116 /Or PATIENT REFUSED SERVICES:(SIGNATURE) X 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES 0 NO NO. OF PATIENTS: '� C•� S.S.N I PRIVATE INS. CO.: BASE RATE: KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE N: E•O.B.ATT. ROUND TRIP: O YES 0 NO I 0 YES ❑ NO NIGHT: (19:00-07:00) , CCHP/PPRP C EMERGENCY RUN: , MEDI-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 0 NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) i NEAREST nELATIVE/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) EMPLOYER: OCCUPATION: OTHER: 1 ADDRESS: i CITY: STATE: ZIP: COMMENTS: CTO A rno W O W-. TOTAL: "�y �v PATIENT RECEIVED BY:X Provider retain. White and Pink copy Return YO'iuu copy t ENS when Dii:ing (SIGNATURE) GIS-1 CONTRA COSTA COUNTY AMBULANCE 3_3- N 32-5 PRE-HOSPITAL CARE FORM I UNIT �.: � AUTHORIZATION N I * L------i CHECK OR fllL IM APPROPRIATE SPACES DATE: 12 2 'PATIENTS NAME ❑ M ❑ F COMPANY N is 3 l ADDRESS AGE CITY TATE ZIP DOB ❑ Sn �M OT ❑W O Th ❑ F DS DRIVER'S SDRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O STATION 1(A) )_3(C)_4(D)_5(E)_ INCIDENT LOCATION:' RESPONSE CODE'. REQUESTED BY: TIME—(24 HOUR COCK) fC y -7 � e f �r�` TO SCENE 3� O D. TIME a8 S�Ls CALL RECEIVED - : � PATIENT DESTINATION-. FROM SCENE ❑ FIRE TIME 10-97 ; O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ��'•. END TIME 10-98 y DOCTOR.- PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME cam.`.:..O NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: C� PT. AMBULATORY71, PATIENT TAKE 1vIBULANCE: L; RESPONSZONE — 11 YES ❑ ❑ WAL' GUERNEY ❑ OTHER .•qT TIENT CONDITION: j DRIVER L't ' EMT-1A TECHNICIAN Al / PARAMEDIC H.- DISPATCHER: Ll i) 271 CHIEF COMPLAINT: DRY RUN:RYES O NO REASON FOR DRY RUN (� U AU ORIZATION FOR DRY UN(EMS USE ONLY) �Nrl ��� T� ��yy :PATIENT REFUSED SERVICES: (SIGNATURE) X �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 N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O 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 ❑ YES .❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) — E.K.G.: (PER EPISODE) I NEARESTRELATIVE/RES ONSIBLE 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) j —EMPLOYER: OCCUPATION: OTHER: ADDRESS: - CITY: STATE: ZIP: COMMENTS: TOTAUSON • • PATIENT RECEIVED BY:X \' PMn(drrl rvhvl; lr,i r,. / /':al ..l.l o r., r .•. ( I ..r SIGNATUR E CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CNECK OA lilt IN AP ROPRIATE 3PACi3 DATE: 2 /0 x '. n PATIENTS NAME ^ � f M -❑ F COMPANY A ADDRESS � " 'i.7 el - AGE A01391 , CITY STATES' . ZIP nn B O Sn Om O T ❑W ❑Th ❑ F 13S' DRIVER'§LICENSE lI PHONE )jh n C NATURE OF DISPATCH ^ S TYPE OF TRANSPORT: AMBULANCE OTHER❑ - STATION 1(A) 2(B)_3(C)_4(D)_5(E), INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR C FK) s I -� JJ �1 TO SCENE- 3 EIVED P.D. TIME o-8 y j1 PATIENT DESTINATION: - 1 FROM SCENE- 2 13FIRE TIME 10-97 D PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ' ��L END a TIME 10-98 DOCTOR �-�`� lLG� PMDo START cO TIME 10-22 HOW CHOSEN: TOTAL ,_ STANDBY TIME NEAREST••-` ❑ FAMILY ❑ TRANSFER WAIT TIME r ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: cl PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE____j_ YES ❑ NO .; WALKED O GUERNEY ❑ OTHER PATIENT CONDITION: DRIVEREMT-1A j �.7 ,,j TECHNICIAN PARAMEDIC Hx: DISPATCHER: At CHIEF COMPLAINT: O� a 5 "k4�1" DRY RUN: O YESNO REASON.FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) f 3 iI. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: •� -l� S.S.N PRIVATE INS. CO.: BASE RATE: ' 9AISER c MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X �� �� MEDICARE N: ' E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES •❑ NO NIGHT: (19:00-07:00) '/ CCHP PH N:" Z-�'7 Z� EMERGENCY R.VN: hh'(K I-CAL N CODE 2,,/3 HER: ' OXYGEN: (PER TANK) P.O. STIC ER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES _ ED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: " I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "NAME:• L OLp WL RELATIONSHIP:M0 E.O.A.: (IF NOT REPLACED) ADDRESS: ejEr-0 {AV L ORAL AIRWAY: (IF NOT REPLACED) CITY: IC I STATE__ZIP: C-COLLAR:.(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) —EMPLOYER: Q hlC' OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP: ---'COMMENTS:- - - TOTAL jKq: �J 1 ____ PATIENT RECEIVED BY X CON I RA COSTA COUNTY AMBULANCE W PRE-HOSPITAL CARE FORM I UNIT f ,( I�I� AUTHORIZATION N CHECK OR FILL IN APPn OPWATE SPACES 1 ^ /(, ✓ DATE: PATIENT'S NAME--= r% ��:__ - r,,I $) M ❑ F COMPANY K _ /2,E /ADDRESS AGE ZIP9YC � ❑ T ❑ ❑Th VO F D SCITY 7AU A, STATE- DRIVER'S LICENSE q _ _ PHONE_�a - NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Qc OTHER❑ ___ STATION 1(A)._2(8)_3(Cl_4(D)_51E)_- I CIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR C OCC)/ _ TO SCENE- S.O. CALL RECEIVED i ��_._� • vim' ❑ P.D. TIME 108 - PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �- 3 ❑ PSAP TIME 10=49 MILEAGE: ❑ OTHER/PVT TIME 10-7 t f� END � � � TIME 10-98 DOCTOR I PMD/ER START U• TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME R NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 1 ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY- PT OMPANY PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ;l\' RESPONSE ZONE *vc ❑ YES `ONO O WAL'CED UYGUERNEY ❑ OTHER ' PATIENT CONDITION: DRIVER C EMT-lA I - i TECHNICIAN ,-1 DIC t I! Hx __ t '--D V 6 ALIDISPATCHER: I G CHIEF COMPLAINT: �,L__ DRY RUN: O YES NO REASON FOR DRY RUN i' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X I CAL COVERAGE: INDUSTRIAL ❑ YES ANO NO. OF PATIENTS: :I SPATE INS.CO.: C�,Qf6�Ti4� BASE RATE: I! KAISER#: ' / MULTIPLE PTS. BASE RATE BLUE CROSS p:' TOTAL MILES: X ,' '50 ' T sO• �) MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN- n.c� MEDI-CAL#: CODE 2'3 OTHER: OXYGEN: (PERUNK) � •C. 1' 1'vI 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 c ���,��� DRUGS: (PER ADMIN.) X �I NAME: / � � T7 S RELATIONSHIP: MbN1 E.O.A.: (IF NOT REPLACED) ADDRESS: 3 ORAL AIRWAY: (IF NOT REPLACED) w IJ CITY _ rL1_t«''Nv_ STATE_ t11P: C-COLLAR: (IF NOT REPLACED) PHONE- 7J-2-WORK PHONE: I DRY RUN: (AUTHORIZED) IV EMPLOYER:t�YL—'( __ `OCCUPATION: `A41f 5 OTHER: • ADDRESS: y41%,, Rc.t li CITY: fsq� F)Ae-LU STATE: ('A-,ZIP: �l'�> — ISS® (r-' COMMENTS: ZP-�`� � PCE���lL3(_U I/7�u+ I� �11 �i s/J �•(�j•L� .2 CP) 1 TOTAL:,;C 7 w Q 7 PATIENT RECEIVED BY:X �` Provider rota!*. Yhi tr xi r!r,: u orfu. Yr'•.•,• (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE ��( ( ' t' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M `�' d vv o Y4T r CHECK ON FILL INAPPROPRIATE SPACES DATE: 'PATIENTS NAME .► f!�-D _-DlnN ►"L P wAYN0- i 1 O F COMPANY M ADDRESS-29 C' �` `" AGE CITY- i CITY iSTATE ZIP DOB 16 ❑ Sn �(M O T O W O Th O F O S /�'` . DRIVER'S LICENSE 0 ) PHONE_Lilp-r- NATURE OF DISPATCHf�- TYPEOFTRANSPORT: AMBULANCE 0 OTHER 0 _ — STATION 1(A) 2(B).-3(C)_4(D)_5(E)_ I INCIDENT LOCATION; - i RESPONSE CODE: RE UESTED BY: TIME-- (24 HOUR CLOCK) { ./ TO SCENE- 3 O. CALL RECEIVED (^ J, ! L - ❑ P.D. TIME 10-8 ! PATIENT DESTINATION FROM SCENE- O FIRE TIME 10-97 O IAD�j Cl� PSAP TIME 10-49 i �y 1` �i 1 MILEAGE: C� ❑ OTHER/PVT TIME 10-7 :L END 1�'Z TIME 10-98 r OCTOR'.:_L� Ph4nSTARTFF TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME I MI.i13 AREST, :,a O FAMILY ❑ TRANSFER WAIT TIME .TIENT O DIRECT ❑ OTHER CALL BACK K: AM Uh CE COMPANY: P AMBULATORY? PATIENT T E TO AMBULANCE: RESPONSE ZONE f � YES 11NO _ ❑ WALKED G ERNEY ❑ OTHER ` I I PATIENT CONDITION: DRIVER RN S 'v ` EMT-1A TECHNICIAN �'^ �L L� PARAMEDIC Hx: DISPATCHER: C) CHIEF COMPLAINT: DRY RUN: ❑ YES O REASON FOR DRY RUN 2, - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ! PATIENT REFUSED SERVICES: (SIGNATURE) X (J I MEDICAL COV R1 E: IAL ❑ YES ❑ NO NO. OF PATIENTS: s.s. 0 PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X kDICARE N:' ! f E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00)RP M:' ' ( EMERGENCY RUN:..LN: ' ' CODE �/3 OXYGEN: (PERTANK) IC ❑ 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_ I-)#, �ELATIONSHIP: D E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: Al) STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) "�EMPLOYER: OCCUPATION: OTHER: ADDRESS: --'CITY: STATE: ZIP: ""'COMMENTS: TOTAL• I SD PATIENT RECEIVES BY X f CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION .. �CHECK OR FILL IM�APD ,nPROPRfATE SPACES 1 I � ATE 'PATIENTS NAME_1'_1 !APTI T V tt-�yP ❑ F COMPANY M ADDRESS "�, 5 �� �� AGt5a: O 3 .!CITY_ `; .y +STATE CAA ZIP 1YDDOB ❑ Sn ❑ T ❑W O Th ❑ F O S DRIVER'S LICENSE 0 �� PHONE JA."fl. IK c. /�lv N Tl1RE OF DI PATCFj,% 1�r .?r= � � •�•--,x .15 0 3 A" tq TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: UESTED BY: TIME- (24 HOUR TO SCENE- S.O. — CALL RECEIVED � P.U. TIME 1d-8 PATIENT DESTINATION: FROM SCENE - L7 FIRE. TIME 10-97 " ❑ PSAP TIME 10-49 2Lx_ -ly— r �- d✓� `�J M MILEAGE: ? ❑ OTHER/PVT TIME 10-7 I END - .J— TIME 10-98 310OCTOR t]_ 1�L L P (5 PM STARTI_J_�! �__ TIME 10-22 HOW CHOSEN: I TOTAL STANDBY TIME 2T'.. ❑ NEARESTi,: ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBtAp� COMPANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: _SCJ RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ) >�Z fiPATIENT,CONDITION:, i DRIVER EMT-1A ^� TECHNICIAN �NC�� ! �,I PARAMEDIC Hz: --�J r 0 PATCHER: 6 CHIEF COMPLAINT: f Y RUN: ❑ YEYOR O REASON FOR DRY RUN I ' AUTHORIZATIO RY 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#: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO en'^ } ❑ YES ❑ NO NIGHT: (19:00-07:00) 0, �/' P OMCAL#: /PPHP M: t ) EMERGENCY RUN: .� C•v. ( CODE2/ R:— AS As N eKJ OXYGEN: (PER TANKSTICKER ❑ YES ❑ NO (Ja CfAe_o NEONATAL: (INCUBATOR) S 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) yCITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:, COMMENTS: PATIENT RECEIVED BY' X Providrr retai- rT ONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION x r CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME it d=14 ❑ M ❑ F COMPANY# ADDRESS AGE U Aj (i CITY STATE ZIP DOB ❑ S"A M 11T O W ❑ Th ❑ F O S. I DRIVER'S LICENSE N _ PHONE _ — NATURE OF'DISPATCH TYPE OF TRANSPORT: AMBULANCE THER❑ INCIDENT LOCATION: I RESPONSE CODE: EOUESTED BY: TIME— (24 HOUR , CK) ,( � TO SCENE S.O. CALL RECEIVED �1—�L �y _51�/ a�aN�V��/ ❑ P.D. TIME 10-8 d� PATIENT DESTINATION: FRO SCENE- ❑ FIRE TIME 10-97 f�Q ❑ PSAP TIME 10-49 • MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98 'DOCTOR j' PMD/ER START TIME 10-22 L HOW CHOSEN: TOTAL STANDBY TIME i %1 .. ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE COY. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE r) ❑ YES ❑ NO . O WALKED ❑ GUERNEY ❑ OTHER .. PATIENT CONDITION: DRIVER—M, ' EMT-tA TECHNICIAN / ' PARAMEDIC i . Hz: ..—.. DISPATCHE'4 C) CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN J AUTHORIZATION FOR DRY RUN (IMS USE ONLY) I /11�lJ PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: i 1 I e S.S. p PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B. ATT, ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) � r CCHP/PPRP k: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) I 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) 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: CITY: — STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X j I�., ... ... -- (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE Cj PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#FS 'CHECK OR FILL IN APPROPRIATE SPACES DATE: Q1- .•L l PATIENTS NAME ❑ M ❑ F COMPANY.L ADDRESS' ) - AGE CITY STATE ZIP DOB—. ❑ Sn M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE k _ PHONE ATURE OF DISPATCHok)` - TYPEOFTRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION) # RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C)..Q.CK) , I {�� eU (-n Q' L�67 TO SCENE p P.D.. CALL S. TIME 0 9 RECEIVED PATIENT DESTINATION: J I U( VN;/ FRO SCENE- ❑ FIRE TIME 10 97 ❑ PSAP TIME 10-49 11 MtLEAG ❑ OTHER/PVT TIME 10-7 r END TIME 10.98 T�1 A'.i •` DOCTOR ' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME r=l.i:❑ NEAREST! ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: c) PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J U RESPONSE ZONE- 0 ONE❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ``�� PATIENT CONDITION: DRIVER EUE0-n > �'-� EMT-1A i I� TECHNICIAN M oc)1_�_ '� PARAMEDIC Hx: _ DISPATCHER: L9 72 - CHIEF COMPLAINT: I DRY N: YES NO REASON FOR DRY RU' S " AUT I O (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 CROSS M: TOTAL MILES: X MEDICARE E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO '1 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: a MEDT-CAL N: CODE 2/3 r 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) Jy - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: 1 r COMMENTS: I TOTAL J w a � , PATIENT RECEIVED BY: X ►}v tri dor roAvir, whit, .+•.1 Pi,;: (SIGNATURE) •��� Nrli�nr Y,•'; t "u Lhrn t i 1 ia,r EMS-1 i r CONTRA COSTA COSTA COUNTY AMBULANCE P E-HOSPITAL CARE FORM I UNIT AUTHORIZATION#P,:3--j� j:3_0 CHECK OR FILL INAPPROPRIATE SPACES DATE: ._ _2' PATIENT'S NAME—_ _ _ O M O F COMPANY# / ADDRESS —_— AGE—_—_ A CITY STATE --- ZIP—___—_-. __ DOB-__.—_._ ❑ Sn OM ❑ T OW ❑ Th ❑ F ❑ S ) DRIVER'S LICENSE# __--_--_-_ _ ._-.._..._.._.. PHONE.___ - ____..—___— NATURE OF DISPATCH.k lt) 1ylk)LSS - TYPE OF TRANSPORT: AMBULANCE❑ OT/HER❑ INCIDENT LOCATION: /f7/ -/'I RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR C4pS,K) y Y (�/,,ff//'',, t ` /� TO SCENE �S'.O. __—_.__. CALL RECEIVED �1 1 1 V l�J. ►"1��. -- — ❑ P.U. TIME 10.8 —� PATIENT DESTINATION: FROM SCENE - ❑ FIRE — TIME 10-97 —3 lc ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10.7 END —_ TIME 10-98 DOCTOR _ PMD/ER START-. `LTIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME O NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK#: AMBULANCE COMPAgY:. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO ❑ WAL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION, DRIVER.-_�`'S_( LCMM . ___�__ EMT-1A TECHNICIAN Y _ PARAMEDIC Hv — —_ DISPATCHER: ^ _ t J CHIEF COMPLAINT: —_ DRY RUN: AYES ❑ NO REASON FOR DRY RUN - T I AI A / —__ A THORIZATION F R 4UN{EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X f` ;l MEDICAL COVERAGE- INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: C)r 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 ❑ 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 ❑ 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 V -------f—_—__---------._._. -.__-- ._.._.. ---.---. PATIENT RECEIVED BY: X ,., (S1C;NATI)RE) </ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FOR I UNIT AUTHORIZATION M 5 j "/ 2 7 3 .1 6 CHECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME-It •+ a•— T F 1 ® M• O F COMPANY a ADDRESS l Q -7b L ro! A.,*. 13 / AGE`•U I CITY Z r STATE C ZIP DOB O Sn O M ® T O W O Th O F ❑S DRIVER'S LICENSE N _ PHONE 1b4__LS'i�l_— NATURE OF DISPATCH �/�r�t •-� - TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _ — STATION I(A)_2(B)._3(C)_4(D)_6(E)_ INCIDENT LOCATION:` I RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- tR S.O. CALL RECEIVED /5,0 1 0 7 6Log ,.0 1 I ( • 3 ❑ P.D. TIME 10-8 PATIENT DESTINATION- FROM SCENE - O FIRE TIME 10-97 O ❑ PSAP TIME 10-49 /��( L'fiic_lr-ram MILEAGE: ❑ OTHER/PVT TIME 10-7 - • END TIME 10-98 , {; {,• r j DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: _ .. . TOTAL STANDBY TIME O NEAREST„ ! ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN T CE: S LD RESPONSE ZONE S ❑ YES \��3L7�� ❑ WALKED ❑ GUERNEY ❑ OTH ' PATIENT CONDITION: DRIVER RG, iw, EMT-1A TECHNICIAN L/ PARAMEDIC X 9 / Hx: - DISPATCHER: ' T y tt/ CHIEF COMPLAINT: d S S DRY RUN: S? YES ❑ N • REASON FOR DRY RUN /G - S5. t7 q / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 95;- :1 i . : PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF ATIENTS: S.S. l y� PRIVA INS.CO.: BASE RATE: KAISER M: �' MULTIPLE PTS. ASE RATE BLUE CROS K: I� TOTAL MILES: X MEDICARE 0: E.O.B.ATT. ROUND TRIP: ❑ YE ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M:” ' EMERGENCY RUN: MEDICAL M: CODE 2/3 OTHER: OXYGEN:. (PER TANK) P.O.E. STICKER ❑ YES O NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSiBLE RTlI: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: REL IONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: .(IF NOT REPLACED) `CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) 1 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) -!-Id c EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: - STATE: ZIP: COMMENTS: TOTAL: `.I PATIENT RECEIVED BY: X (SIGNATURE► Provider retain Yhi t, (mf I'o _pj, 4vtur•n V' ."L' ,q+ .. .1 !..r ,..., TN`'1 ' \ CONTRA COSTA COUNTY L/ RM I UNIT AUTHORIZATION)R FILL IN APPROPRIATE i SPACES DATE_J PATIENT'S NAME 7 ' /)//'j --_'_ '--__-- Ow OF / xooncsy ___'_____-_----__ c/rv- -_ srAre __. z/p ' - ooa - - O n" o m AT OW O r^ OF OS . � '' /4»������'� DRIVER'S LICENSE - - - nmws wAx/ns nrmo`*l Cn' xnd� Ll� .^'���-_' `~ TYPE OF TRANSPORT: AMBULANCE�-( CTHER � INCIDENT LOCATION: RESPONSE CODE- REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE CALL RECEIVED / (1 � PATIENT DESTINATION FROM SCENE- 11 FIRE TIME 10-97 PSAP TIME 10-49 END TIME 10-98 ' DOCTOR __'PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 13 NEAREST 0 FAMILY 0 TRANSFER WAIT TIME 0 PATIENT 0 DIRECT 0 OTHER CALL BACK AMBULANCE COMPANY: � � � � n^nswr cnwomow. on PARAMEDIC *x- mupA/cHsn: CHIEF oowpLA/wT. onv nuw;85 YES O wo« AAsnm FOR onv nu AurHon/zAnow FOR onv num(EMS USE uxun / pArIswr nsruyso ssnWCss� (o/swAruns) � MEDICAL COVERAGE: /wousrn/AL O vsa O NO NO. opPATIENTS: S.a * pn/vATs /wa CO: _-_-_----_--__' aAas nAre xmasnMULTIPLE PTS BASE RATE BLUE CROSS cnossw -_-___-_ TOTAL w/Len� x wso/cAns E.O.B. Arr. nouwo rn/p- O vsa O NO O vsa O NO w/sHr (19:00 or:oo) ocHpvppnP#: _____-_-__-__ smsnsswcv nuw. mso/'oAL *:-_------''--___---'-----' CODE o/o OTHER: oxvssw: (psn TANK) P.O.E. aT/cxsn ovso 0 N NEONATAL: (/wcuoAron) \ DATES BILLED. srxwoay. (OVER /sm/w) _____' ------- sa.s' (PER EPISODE) -___-_ ---_-_- msARssr RsLAr/vs/nsopoma/oLs pAnrv- /v: (psn Aom/w)_'___---_--� x ----__ _---__ onuoa: (PER Aou/w.)----__--_-- x NAME: nsLAr/owsH/p:__'__-- c oA.: (/r NOT nspLAcso) Aoonsoa: ORAL A/nvvAv (IF NOT REPLACED) c/ry srArs_---_Z/p:__-_-- o'CouAn: (|p NOT nspLAcso) pHows: wonx pHows onv nuw (AuT*nn/zso) ------_ ��&�-_ swpLovsn: oonupAr/om.---_''-__-- orHsn ADDRESS:------ ' - C/T,- ____-_____--_---___ srAre:___- z/p:__--_- � oowMswTs:--_- ---_---_-'-_ --- ' - -------__-'--_-_--_-�_----_' I»Im /wl/iw/ oLcs/v/o ov x 'nfu^nx,/I . � 1'v CONTRA COSTA COUNTY AMBULAI`)CE� X�7 •�� PRE-HOSPITAL CARE FORM I ONI1 I //(f1 AUTHORIZATION a CHECK OR FILL IN APPROPRIATE SPACES l� / I 'J PATIENT'S NAME ❑ M ❑ F COMPANY# ADDRESS _ _ AGE. CITY-- S ATE.. .______`_ 1P__—_-.__ DOB___--_. ❑ Sn ❑ kj,� ❑ W/O TThh ❑ F ❑ S DRIVER'S LICENSE a PHONE -__ _. .__.-__._. NATURE OF DISPATCH.— TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CO�) EOUFSTED BY TIME - (24 HOUR CLACK) .. TO SCENE �<� O. CALL RECEIVED ( ❑ P.U. TIME 10.8 }� 1-1- 1 PAJIENT DESTINATION: FROM SCENE - ❑ FIRE --- TIME 10-97 4 Ll-K2 E��; — ❑ PSAP TIME 10-49 �J -�e �—L`. MILEAG ❑ OTHER/PVT TIME 10-7 f p END'— _-- TIME 10-98 �— DOCTOR -_ PMD/ER START— _ TIME 10-22 _ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMEC-(�It PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' ❑ YES ❑ NO ❑ WAL`:ED '❑ GUERNEY ❑ OTHER �` } PATIENT COND TION. DRIVER_ \ _ _ EMT-lA— f TECHNICIAN _ l. ✓ � � !�V PARAMEDIC Hx: - _ ^ DISPATCHER: CHIEF COMPLAIN _.__ _--_ DRY RUNI. ES ❑ NO REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) ✓ �-- 'V �(1(� PATIENT RE USED SERVICES: (SIGNATURE) X—__-_ �I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.:-_— --_--_--._._-- BASE RATE: ' KAISER a: MULTIPLE PTS. ATE BLUE CROSS#:—__— TOTAL MEDICARE #: E.O.B. ATT. ROUND TRIP: ❑ YES Cl NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: MEDI-CAL#: --^ CODE 2/3 OTHER: �__ OXYGEN: (PER TANK) P.O.E. ICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) _ �1DAT BILLED: _ STANDBY: (OVER 15 ) I E.K.G.: (PER EPIS E) EAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER AD )_-. _X DRUGS: (P R ADMIN.)__— —X NAME: RELATIONSHIP:`-- E O.A.: ( NOT REPLACED) DDRESS: _ ORAL IRWAY. (IF NOT REPLACED) Cl STATE-,ZIP. C-COLE .R: (IF NOT REPLACED) PHON WORK PHONE:_-_,.___—_-._- DRY RUN: AUTHORIZED) EMPLOYER: OCCUPATION ---- --------- OTHER: ADDRESS:--=- ----- -- -- - - - - -- . -- ---- - -- --- - -- CITY: —_ _ STATE:.----- ZIP:_-- --- ----- - COMMENTS: - -- ----- -_ - -. . TOTAL �J.V - ------ --------- - PATIL NT RECEIVF.n BY. X 1•n�rlrr rrhrLn:;l. .( r•:.: ..I.. . .� (SIGNArURF) fn• I CONTRA COSTA COUNTY AMBULANCE L PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION R � CHECK OR FILL IN APPROPRIATE SPACES DATE PATIENT'S NAME._�! � a..k)uU v0` 0 N - - -._J _ __. . ... - ❑ M F COMPANY 9 ADDRESS -2- 00c) �-e\ 4 Lrp�,-1� n ,tA� .. AGE CITY.-_M-. �. _`� A,// STTATE___.L.`._�-.___ ZIP._.(.`t SS ? _ DOB US'��.�I!9^I ❑ Sn ❑ M2/TOW ❑ Th ❑ F OS DRIVER'S LICENSE a _._/ 1' ` PHONE J7`�- V 27-- NATURE OF DISPATCH _ ��l ru/1s TYPEOFTRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY TIME - (24 HOUR CLOCK) TO SCENE - ❑ so. CALL RECEIVED ---WC,_-- _ _-.___ ----...._ __ ___ ❑ PD. _____-_.. TIME 10-8 PATIENT DESTINATION: �� �/ � FQOM SCENE - ❑ FIRE ___.._.__ TIME 10-97 ❑ PP TIME 10-49 MILEAGE a OTHER/PVT TIME 10-7 END__ _ • _ TIME 10-98 DOCTOR ��_`�� '( 5 PRAN RSTART_ . TIME 10-22 HOW CHOSEN TOTAL � i -_ —_ - STANDBY TIME O NEAREST ❑ FAMILY ER _- WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER JAI- CALL BACK R: AMBULANCE COMPANY: PT AMBULORY9 PATIENT TAKEN O AMBLICAN f t� RESPONSE ZONE �-- ❑ YES NO GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER_V�_-- EM �(E ia_ C I_� . � T-1 t TECHNICIAN PARAMEDIC r / Hx. �R�.. -___ _— -_ DISPATCHER: CHIEF CO h1PLAINT:r�QQ" _`N t rgA_s5 e! DRY RUN ❑ YES Q'NO REASON FOR DRY RUN L� 41 l�i'LS_ 4 �1.LY - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL V RAGE: II�(DUSTRIAL ❑ YES O NO. OF PATIENTS: PRIVATE INS CSC) Q��•�1 —� BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE _ BLUE CROSS#: _ TOTAL MILES: _ 1q X �• � -fU 1 MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES O NO DYES ONO NIGHT: (19:00- 07:00) CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL a: - CODE 2/3 OTHER: OXYGEN: (PER TANK) i 'f 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: LOQ.�i�i C_t SI-UA RELATIONSHIP.1.:_ E.O.A.: (IF NOT REPLACED) ADDRESS: t _-__ _ _______._. ORAL AIRWAY: (IF NOT REPLACED) CITY:,2aI`1' A 4c, U STATES ZIP:._ C COLLAR: (IF NOT REPLACED) PHONE: �y� ~3 WQF;FC HONE: DRY RUN (AUTHORIZED) EMPLOYER:L + u``,,``N UQ�`ION: rc� IN- OTHER: ADDRES 4 �}J ��// CITY: A r STAT :�A_ZIP:q�!- COMMENTS: - _.._, ------- -- - IOTAL PATIENT RECEIVED BY X��1�j _ > N L $I ATUHfI Ih•ari.l,'1 IY'f rl: . 4'I;i•. r,.l .. I. ., .o rr , CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT yJ AUTHORIZATIO•N-# • CHECK OR FILL IN APPROPRIATE SPACES r DATE: `PATIENTS NAME } pl M ❑ F COMPANY# ADDRESS AGE �'� "/"1 2/ 0 -/ CITY fAL5A r STATE ZIP DOB" _ ' ❑ Sn O M kf T ❑ W ❑ Th ❑ F ❑ S. 2•-� I DRIVER'S LICENSE It _ _ PHONE __4ATURE OF DISPATCH M fI)/C�L TYPE OF TRANSPORT: AMBULANCE OTHER❑ — _ STATION I(A)_2(B)_3(C)_4(0)_51E)_�_ INCIDENT LOCATION: RESPONSE CODE: FjEQUESTED BY: TIME— (24 HOUR CLOCK) [/ �/C p� r�1 TO SCENE- 3 �*(S.O. CALL RECEIVED 7 /� T_/`1 / ❑ P.U. TIME 10-8 �- PATIENT DESTINATION: FROM SCENE-� 13 FIRE TIME 10-97 y 0 !I� /� /� {Q ❑ PSAP TIME 10-49 COyw7X OJ1 • MILEAG ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PM ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME • 0 NEAREST . Cl FAMILY ❑ TRANSFER 1 WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER /I. ! CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �_� j } RESPONSE ZONE ❑ YES P(NO ❑ WALKED O(GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LUQ LOAM f LI` EMT-tA ` ( I TECHNICIAN L^ti('))1AM -5 Hx:�(fOtlo( AAyJF I U LLIt (SLG-!(DISPATCHER: CHI F COMPLAIN7,: I>'. LU �. DRY RUN: 0Y ES NO REASON FOR DRY RUN I. d'WW AUTHORIZATION FOR DRY RUN(EMS USE ONLY) f ATIENT 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 C TOTAL MILES: . ~ X MEDICARE-#: -'< i- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r7 •?•� ❑ YES ❑ NO NIGHT: (19:00-07:60) EMERGENCY RUN{: � L 1 MEDT-CAL C CODE 2/r3 1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) c,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: Y RUN: (AUTHORIZED) EMPLOYER: OCCUPATION .d FfER: ADDRESS: CITY: STATE: ZIP: COMMENTS: — TOTAL PATIENT RECEIVED BY X tti• ::':r •, i (SItiNRT11AF) .. . Irl CONTRA.COSTA COUNTY AMBULANCE. �J PRE-HOSPITAL CARE FORM I UNIT ® AUTNORIZATION N L� CHECK OR FILL IN APPROPRIATE SPACES DATE: 2 PATIENT'S NAME ����^�.r. i � /�,�'L'f?"J (� _ M ❑ F COMPANY p ,� ADDRESS AGE CITY ..cj1_. / --- iLrFJ( /^J� �------ / y STATE—�!— ZIP—_ DOB_____ b0 Sn D M D TAW O Th OF OS '' // •• DRIVER'S LICENSE is _ ._ ....__ .-_ _. '..__...._ .__._.- PHONE 5._.-- NATURE OF DISPATCH �w I TYPE OF TRANSPORT: AMBULANCE OTHER❑ r—) INCIDENT LOCATION RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR LOCK) -- o� TO SCENE ❑ S.O. CALL RECEIVED D P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - Z D FIRE — TIME 10-97 l� ❑ PSAP TIME 10-49 r i .. � MILEAGE. ^^ // 43 OTHER�PVT TIME 10-7 END ! LXTIME 10.98 tiLL.L DOCTOR _ — PMDR STARTa . ✓ " l ox TIME 10-22 HOW CHOSEN: ''ll// TOTAL !:4--- C — STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER l WAIT TIME ; ❑ PATIENT ❑ DIRECT ❑ OTHER Z l CALL BACK M: AMBUL C PANY: PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: fy RESPONSE ZONE_ YES ❑ NO WAL:ED ❑ GUERNEY 13 OTHER PATIENT CONDITION: DRIVER-�U�4_41 aS —EMT-tA TECHNICIAN _ _ �(1`_ PARAMEDIC Hx: _L_�_r�/�_!/ L/ C�' DISPATCHER: _11L�J CjF✓ I b C� IEF,,CO11MPLAINT: __ .._.�L �<<- DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ` PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE INDUSTRIAL ❑ YES)o"NO NO. OF PATIENTS: v S.S PRIVATE INS. CO.'. BASE RATE: LrL_6 KAISER a: _. _—._____ __ MULTIPLE PTS. BASE RATE BLUE CROSS p: ___._.— _ — TOTAL MILES: o' X L�� MEDICARE(t:— —_.—_— E.O.B. ATT. ROUND TRIP: D YES O NO �� ❑ YES ❑ NO NIGHT: (19:00- 07:00) -50 d-} CCHP/PPHP EMERGENCY RUN: MEDI-CAL a: —. __—_._--- CODE 2/3 OTHER:_ —__ —_._ OXYGEN: (PER TANK) t ' P.O.E. STICKER ❑ YES ❑ NO — NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 j I E.K.G.: (PER EPISODE) NEAREST RELATIVE/RE PONSIBLE 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: - — --- -- —— — CITY: __ __.__.___________ STATE:. ZIP:-- r IP: _r ---- r.IMENTs:_1....1. -------- ------- ------ ----------..— TOTAL c PATIENT RECEIVED BY: X (SIGNATURE) r1':�u:..rr rr�„�• ... Tn :.r! _ .. F%C LArn Fil-inp 015-1 _sem CONTRA COSTA COUNTY AMOYkANCE �j /!/( /�, PRE HOSPITAL CARE FORM I UNIT i� AUTHORIZATION# d - - 7 L CHECK OR FILL IM PPROPRIATE SPACES DATE: PATIENTS NAME re ❑ M FF COMPANY N t ✓` / 1 I ADDRESS AGE , i . O J / CITY_�� A tC�• STATE ^ ZIP — DOB L ( 3 O Sn ❑ M O T A W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ __ PHONE___._—___—_ NATURE OF DISPATCH Au rd - TYPE OF TRANSPORT: AMBULANCE D OTHER O _ -- STATION 1(A)_2(B)_3(C)_4(D)_5(E)7 INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY. TIME— (24 HOUR CLOCK) TO SCENE- P.D. TIME 0-8 RECEIVED I PATIENT DESTINATION: Hu FROM SCENE - ❑ FIRE —_ TIME 10-97 iri ❑ PSAP TIME 10-49 t-q �— . N MILEAGE: ❑ OTHER/PVT TIME 10-7 r LI �+ END_-1�L1L TIME 10`98 09 DOCTOR STF�nI PMD('I--y START TIME 10-22 HOW CHOSEN: TOTAL--qSTANDBY TIME AINEAREST ❑ FAMILY TRANSFER WAIT TIME _— O PATIENT ❑ DIRECT ❑ OTHER cf) CALL BACK M: AMBULA=PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ZONE YES ❑ NO ❑ WALKED *GUERNEY ❑ OTHER r PATIENT CONDITION: DRIVER 4? C1_1X1Y `f �� EMT-tA TECHNICIAN / y -' PARAMEDIC ✓ Hx: DISPATCHER: 13(' CHIEF COMPL J T: L CL C DRY RUN: ❑ YES )q NO REASON FOR DRY RUN / U/ L--R-) 112C V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REF ED SERVICES: (SIGNA RE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: �� I KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) r CCHP/PPHP0: EMERGENCY RUN: ��• ` �J MEDI-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) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:A� _ TOTAL:-.-A _Q�.._ C. -- -- — — PATIENT RECEIVED BY: X - (SIGNa* IRE) I•n mi/o r• r�f.r �Q•r. INC-1 1 I CONTRA COSTA COUNTY AMBULANCE i- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FIL[ IN APPROPRIATE SPACES GATE: 2 t- Llf ATIFNT'S NAME ,�L�"/V17'/ ..1 _F_ 1�1/SII . . -------.- ❑ M VF COMPANY p. ADDRESS - ---1 - - --- ---- AGE CITY- STATE__ �_J:� ZIP__ DOB ❑ Sn ❑ M ❑ T>%W 13 Th O F O S DRIVER'S LICENSE it ..... _ .... _..__ PHONE ...__ _.- NATURE OF DISPATCH 0• ✓, TYPE OF TRANSPORT AMBULANCF OTHER❑ INCIDENT .00ATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- r` S.O. -_ CALL RECEIVED LQ r.CI�r7r - ------ -- v-- ❑ P-O. TIME 10-8 _L/�,,L PATIENT DESTINATION FROh� SCENE ❑ FIRE —� TIME 10 97 �•v ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 :7 Z jf 1 END -. TIME 10-98 -/ DOCTOR PMO/ER START— TIME 10-22 :� HOW CHOSEN: TOTAL .- _. STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMB C COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE ❑ YES Cl NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVECJ)-U1.\JtA.C__ t4 SEMT-1A TECHNICTAKTJ,4 0 PARAMEDIC H". 1 L1. .:..--In1'�- >.•. --�. -�.._.I' rn DISPATCHER: _ �C' CC _ L 0 c CHIEF COMPLAINT: _..... ._.... .- ___._-..._.-___.__-__- DRY RUN: WYES ❑ NO REASON FOR DRY RUN AUTI{pRIZATION FO$�{iY RUN(E USE ONLY) , PATIENT REFUSED SERVICES (SIGNATURE) X rPoll MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO Of PATIENTS: � I S.S. it - -- ------ ---- PRIVATE INS CO.: BASE RATE: KAISER sr= -�_ MULTIPLE PTS. BASE RATE BLUE CROSS++:__- _ _ TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES Cl NO NIGHT: (19:00-07:00) CCHP-PPHP a: _ ___ -- - EMERGENCY RUN: fir, MEDI-CAL�:-- CODE 2/3 ll OTHER OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES Cl NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPOrSIBLE 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.- DRY RUN: (AUTHORIZED) 2� EMPLOYER. - -____,__. OCCUPATION: OTHER: - ADDRESS:----- --- --- ----- — CITY: .-^-. -_-_------_------.__ STATE:---ZIP:-- - COMMENTS:.1-L-�,_ nw-!vrc TOTAL:55 -2 ------ --._ -_--_ ---- -- --__-- ---.—._.-. PATIENT RECEIVED BY: X 5C 1r dimer• (SIGNATURE) CONITIA COSTA COUNTY AMFIULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: q.5 tom] to -. PATIENT'S NAMEC-�_T_P�� ( 13M RF COMPANY M I2-7 ADDRESS �ZC Z Il vC_\ CQ V� i JLr'G%t-A6E�� CIT tri I P STATE a uC21"6 I � DOVJ9-16-6 ❑ Sn O M O T O Th O F O S ' . DRIVER'S LICENSE a P ON� 6�•LS�L NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE CK OTHER❑ STATION I(A)_2(B)._._3(CI&"4(D)_5(E) _� INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- OrS.O. CALL RECEIVED l.•T ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10.97 �1 ` 1 ❑ PSAP TIME 10.49 1151 �L�1 rn I� MILEAG 13OTHER/PVT TIME 10.7 / END a TIME 10.98 DOCTOR Ls_4 , vl PM Q8A START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME t' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ,$PATIENT ❑ DIRECT ❑ OTHER 2� CALL BACK N: AMBIJL#NgqCAINTT��'' �) ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE _ YES ❑ NO O WALKED) GUERNEY ❑ OTHER PATIENT CONDITION: DRIVE Ft�-� h 6O0 EMT-lA TECHNICIAN �n � fbRAMEDIC ' Hz: .__1�SL����_- DISPATCHER-!!:R'_I L e m y CHIIPCOMPLAINT: Z Z 4- DRY RUN: ❑ YES GKO REASON FOR DRY RUN 1 ' S I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X ' v MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: I S.S. M UH K ,I 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/PPRP M: EMERGENCY RUN: ti uk MEDI-CALM: CODE 2/3 (- OTHER: �vl l�} b T F�r� Fo- Fr+yOlo_ OXYGEN: (PER TANK) -+ P.O.E. STICKER' ❑ YES ❑ NO NEONATAL: (INCUBATOR) } DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST]RE i�jIIVAF.[R SPOtsISIIB(E��TY.. �� I.V.: (PER ADMIN.) X W ( I r/'\ DRUGS: (PER ADMIN.) X NAME: ( r V r W(ELATIONSHIP: (� 0 E.O.A.: (IF NOT REPLACED) " ADDRESS: S__ ` p ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE.__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYERC_NeV_ `1l__L6�?OCCUPATIONS Il"i 34ur OTHER: ADDRESS: aI;h Cc__ CITY: �''' STATE: ZIP: COMMENTS: .�� 56 CIO PATIENT RECEIVED BY:X ,SC_ Prhuider recaic Vhie ,.rd (SIGNATURE) •no fir•..- IY'j.�• nr .•4,. }. ;q0 D�f-1 NI (� CONTRA COSTA COUNTY AMBULANCE p PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION R CHECK OR FILL W APPROPRIATE SPACES DATE:. �°1y ISS PATIENT'S NAME__ ! M ❑ F COMPANY ADDRESS --kola_Q�— t _ AGES 13 CITY 5,�. _-.. STATE G� ZIP p O(✓ DOB"'1.�� 4� O Sn O M ❑ T ❑ Th O F O S ') DRIVER'S LICENSE # ---------- .... _. PHO•Ny�•- - �_ T E OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME— (24 HOUR CLACK) — _ 70 SCENE- j S O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- Z ❑ FIRE TIME 10-97 13PSAP TIME 10.49 • 1 MILEAGE: ❑ OTHER/PVT TIME 10-7fr? :�• �p END 55i0 TIME 10-98 DOCTOR _ RJLS?1lN�_L�-- PM ER START__ TIME 10-22 HOW CHOSEN: TOTAL —_Z•b STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ATIENT ❑ DIRECT ❑ OTHER I > CALL BACK N: AMBULANCE COMPANY: .- C c-10- r' , CA j kTyES AMBULATORY? PATIENT TAKEN TO AMBULANCE: SRESPONSE ZONE ❑ NO ALKED ❑ GUERNEY ❑ OTHER _...— PATIENT CONDITION: DRIVER - EMT-11A II TECHNICIAN MA2?,nj�h,--j 21LI PARAMEDIC Hx- .,. �C �T=-rj b rJ_ _ DISPATCHER: t [,r ( CHI EFaMPLAINT: _ —j� DRY RUN: OYES REASON FOR DRY RUN AUTHORIZATIO R DRY RUN(EMS USE ONLY) ( 1 PATIENT REFUSED SERVICES: (SIGNATURE) X_— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. n -- PRIVATE INS. CO.:—_ BASE RATE: KA115FR#I Il MULTIPLE PTS. BASE RATE BLUE CROSS $I*-L- ' " 4 ! TOTAL MILES: b` X �•✓y IvEQ1CAAEM ` E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO �✓ . ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: ct) "Z 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) EMPLOYER: — OCCUPATION: OTHER: ADDRESS: —� CITY: STATE: ZIP: COMMENTS: -- — -- TOTAL: PATIENT RECEIVED BY:X _ #SIGNATURE) ►JfS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION a— CHECK OR FILL IN KROPRIATE SPACES DATE: �1 d Ll �3 I PATIENT'S NAME _47% _____-v ❑ M ❑ F COMPANY#/ ADDRESS _ AGE I A 1)'11 Al 4 t ` CITY,.---_-.-- STATE --.----.---.-.... ZIP_..._ _ .----- - DOB ._ ._.._ . ❑ Sn ❑ M ❑ TW GJ'Th OF ❑ S T DRIVER'S LICENSE M PHONE _ NATURE OF DISPATCH ._..1L_-_.i_,_ —_..._ TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE REOUES TED BY: TIME - (24 HOURC OCK) i -� c Lv TO SCENE ❑ P.D. _—--_ TIME 10-8CALL EIVED 41 :417- I PATIENT DESTINATION: �'I�. FROM SCENE ❑ FIRE —_ TIME 10-97 � �/�' Y � ` � -_ _ O PSAP TIME 10-49 i �l MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER STAR'— -- TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME L ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER _ F I f PATIENT CONDITION. DRIVER TECHNICIAN _— ____ " PARAMEDIC Hx: _� ?_ l�r� I�.t� ��. C - DISPATCHER: 11 CHIEF COMPLAINT: DRY RUN: KES ❑ NO REASON FOR DRY RUN -Z AUTHORIZATION FOR DRY RUN(EMS USE ONLY). / PATIENT REFUSED SERVICES: (SIGNATURE) X �- I 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a - ------- ----- PRIVATE INS. CO..—_—_—____._... _._____..--.__.______-. BASE RATE. — KAISER a: —_ _._.. .......___. _....____ ._.._.... .__ MULTIPLE PTS. BASE RATE BLUE CR a TOTAL MILES:-_.___.__—.___-- X , MEDICAR�a:— E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHPJPPHP a: EMERGENCY RUN: MEDT-CAL a: CODE 2/3 OTHER: __ OXYGEN: (PER TANK) P.O.E. STICKE ❑ YES NO NEONATAL (INCUBATOR) DATES BILLED — STANDBY: (OVER 15 MIN.) i E.K-G G . (PER EPISODE) NEAREST REL TIVE/RESPONSIBLE PARTY: I V.. (PER ADMIN)_.� — X — DRUGS: (PER ADMIN.) _..__.__.�X 1 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) S- EMPLOYER: — OCCUPATION:-.---- .-.------ OTHER ADDRESS:----------- ---- ------ — —..—- - -- ----- - CITY: STATE:------ZIP:-- COMMENTS: TATE:------ZIP:_-.—COMMENTS: —__— TOTAI - ----- -- I - I,AIII NI NI c:I:IVI II 14Y X :I/ulnnnlrI CONTRA COSTA COUNTY AMBULANCE oI PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N t I CHECK OR FILL IN APPROPRIATE SPACES DATE- -I ATE: PATIFNT'S NAME-L. NC_�_,____. r v',� XrM ❑ F COMPANY a (,I ADDRESS _ # J l -1 i �2- AGE )/ LtA015lia, CITY � IC. L_ STATE_�� ZIP �n _ DOB Ste_' ❑ Sn D M O T O Th O F O S DRIVER'S LICENSE a _._.. _ PHONE�� �.—_ NATURE OF DISPATCH � TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _—.—__ STATION 1(A)_2(8) IC)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REqWIfSTED BY: TIME•— (24 HOUR CLOCK) j TO SCENE - ? S.O. CALL RECEIVED -�-- V D P.U. TIME 108 *..�5 - PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10.97 :3Q �f _ O PSAP TIME ID-49.(�u MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 j DOCTOR _ ,� -- PMD/ER START--- TIME 10-22 HOW CHOSEN. TOTAL STANDBY TIME ❑ NEAREST ❑ A ❑ TRANSFER WAIT TIME O PATIENT ❑ T ❑ OTHER CALL BACK a: AMBU�IE COMPANY: - PT ULATORY? PATIENT TAKEN TO AMBULAN J RESPONSE ZONE _ ES ❑ NO ❑ WAL':ED ❑ GUERNEY OTHER ` PATIENT CONDITION: DRIVE )1�'A ���- EM IA ' TECHNICIAN C 'e- PARAMEDIC_ L H. S DISPATCHER: !• S / CHIEF COMPLAINT:�� DRY RUN: YES ❑ NO REASON FOR DRY RUN UT //1��gqT��IOty DRY R (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 a: MULTIPLE PTS. BASE RATE BLUE CROS$a:_ TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO - D YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP a: EMERGENCY RUN: MEDI-CAL a: CODE 2/3 --.• . OTHER: OXYGEN: (PER TANK) - I P.O.E. STICKER ❑ S ❑ 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) V/7 ' EMPLOYER: ,_ OCCUPATION: OTHER: -' ADDRESS: CITY: _ STATE: ZIP:- MW IP: -- C MTS: 1 v � f �r- TOTAL: U' - C PATIENT RECEIVED BY:X S c OIf-1 Pr-ovider r.toi: L'hi[r '-r'! P:r: (SIGNATURE) .. ,•qp 5atur+• )Y'Irc -,Ir?.1 !TLS uArn DiT inp , CONTRA COSTA COUNTY AMBULANCE r P.RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M L� ' CHECK OR Ffll INAPPROPRIATE APPROPRIATE SPACES DATE: .��_J =I C Z PATIENTS NAME OM OF COMPANY# / ADDRESS � AGE J I t CITY ��� STATE ZIP_-__. D08 �_�L1xro SR ❑ M ❑ T W) O Th OF ❑ S DRIVER'S LICENSE M PHONC3AD _U L—C14ATURE OF DISPATCH C om! TYPE OF TRANSPORT: AMBULANCELT OTHER❑ __ STATION I(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REgLJESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. _ CALL RECEIVED l �o 2ocO �� ��.n-t�� y, O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE -- TIME 10-97 TZ .T 7 J 7� O PSAP TIME 10-49 MILEAGE: C� O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR�� � PM /ER START TIME 10.22 HOW CHOSEN: / TOTAL STANDBY TIME ❑ NEAREST efFAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPANY: PT./�MBULATORY? PATIENT TAKE ,WfO AMBULANCE: RESPONSE ZONE YES ONO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ' EMT-1A_ TECHNICIAN PARAMEDIC Hz: DISPATCHER: f CHIEF COMPLAINT: VA 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. M PRIVAmoss C .: BASE RATE: ISEMULTIPLE PTS. BASE RATE p: TOTAL MILES: 1 X +�7 MEDICARE tt: E.O.B. ATT. ROUND TRIP: O YES ❑ NO 3 O S O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL p: CODE 2 i 3 I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) J E.K.G.: (PER EPISODE) �'. NEAREST.RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 1� DRUGS: (PER ADMIN.) X `I NAME. ELAT IONSFH_IP E.O.A.: (IF NOT REPLACED) I ADDRESS: ORAL AIRWAY: (IT NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHQ4[�N: DRY RUN: (AUTHORIZED) EMPLOYER. �lJL VUt HL�N: C+THER: �• 1 1` s' ADD SS: CITY: %r I STATE: ZIP: I . COMMENTS:Lv ,�� � __ � •-,1-('L'�`� __ �j�„(f�..• .. Z ( �1- TOTAL: PATIENT RECEIVED BY. X (SIGNATURE)_ . H+uvilor rltairs 4hitc uId PirsK ropy koturn Yr:i.v ••q�� t • '.u:: uhrn f.iJ'ind Gt5-1 I CONTRA COSTA COUNTY AMBULANCE (TN�I PRE-HOSPII AL CARE FORM I UNIT ( AUTHORIZATION NR3 _ CHECK OR FILL IN APPgOPRIATF SPACES DATE.1 r C- PATIENT'S NAME ❑ M ❑ F COMPANY a 1 ADDRESS " r I Aoi5�2�, AGE - CITY_.." STATE... _._. ZIP_!_%c�� --. DOB____`-- ❑ Sn ❑ M ❑ T W D Th C3 F 0 S DRIVER'S LICENSE a _ . . _. . P NE _ ._.—.._.__._.—__ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER INCIDENT LOCATION: RESPONSE CODE: RE JESTED BY: TIME— (24 HOUR qL CK) TO SCENE-7S.O. CALL RECEIVED ' D P.U. _ TIME 10-8 ^ ^ PATIENT,DESTINATION: FROM SCENE ❑ FIRE _ TIME 10-97 ❑ PSAP TIME 10-49 _...._.._....... MILEAGE. D OTHER/PVT TIME 10-7 END.— .._ —_ TIME 10-98 DOCTOR ..__...____._... ___._.. PMD/ER START_ __.- TIME 10-22 �� t HOW CHOSEN: TOTAL STANDBY TIME ❑. NEAREST A LY ❑ TRANSFER WAIT TIME _— ❑ PATIENT igCT ❑ OTHER CALL BACK It: AMBUL6NCE..CaM'PAANY: , PT BULATORY1 PATIENT TAKEN T BULANCE: cRESPONSE ZONE_y� ES ❑ NO ❑ WAL ED ❑ EY ❑ OTHER PATIENT CONDITION: DRIVER-. 3 D EMT-1A Z TECHNICIAN .. P RAMEDIC I Hx: ._—�� '�. __—__ DISPATCHER: a v/ CHIEFC,�.�1PLAINT: DRY RUN YES ❑ NO REASON FOR DRY RUN - I AUTRIZAT ON FOR DRY MS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) Xl� i MEDICAL COVERAGE: INDUSTRIAL ❑ 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 O NO O YES ❑ NO NIGHT: (19:00- 07:00) CCHP/PPHP a EMERGENCY RUN: MEDICAL 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 NAKIE:—. RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:___ _ — ORAL AIRWAY: (IF NOT REPLACED) CITY _.. _.�_.._.____-_._, _-.- STATE..____ZIP:.___—_— . C-COLLAR: (IF NOT REPLACED) PIIONE ..—__.._._._._:__.._.. WORK PHONE:_— DRY RUN:'(AUTHORIZED) ] EMPLOYER: _.. _. .__.._ . _. OCCUPATION: _—_ OTHER: Anpnr.qe CIT1' ... ... . STATE:._--_ZIP:- 1 P: ^—^ COMMENT9'�_ __- TOTALS O.0 PATIENT RECEIVED BY: X (SIGNATURE) do-1 CONTRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I }— UNIT AUTHORIZATION K rJ, 111 1S- CHECK OR FILL ONAPPROPRIATE SPACES DATE: - z g 3 PATIENTS NAME�`� � ly �`'1 OM OF COMPANY M ADDRESS AGE� CITY STATE ZIP DOB - O Sn O M O T O Wrp Th OFOS DRIVER'S LICENSE N I PHONE t2E" NATURE OF DISPATCH - TYPE OF TRANSPORT:, AMBULANCE-JO OTHER❑ _ — STATION l(A)_21B)_3(C)_4(D)_51E)_ INCIDENT LOCATION:' RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED C.�, YY ct r.rtr ka 1 W c 3 O P.D. TIME 10-8 ' 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 z If ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR• ' PMD/ER STAR TIME 10-22 f HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBUTA Y? PATIENT TAK,EEN 'IMBULANCE: / ( ) RESPONSE ZONE-S 13 YES NO O WALKED �GUERNEY O OTHER PATIENT CONDITION: DRIVER �C�� G w� �� J�;�' EMT-IA TECHNICIAN _ �d� I a '� PARAMEDIC zr!� Hx: DISPATCHER:( int i'I� .d LIZ. I `ll I CHIEF COMPLAINT: DRY RUN: ;1 YES ❑ NO REASON FOR DRY RUfV�kf I r A TRIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X L MEDICAL COVERAGE: . INDUSTRIAL ❑ YES-6 NO NO. OF PATIENTS: S.S. K fPRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O YES O NO O YES ❑ NO NIGHT: (19:00-07:00) Y CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL K: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) y 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) ,,f PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) 'v EMPLOYER: OCCUPATION: OTHER: ADDRESS: I CITY: STATE* ZIP: COMMENTS: TOTAL: G'Cis c PATIENT RECEIVED BY;X .1'nnilortvfa Vhifr nlli q•� �o/, •• (SIGNATURE) PATIENT'S NAME: Mull er,Kimberly ADDRESS: 1966 Ardith dr_ Pleasant Hi11Ca. DATE OF SERVICE: 08-25=83 AUTHORIZATION NUMBER: 83-14506 AMOUNT DUE: $317.00 INCIDENT LOCATION: Contra Costa County Hospital .A Ward PATIENT DESTINATION: Alta Bates Hospital .Berkely 41 ' 9 14 a� '83 i (!�_� �1uc 25 '91 ',� nuc 15 �► T.(D CAU RECEIVED ! AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 CALLED BY-- PATIENT INFORMATION > I O A(,f N(.:Y -... .. 1-1,�1 1•.t' ' r1C'.,��t.�C� i CUSTOMF-? 4(PT. 1): - D08, 6T1 LJ D DEPT FLOOR ROOrr, a, /�j7.? -.� ___..----------- NAME: .____13"lulle.1C__..._�.mk-)_rk n ,,AA _ L. Z �� m W Zr CALLBACK a �- /,..' I_ „__-_..._.. INS. TYPE: PVT MCAR KHP PHP VA AND CHAMPUS JD U , + IV INCIDENT IOC: 'rr_LCA).—_1POLICY:MCAL a: �- •� � n N a _ ... -.._.._...... --— - - -- - MCAR a: - Z Ss '. m t J ` CROSS STREET: ..... .. .. 11 - ._-----_-_---------.�-------�— VERBAL PRIOOK-19- AQ-0 1 JURIS. �- aa Y - o.o aD DESTINATION: a_._..� C�,�,E'S_._. ��% _— PT. #2 NAME: DOB: s , NATURE: - — - -- - CUST. # _ ; '� '• t' .. .__._ PT. p3 NAME: DOB: r CUST. TYPE OF CALL: EMG knN IIME UNIT 13 - G ' d _.-._�_—_ a m GR ' CREW: ndWAIT TIME: YES NO REASON: m i O UNIT TYPE: ALS L WC RESPONSE CODE: 0 1 Q 3 4 REASON FOR 10.22: p C \ INCREASE/DECREASE CODE:2 3 10.49 CODE: 0 1r) 3 4 CANCELLED BY: /p BY - END MILEAGE: —?V�'� COMMENTS: Nu/�/1R p ty N a TIME. ----_ BEG MILEAGE: a. _.. m D PAT HER: 7 ,j �•, F , TOTAL MILES: _ a P 10 X&Q0 OI1v1S 1V 3DNvin9wv 61.01 9NIN8n13 vin8wv 86.01 31OVIlVAY 3DNV1n8wV L-01 1VildSOH 1V 3:)NV1n8WV 0! 01 �9� Nn 60 01 5Z snb `- LE 5l �c, E8� µd �E 52 �n ' ' t.\.-'„.•�:”�f't1. %it_i���.I..j?''.ti�{,y.':�-��..r:�.•.-'T•f'-�.• ,�:?.V-. f f. • 'F , ow V .earn. .. {�._ .1.+ _n:,,#+y�+fir.''ri•� xS t`., Lo( -. 1 1 i a CONTRA COSTA COUNTY AMBULANCE n ' PRE-HOSPITAL CARE FORM I UNIT n / AUTHORIZATION M CHECK ON FILL IN APPROPRIATE SPACES r U DATE: 3 _ KTIENT'S NAME` I - n t V (2 L- r ❑ M ❑ F COMPANY(M ADDRESS 1 + AGES \ CITY STATE_ ZIP DOB ❑ Sn O M ❑ T O W Rq Th ❑ F O S "+ DRIVER'S LICENSE M ! ! PHONE------ NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE 0 OTHER _ STATION 1(A)_2(B)_3(C)-4(p)_5lE►_ ! INCIDENT LOCATION:! ( \N C . RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) /l `� �I -- --• TO SCENE - S.O. CALL RECEIVED c.I••,G ' •r'� 4. 1• 3/Z ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 � 1 O L212 i G k X22 MILEA ❑ OTHER/PVT TIME 10.7 END TIME 10-98 PDOCTOR T F I PMD/ER START TIME 10-22 - HOW CHOSEN: TOTAL STANDBY TIME rrrL-� •❑,NEAREST,':, ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: 4A :5 PT.-AWULATORY9 PATIENT T TO AMBULANCE: �J i(� RESPONSE ZONE 5 ❑ YES LJ"NO ❑ Whl'<ED ❑ G NEY ❑ OTHER PATIENT CONDITION:; DRIVER :EMT-1A + TECHNICIAN "�� I� �� PARAMEDIC ' I DISPATCHER: 1/30 CHIEF COMPLAINT: DRY RUN:--M YES�O O�REASON FOR DRY RUN G V ' pYj AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /q52 •.. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICA OVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: • - 1 S.S. K PRIVATE INS. BASE RATE: KAISER K`: MULTIPLE PT BASE RATE BLUE CROSS p: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ S ❑ NO O YES ❑ NO NIGHT: (19:00-07:00 CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL q:. CODE 2/3 OTHER:_ OXYGEN:I (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �-NEAREST RELATIVE/RESPONSIBLE PA TY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: REL TiONSHIP; E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) --CITY: STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) --EMPLOYER: OCCUPATION: OTHER: ADDRESS: ---CITY: STATE: IP: -COMMENTS: ' TOTAL: PATIENT RECEIVED BY. X._ — P. ,:i.f�r rvt.tia Vhit• .•/ ni..t 4oti,• .., (SIONAIURE) !h, CONTRA COSTA COUNTY 'i' AMBULANCE r PRE-HOSPITAL CARE FORM I \ UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPICES DATE: - PATIENTS ATE: - PATIENTS NAME "� ❑ M � COMPANY M ADDRESS , , �- AGE_ 7 CITY W ( - STATE ZIP __ D06__74 � Sn O M ❑ T 11 W 0< '0 f O S DRIVER'S LICENSE M _ PHON�14 _z_lZ._�IATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ ._.. _ —__ .._. ____._.... STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: RSTED BY: TIME — (24 HOUR CLOCK) �((' TO SCENE - S.O. CALL RECEIVED l C2 A �� _ ❑ P.U. TIME 10-8 1 -/ PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: c� ❑ OTHER/PVT TIME 10-7 (� END (1 TIME 10-98 DOCTORS {" PM ER START TIME 10-22 HOWCHOSEN: TOTAL .—�j STANDBY TIME ❑ p11AREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER CALL BACK 4 AfNBULANCf� O�ANY: E4O/YES BULATORY? PATIENT TAKENS AMBULANCE: ) I• RESPONSE ZONE ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER J PATIENT CONDITION: DRIVER.LVL A L—( {� I EMT-1A TECHNICIAN — PARAMEDIC J DISPATCHER: �1 L ' Ll CHIEF COMPLAINT: 1 ll ��� DRY RUN: ❑ YES ❑ NO REASON FOR D14Y RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X > : 4/U 72. MEDICAL COVERAGE: I USTRIAL Cl YES NO NO. OF PATIENTS: ( -� S.S. R i PRIVATE INS. CO.: BASE RATE: KAISER w: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE K: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) J P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 7 DATES BILLED: STANDBY: (OVER 15 MIN.) UI I E.K.G.: (PER EPISODE) 6 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN) X L DRUGS: (PER ADMIN.) % X •� 3� NAME: RELATIONSHIPI� J.O.A.: (IF NOT REPLACED) ADDRESS ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WO� �jE: - DR RUN: (AUTHORIZED) Yt, MPLOYER: A ± OCGATIONl'-l� ftf ADDRESS: CITY: STATE: ZIP: COMMENTS: rT;�:' O� TOTAL:__.._. . . .. __. PATIENT RECEIVED BY: X (SIGNATURE) • Pn,vidar tvtair. White 4r:d Pi,;; -,,j+ hute.r+: �. .,_ , W. ul..�.i t i i i,:.I [>+S-1 CONTRA COSTA COUNTY AMBU NC PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 1$ 8sCHECK OR FILL IN an gOPRIA7F SPACES DATE: • 1 lam- PATIENT'S NAME -1" �� F � � c_1�����-� 2AGE F LCOPANY q ADDRESS '.-- '-";71�.�C �_.�>7 ��._ " 13 40 CITY___'Z� E STATE_._._ _ ZIP-__--_-- D - ❑ Sn ❑ M ❑ T ❑ W ❑ F SDRIVER'S LICENSE n _ PHONE ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULAN OTHER❑ INCIDENT LOC TIpN RESPONSE CODE: REOUESTED BY: TIME - (24 HOUR CL CK) �1 17 TO SCENE S.O. __ CALL RECEIVED }�- u 17 1 j_ �1, ---._v. v� / ❑ P.U. - TIME 10-8 - PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 r �� C ❑ PSAPTIME 10 49 I A1ILEAG ❑ OTHER/PVT TIME 10-7 - T TIME 10-98 ' L ,/' � — DOCTOR .- _ (r� 1� PMD START__ - TIME 10-22 HOW CHOSEN: TOTAL -CL - STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME I /�ATIENT ❑ DIRECT ❑ OTHER / CALL BACK N: AMBULANCE COM D PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE D YES, N,O ❑ wr,L':E-? ,UERNEY Cl OTHER v PATIENT CONDITION. DRIVER._!b '{_lJl C� EMT-1A TECHNICIAt 41_j_p - �- PARAMEDIC ._'/Ll ►SDI i�I fix / __ .-L4 ��"z ___ .--. - DISPATCHER' ��_�CHIEFIIOMPLAIN (��. ..°-���fZL�.. � DRY RUN ❑ YES lw O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) J ,( PATIENT REFUSED SERVICES. (SIGNATURE) �•' MEDICAL COV_ERAGE.- / INDUSTRIAL Cl YES_)�O NO. OF PATIENTS: S.S - — PRIVATE INS. CO.: .------- --- -- -- BASE RATE: KAISER a __-_--_.__.____..__._. MULTIPLE PTS. BASE RATE %.. BLUE CROSS if -_--_-.-._____. - TOTAL MILES: X i7 MEDICARE N: - E 0 B. ATT ROUND TRIP: ❑ YES ❑ NO / ❑ YES ❑ NO NIGHT (19.00 - 07 00) CCHP;PPHP N:_- -.._.__- __ EMERGENCY RUN: MEDT-CAL It CODE 2/3 OTHER _12 OXYGEN: (PER TANK) lJ ' P.O.E. STICKER ❑ YES Cl NO NEONATAL: (INCUBATOR) , - - --- -- ' DATES BILLED: STANDBY (OVER 15 MIN.) E.K G . (PER EPISODE) NEAREST RELATIVEiRESFI(.)NSIBL�PARTY, I.V.. (PER ADMIN.) X I(``Il rr DRUGS: (PER ADMIN.) X NAA11 _4 �1 __L�Y__, RELATIONSHIlS_. E O.A.: (IF NOT REPLACED) ADDRESS_.__.___-_..__.___. ._ --__.. ._ .__._.___._- ORAL AIRWAY: (IF NOT REPLACED) CITY STATE.. ....___ ZIP:-._ .__ C-COLLAR. (IF NOT REPLACED) PHONE' :'.]�1 _. WORK PHONE..----.— _ DRY RUN: ,(AUTHORIZED) -- EMPLOYER: ___ _ ._____.___--_ OCCUPATION:--_--- OTHER: ADDRESS:.----- --- - -- - ------ CITY ---CITY' ----�--------..-.__..--- STATE._-__ZIP: _-- COMMENTS:-------------- ------- -- - +" -- - --- --- ----- - ----- ._ TOTAL:�Lks `' PATIENT RECEIVED BY: X !'r•rr„+rte ,.,..,::,. Gti IGNATURE) ctir� ft iiaJ UIS-1 CONTRA COSTA COUNTY t 'AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M l CHECK OR i/lL INAPPROPRIATE SPACES DATE: PATIENTS NAME _ O M O F COMPANY N 7,5 ' ADDRESS; ` (� =�` - � � AGE CITY STATE ZIP DOB - O Sn OM OT OW C7 Th O F O S DRIVER'S LICENSE M PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ -- STATION t(A)_2(B)_3(C)_4(D)-5(E)_ INCIDENT LOCATION:I j RESPONSE CODE: RESTED BY: TIME– (24 HOUR CLOCK) 1 TO SCENE n S.O. CALL RECEIVED til- : /-3 O PO. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 J4 O PSAP� TIME 10-49, OTHER/PVT MILEAGE: ❑ OTHER/PVT TIME 10-7 - END TIME 10-98 PMD/ER START TIME 10-22 1 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST,-:, O FAMILY O TRANSFER WAIT TIME —_ O PATIENT O DIRECT O OTHER CALL BACK M: AMBULANT OM ANY: /b "l I PTT 1v1BULATORY7 PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE +� YES El O WAL KED ❑ GUERNEY ❑ OTHER' �. ter. - PATIENT CONDITION: DRIVER t EMT-lA_ y0 1 r' TECHNICIAN IMS 1") 1 1 DC N L11i7�PARAMEDIC Hx: DISPATCHER: C EF COMPLAI T: T DRY RUN: O YES ❑ NO REASON FOR DRY RUN I zi� ORIZATION FORDRY UI S U LY);Z t .;)Z'.PATIENT REFUSED SERVICES: (SIGNATURE) �[1� I Y 1 1 e Q Y ✓. MEDICAL COVERAGE: INDUSTRIAL ❑ ES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: -•• KAISER K: ' MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE C' E.O.B. ATT. ROUND TRIP: O YES ❑ NO + O YES ❑ NO NIGHT: (1,9:00-07:00) CCHP/PPRP M:, 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.) E.K.G.: (PER EPISODE) '--NEAREST RELATIVE/RESPONSI PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -NAME: -- LATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: S ATE_ ZIP: C-COLLAR: (IF NOT REPLACED) ^/ PHONE: WORK HONE: DRY RUN: (AUTHORIZED) EMPLOYER: OC UPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: V lzi TOTAL '. PATIENT RECEIVED BY: X - (SIGNAiIMF) ria-I ' CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#��iz / . CHECK OR FILL INAPPROPRIATE SPACES DATE: ADDRESS P�6 AGE Th DRIVER'S LICENSE ^ PHONE NATURE urDISPATCH TYPE OF TRANSPORT: AMBULANMq OTHERO ) � INCIDENT LOCATION: I r- D RESPONSE CODE. REOLIESTED BY: TIME- (24 HOUR CLOCK) PATIENT DESTINATION: FROM SCENE - 7 13 FIRE TIME 10-9 0 PSAP TIME 10-4 MILEAGE: 19 OTHER/PVT TIME 115-7 END ccc TIME 10-98 '- . DOCTOR PMD/ER START--'Y- TIME 10-22 HOW CHOSEN: TOTAL STAND13Y TIMV 0 NEAREST 0 FAMILY TRANSFER WAIT TIME 0 PATIENT D DIRECT 0 OTHER CALL BACK it: AMBULANCE PT AMBULATORY? PATIENT TAKEN TO AMBULANCE� 7 If RESPON,SE.ZONE PATIENT CONDITION. D RIVER EMT-1A PARAMEDIC - ���` T----- |- ' Hx: ' � '� -' u/u,«.CHEn: omspoompI A/wr: DRY RUN: Ovsn hl NO REASON,FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) . PATIENT REFUSED SERVICES: (s/GwATuns) x-_-__-- ' ' / . . . /( /'/ MEDICAL COVERAGE: /wousTn/AL uYES L�m*u wc\ oppAT/smro " -/ as. � - PRIVATE INS. co: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS TOTAL MILES: x wso/c^nsv- E.O.B. ATT. ROUND TRIP: O vso O NO .'�' x� � ��a��^! � ' °~_~~ O vso O NO NIGHT: (1eo0'07m0. -----_- � w: `, EMERGENCY RUN: MED/-CAL#: CODE c/x ' orHsn: oxvnsw: (PER TANK) -1 Tv __�-__ l pos. or/oxsn O vso O NO NEONATAL: (/mouoxron) DATES BILLED: arAwoev (OVER 1ow/m �» ` snm.: (PER EPISODE) ' NEAREST RELATIVE/RESPONSIBLE PARTY: /x: (PER ADMIN.) n ^ / onuoa (PER*om/w)______-_-_-� ' ' NAME: nsLAr/owoH/p:_-----_ soA.: (IF NOT REPLACED) _-----_ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CIT Y: aTArs___-z/p:---_-_ o-COLLAR: (IF NOT REPLACED) poows. WORK PHONE. DRY RUN: (AUTHORIZED) cmpLovsn: ___---__---__ oocupAr/ow:____-_-__- orHsn: ` AoonsoS CITY: ZIP:- Ey ; . cowmsmno- F~B ~ 11!~~ / TOTAL:-- PATIENT RECEIVED BY: o7AL:-_pwr/swrnscs/vsoaY: X — / CONTRA CW',TA COUNTY AMRULANCE Y3 PRE-HOSPITAL CARE FORM I { UNIT AUTHORIZATION M J CHECK OR FILL INARPRnPRIA7E Sr`nCES DATE: PATIENT'S NAME C/ / l f ` /G�� 1,94d Cl F COMPANY a _—/�_ P ADDRESS --- /r.'1 /•.� 1 — 1 .. I �.. _i. .._ --_.rA LL/n__1 AGS; / CITY__ n•.(J/[�l!)-�jTATE—_�/_t_ _ ZIP.—_—___ DOB ,_f(—�? ❑ Sn ❑ M ❑ T ❑ W tB�Jh ❑ F ❑ $ R DRIVER'S LICENSE H -. PHONE _ _-__._. .__. .._.._.__._— NATURE OF DISPATCH �'" •��v TYPE OF TRANSPORT AMRULANCE OTHER❑ INCIDENT LOCATION RESPONSE CODE REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE !�G . 9SO. —_ _ CALL RECEIVED L P.U. ��— TIME 10 B y f PATIENT DESTINATIONFROM SCENE ❑ FIRE — TIME 10-97 .' Z _ _ ❑ PSAP TIME 10 49 _ - MILEAGE — //- ❑ OTHER/PVT TIME 10-7 rc END L� TIME 10-98 DOCTOR PMD;ER START___-7_i'L_._ TIME 10.22 HOW CHOSEN TOTAL .—.__------- STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT Cl DIRECT ❑ OTHER CALL BACK IV AMBULANCE CO PANY: f .S, PT At,1BULATORY? PATIENT TAKEN TO AMBULANCE ( ( � RESPONSE ZONE ❑ YES ❑ NO W/,I.':ED ❑ GUEPNEY ❑ OTHER y� PATIENT CONDITION! DRIVER 126-A J/�r � ��`— MT-1A� ` GG , TECHNICIAN _- 14zww — PARAMEDIC DISPATCHER: CHIEF COMPLAINT .L�/sC i���!L�� ��)) DRY RUN �❑ YES I}�NO REASON FOR DRY RUN P'..--- \ AUTHORIZATION FOR D Y RUN(EMS USE ONLY) PATIENT REFUSED SERVICES MEDlC61 COVERAGE. INDUSTRIAL Cl YES NO NO. OF PATIENTS: tl 1 PRI\'A1 E INS. CO.: BASE RATE: /0 KAISER a: _________--._____ __ _ MULTIPLE PTS. BASE RATE BLUE CROSS it . — __—___ —_._—_--- TOTAL MILES: X �J MEDICARE E O B. ATT ROUND TRIP ❑ YES ❑ NO I 1 ❑ YES Cl NO NIGHT (1900-07.00) 1 CCHP,'PPHP a:—___— __ EMERGENCY RUN: ' MEDI- AL a: ____._—_._—. --' CODE 2/3 Il OXYGEN (PER TANK) � P,O.E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR) I I)I DATES BILLED _ _—__.—_ ___ _ STANDBY. (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: IN (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: ' A D D R E S S: ---- —-----—-- — —-- CITY - ----_...-.- ---.._.._-. _._— STATE __----ZIP:— COMMENTS IP:COMMENTS -- ----- - - -------- -- ----- ' 17Y-- ---- —-^------- -- TOTAL:_ 01 C. PATIENT RECEIVED BY X .....:: (SIGNAT ems-I