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HomeMy WebLinkAboutMINUTES - 09111984 - 1.3 (2) CLAIM BOARD OF SUPERVISORS OF C0l7RA COSTA COUNTY, CALIFORNIA BOARD ACTION Claim Against the Canty, or District ) NO►I'ICE TO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of this document ma ed to you is your "Routing' 12vaorbeaaenT-t, ana noara notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings%ounty Counsel Claimant: Theresa Talbert Rt. 2, Box 164, Marsh Creek J U L 3 1 1984 Attorney: Brentwood, CA 94513 Martinez, CA 94553 Address: VIA CAO Amount: $197.16 By delivery to clerk on July 30, 1984 Date Received: July 30, 1984 By mail, postmarked on I. FROM: Clerk of the Board ot supervisors County Counsel Attached is a copy of the above-noted claim. 1 Dated: July 30, 1984 J.R. OLSSON, Clerk, By to Deputy Cl Jolene Edwards II. FROM: County Counsel 70: Clerk of the Board of Supervisors (Check only one) (0 This claim complies substantially with Sections 910 and 910.2. ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: — By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) Cam Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . j i IV. BOARD OBER By unanimous vote of Supervisors present (�( ) This claim is rejected in full. ( ) Other: `v i i I certify that this is a true and correct copy of the Board's Order entered in its i mi utes for this date-F, Dated: g S-,-/ , Clerk, By U; f�t�-cam,; Deputy Clerk [4p►RNING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) meonths from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FT M: Clerk of the Board 70: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. n DATED: i c J. R. OISSON, Clerk, By��V, �� , Deputy Clerk cc: County Administrator (2) County Counsel (1) CLAIM ' !' AIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions --o Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106 , County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, .CA) . C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity.. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps PIECEIVED tt� CRO Against the COUNTY OF CONTRA COSTA) ,JI1L '30 1984 J.p. OLSSON or DISTRICT) CLERK BOARD OF SUPERVISORS t'WNTRA S ACO. (Fill in name) ) By eputy The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) -----------T------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) t�F i N-1�Z 3How did the damage or injury occur? (Give full detai . ls, use extra sheets if required) �� �� H� btEQ bovs> — ���� 5t✓ wry G_ sJPASS c-6 rv,\ -------------------------------------------------------------------IS�Z1�.0 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? -­V_H �_> o �_, vJ A.�Vr R l er 5.., �What.are the names of county or district officers, servants or " employees causing the damage or injury? 1 \\A - ---- - - ��- - - - ---- -- -------- -- -------- --- -------- ---- ------ ----- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage),.T-w ---------------------- --------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) ------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Govt. Code Sec. 910. 2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or b some person on his behalf. " Name and Address of Attorney I Claimant' s Signatur Address �3 wain Cis 9 WS 3 Telephone No. Telephone No. LL3 V &3!1 73 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer , or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " 00824 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CAI,U"WIA BOARD ACTION Claim Against the County, or District ) NMCE TO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of th s document ma ed to you is your zmut6a ents, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". .21aimant: Thomas Max Stofle 1773 Sharon Drive County Counsel Attorney: Concord, CA 94519 J U L 3 1 1984 Address; Martinez, CA 94553 Amount: $5,529.60 By delivery to clerk on Date Received: July 30, 1984 By mail, postmarked on July 27, 1984 - I. FROM: Clerk o the Board ot supervisors County Ccunsel Attached is a copy of the above-noted claim. Q Dated: July 30, 1984 J.R. OLSSON, Clerk, By Deputy ff Jolene Edwards II. FROM: County Counsel T0: Clerk of the Board of Supervisors (Check only one) j This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: 44 Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) Canty Kounsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD SER By unanimous vete of Supervisors present (() This claim is rejected in full. ( ) Other: I certify that this is f° true correct copy of the Board's Order entered in its minutes for this date. 1-1Dated: Clerk, By �� �' �� , Deputy Clerk �saa�t saga a WAMING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. P .� DATED:4 1 1 9s- , Clerk, BY �u. a. �2 Q�c�c� , Deputy Clerk cc: Canty Administrator (2) County Counsel (1) 0('825 CLAIM CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COR*r994Yapplication to: Instructions to ClaimantVerk of the Board P.O.Box 911 Martinez,California 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 oT this form. RE: Claim by ; L T!b;VV1FJBS filing stamps THOMAS MAX nI CELL ) L L ) 1984 Against the COUNTY OF CONTRA COSTA) J. R. OLSSON CLERK BOARD OF SUPERVISORS or DISTRICT) ONTRA COSTA CO. 11poutv Fill in name ) e The undersigned claimant hereby makes claim against the County oaf.\ Contra Costa or the above-named District in the sum of $ �5 5 a 0 and in support of this claim represents as follows:DyL -1-p D&G,a,( oF- 2.r code,f -------------------------------------------------------------------9fs3�o�cn, 1. When did the damage or injury occur? (Give exact date and hour) UU LV (p i t q?LJ 57F)(Ltr_3 Prr Fs;00 A.m . ter- Pe rs tS4e_8_ l_�tI JULY i3 /2. : 00 a.rn. 'r- ------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) COn+ra C'05+C. Co0n-+1 (&A\0- 1la:�►or, CQn-k� (2AQA,+0-r. C0 ,-9Qrn,o. ---- R- ---d-i- ----------------- ---------------------- - -----T -------------- 3. Row did the damage or injury occur? (Give full details, use extra ` sheets if required) LAck_ of Me c_a..l Treo_+w,R.. t. ,_ ►-�Q�{ p� Qxc,o S Q ro r+� _ 17 oc o r -F i a5 -b b!t n `F(tea ! d t Cc.�( �'l Odirl� 0. `tCUtn4-C6nft—=4 -Fn cti 1 t o rrLa r�r►� Z -� z w Q S fCa.�,r. '-l o C IC•�{�or► , y rC9006 4e.d 40 44A- C- CLO C.-40 f + 441La 4. What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? � f-e,q v2xs-Leal. J-o S.� oL d.o cAo r Q1- 0_S U d G1.bm o - ry\-,1 rres.�i .c _4i_o-. . , 0 as rLo+ �t u e-n C n 11 -Por C`. d U. = S+cz,,-e-d S eT�,( o o as►D;,s 4.cD 4t,, n 0 r--v_ q+_P_ 1tiv r4ed r b e,mak: rug re- ed 4o he dransd bacl� �(o C'aLn-�� (over) �a� act Upon- red, 00826 5. What are the names of county or district officers, servants or - -employees causing the damage or injury? 00--f - 0-4- °�� e hab• -Fa41 j� S - o, 4 abddv U50-5 OAC6.r- %r5l"J n`2, M&4• , Gond,.a-t.m, 6. What damage or injuries do you claim resulted? - - Give full extent of injuries or damages claimed. Attach two estimates for auto. damage) 12U0_,_, o.,, r,r\,, Lo Wer bac. - - -Pka-Yo+( , -&aVv- •e. bock_ o4- ----------------------------------.--Howw-a--the-am-ount--c-aimed - ----- above computed? (Include the estimated amount of any prospective injury or damage. ) �rorn wont 2 s�e� --o rn-o r-- d4O rut- �o r+ 6 ac ------------- L) ------------ and addresses of witnesses, doctors and hospitals. 172• +�u �. rn� r� z C�o�„�-� i�osp:�o✓l -To nn >?0 L F- Cori c or d- e4 IZOb�r�� 'STbk E Q4:)A CO C-71 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Un ICO o 1-1 n Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his- behalf. " Name and Address of Attorney 'Claimant's ig t re / 7 73 -S � Address 4)a,�_2Z) , C.9- Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud., presents for allowance or for payment to any state board or officer, 'or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, .account, voucher, or writing, is guilty of a felony. " C A3M BOARD OF SOPS MSOR.S OF COUATPY. cALm m m BOND ACTION Claim Against the County, cc District ) !NICE TO CIXTMWr September 11, 1984 mwerned by the Board of Supervisors, ) The copy of s t ma ed to you is your .:outing Endcrsements, and Board ) notice oot the action taxen an ycxu u.LaLt, ny we Action. All Section references are ) Board of Supervisors (Paragraph Iv, below), to California Government (lodes ) given pursuant to Government Code Section 913 Sarrott Construction Company 915.4. Please note all 'Warnings•. Claimant. County Counsel Attorney: Timothy F. Winchester, Esq. AUG 0 9 1984 McInerney & Dillon Address: One Kaiser Plaza, Suite 1850 Martinet, CA 94553 Oakland, Ca 94612 Amount: $8 , 150. 00 By delivery to clerk on August 6, 1984 Date Received: August 6 , 1984 By mail, postmarked on •J I. FROM: Clerk of the Board BT supervisors y Counsel Attached is a copy of the above-noted claim. Dated: August 6, 1984 J.R. OLS.SON, Clerk, By Deputy o ene Edwards II. FROM: Canty Counsel 70: Clerk of the Board of Supervisors (Check only one) (x) This claim complies substantially with Sections 910 and 910.2. ( `) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on grand that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: 77 - 37 By: Deputy County Counsel III. FROM: Clerk of the Board 70: (1) County ounsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD Ft By unanimous vote of Supervisors present (� ) This claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in is minutes for this date. P 45%�Cr."-ems Dated: / it , rif y �i, Clerk, By-" (� {'vC cr .� , Deputy Clerk MRNM (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FRCM: Clerk of the Board TO: (1) Canty Counsel,, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed cn the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. mm: �,� ,/, i(-1 CREW,, Clerk, By _ c� -u-u�.. Deputy Clerk on: County Administrator (2) Co mty Counsel (1) O C F32 S> aA'rM v IN THE MATTER OF SARROTT CONSTRUCTION COMPANY CLAIM FOR DAMAGES andj��� � PUBLIC WORKS DEPARTMENT RECEIVEDL-E Project No. 0662-654218-82 Solano Avenue Storm Drain � 1984 TO: BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA R. oLssoN D OF SUPERVISORS COUNTY COURTHOUSE A costa co. DeLutLiMARTINEZ, CALIFORNIA 1. Name and Post Office Address of Claimant Sarrott Construction Company 121 Allen Way Pleasant Hill, California 94523 2. Post Office Address to Which Claimant Desires Notices to be Sent Timothy F. Winchester, Esq. McInerney & Dillon One Kaiser Plaza, Suite 1850 Oakland, California 94612 3. Dates of Occurrence January 25, 1984-May 7, 1984 4. Place of Occurrence Solano Avenue County of Contra Costa 5. Circumstances of Occurrence Contra Costa County breached the subject contract in the following regards. a. It did not comply with Section 8-1. 10 of the Standard Specifications with respect to uniform utility and non-highway facilities in line with the subject storm drain. b. It breached Section 8-1 . 06 and 8-1. 07 'of the Standard Specifications by improperly denying 00829 requests for extension of time. 6. Description of the Losses The Claimant has been damaged for costs of removing culverts in line with the storm drain, realigning the storm drain, and in having improper liquidated damages withheld. 7. Name of Public Employees Having Knowledge of Damage Bob Conners, Phil Harrington. 8. Amount of Claim as of this Date $8, 150. 00 Dated: August 3, 1984 SARROTT CONSTRUCTION, INC. By Timothy F. Winchester Its Attorney CLAIM BOARD OF supmTISORS OF q*TMA OWEN COUNTY, CALUMNIA BOARD AC'T'ION Claim Against the County, or District ) NOTICE TO Q,p,IMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of-Uirs—d-o-c-u-me-n-T—maTied to you is your Routing Endorsements, and Board ) notice of the action taken on your-claim by tire' Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Kelly B. Sanchez County Counsel 3134 Catalpa Street Attorney: Martinez, CA 94553 AUG O 8 1984 Address: Martinez, CA 94553 August 6 , 1984 Amount: Unspecified By delivery to clerk on Au g Date Received: August 6, 1984 By mail, postmarked on I. FROM: Clerk of the Board ot Supervisors County Ccxmsel Attached is a copy of the above-noted claim. 44n Dated: August 6, 1984 J.R. OLSSON, Clerk, By Deputy Jo ene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Secticns 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Secticn 911.3) . ( ) Other: Dated: - By: i Deputy County Counsel III. FROM: Clerk of the Board 110: (1) County cunsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDIIt By unanimous vote of Supervisors present ( Y) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o the Board's Order entered in its minutes for this date. 11 Dated: 1 t e?9-Lf Clerk, By j'L , Deputy Clerk SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. ] z DATED: 42L 1 1, ,rl N, Clerk, By—J/ . Deputy Clerk cc: County Administrator (2) Canty Counsel (1) CLAIM 0 C, 8131 C?AIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions -_o Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. .(Sec. 911. 2 , Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (or mail to P.O. Box 911, Martinez, -CA) . C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims , Penal Code Sec. 72 at end of this form. RE: Claim y ) Reserved fo o ' ' 1 ' g stamps RECEIVED ) Against the COUNTY OF CONTRA COSTA) ALjG L 1 or DISTRICT) J. R. OLSSON C RK BOARD SUPERVISORS (Fill in name) ) MONII ST CQ/ B . Deputy The undersigned claimant hereby i.lakes claim againsK the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows : ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) Imo ; ►3 �� r F?,O.,)+ - - - -- - - - ----- -- ------ ------ -------- ---- --- ------- 2. Where did the amage or injury occur? (Include city and county)---- FRO.,)+ IAOO� I-Rt) __�vP� Pt 5 '�)+ - ------- ------- - ---- 7a- C&y1+ _A _C!ftp _ -- --- -- -- --- ----- --- -- ------ -- - - 3. How dithe damage or injury occur? (Give full details, use extra sheets if required) QRak. is - p-Ltc iV1t-v YnL SCO ------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? 00$32 (over) 1` 5. '.What are the -names of -county -or district :officers, •servants or employees causing the damage or injury? 6 What damage or injuri - esdo you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) iZ;J a Ll 0 .0-7 -------------------=----------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) .Y,n-y� ------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE - ITEM AMOUNT Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some perAon on his behalf. " Name and Address of Attorney a ' an is Sign ure L Ad e s s Telephone No. Telephone NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account , voucher, or writing, is guilty of a felony. " 00833 TRAFFIC COLLISION REPORT—Property`Damage Only original to officer;copyOes)to involued partyOes) ECTAL CONDITIONS H R CI7 Yi __�- 1e .y_ _ _ JV DIGIAL DISTRICT NUMBER -- � r �1 :•y{/� _. tf ''L- 1' � 1 J .� ` :�5` i•. t •• � ){ � vt_ l I'•'L'' 4` REi�R.TING.DISTRICT BF AT G4?LLISIO,1P.00CURRE ON: —. .- -- - ��. �"' MO• EAR TIME 24OS NCIC OFFLCER I'.D. DAY OF WEEK TOW AWAY STATE HWV RELATED LJ AT IN ER8 CTI ON WITH , t'\ t I y.� Lli OR: �7 FEET/WTLes 1� OP -i ` t- '" l.�t�Y� �y I ; ❑YES )+1 NO ❑VES ` NO PARTY NAME(FIRST M OL LASTI- - J ,\HONE Nlr,R SKETCH , 1 r'�►.t 1 J—� 1: � -74 � DRIVER ADDRESS- CITY✓ _ -1 Z�P rOOr /`�]( ,,r.�},•._ (� r. 5 Inti~. '\ { t� 'S._ �. I r /I'�L J�/ t` I, t\. •V* i�. 'ice' NORTH PED. RJV•✓E , PXHDATEJ BE%B fit iel PKD VEN VEHICLE YR MAKE/MODEL- - ,--3 LtCEN9E NU MER (.STATE BICYC. COLOR __. DIRECTION OF ON/JR•Rt7•'S STREET OR HIGHWAY 5 TRAVEL ♦ t \ i OTHER VEHI fLE DAMAGE REMOVED TO, PARTY NAME FIRST,MIDDLE•.LAST) -- (, - - y PRONE NUMBER .p x • , 1" DRIVER ADDRESS t� ..� _C I_TYL• �. ZIP CODE =-� ❑ 1i ! IL ;� ''s� cif 1' 1' f�iL,'`' PEO. D{R,IV9.R'S LJCE7t SE NUMBER STATE ( BIRTHDATE 'SEX MISCELLANEOUS IL 7 LI PKD YEN VEHICLE YR MAKE/MO EL_ / LICENSE NUMBER /STATE `�_ •- /+ '�- / i� 1 -'�l t i �. lJ f\' l li- a 1 -h_ ll�n 2,)� � '1/ %�f-� l `d' - `r BICYC. COLOR DIRECTION OF'`• ON/ „STFkEET OR HIGHWAY~` _ .� , 'i4 ' �• .��� 'R . I TRA, L �.�.�� i_ I �y.;'k_ L '1 .OTHER VEHICLE DAMAGEL REMOVED TO REPjORTINGI QFPICER ❑ [�4t 1',' i ,.� t,' ..;. _1 �_' 1� � l_!.'J._�•i W AGE SEX NAME { l - / ADDRESS t 1 - PHONE NUMBER W m ' FAGE SEX NAME ADDRESS PHONE NUMBER 3 .PROP. NAME ADDRESS DAMAGED PROPERTY OWNER •' IMPORTANT — READ CAREFULLY Keep this report. This is your record of this accident. To comply with California Vehicle Code Section 20002 (duty where property damaged), you must either: a. Give the owner or person in charge of such property the name and address of the driver and owner of the vehicle;' or in the absence of the owner, b. Leave a written notice in a conspicuous place on the other vehicle or damaged property, giving the name and address of the driver and owner of the vehicle involved and a statement of the circumstances. This information is necessary for the completion of your State SR-1 Report and Insurance Report. VEHICLE CODE SECTION 16000 . . The driver of a vehicle-involved in an accident resulting in damage to the property of any ONE party in excess of the amount stated inV "C'`:=1.6000 or in the injury or death of any person MUST submit a State Injury.or Damage Report, Form SR-1 to the'California:Department of Motor Vehicles within 15 days. Note: Failure to comply may result in suspension of your driver's license. Form SR-1 may be- obtained from the Department of Motor Vehicles, the California Highway Patrol, ariy police station, motor vehicle club, or insurance agent. - If City or State property is damaged, you will be contacted regarding possible liability. ; a� 0P. 3 DUARTE & WITTING. INC. CHRYSLER - PLYMOUTH 825 FERRY STREET MARTIN CALIFORNIA 94553 �. OWNERS BODY SHOP:908 FERRY STREET—PHONE 228.0750—228.0768. BOB STEVENS $ GALIN FITZHUGH ESTIMATE OF REPAIRS AS LISTED FOR LABOR AND MATERIALS - VERBAL AGREEMENTS NOT BINDING • ESTIMATES FREE NAME I' / L/ _-y— _�!y—�__ _ DATE �,li' i ADDRESS PHONE_�� ______�—_— 1�r1 MAKE (:l /. f 00EL _ _ STYLE LICENSE__ � i SERIAL NO. �� MILEAGE Symbol FRONT LabwHra_ Parts oymbof LEFT LaborHrs Parts Symbol RIGHT Labor Hrs. Parts Bumper (U) Ex-New Fender 6 Ext. Fender 6 Ext. Bumper Reinforcement Fend r Shield Fender Shield Bumper Brkt. R L or ABS Fender Orn.-Midg. Fender Orn.- Midg. Bumper Gd. R L Bumper Valance R L & CTR Headiamp Headlamp Frt.System Headlamp door - Headlamp door Frame ( )Horn _ Seal Beam In-Out Seal Beam in-out Cross MemberCowl Post j Cowl Post Wheel Front Rear Door Front-Panel Door Front-Panel Hub Cap-Sm.-Lge. Door Lock Door Lock Knuckle Hub 6 Drum Door Hinge Up-Low Door Hinge UP-Low Up. Cont. Arm-Shaft Door Glass- Reg. It Door Glass- Reg. Low. Cont.Arm-Snaft Door Midg-—Stripe Door Midg. —Stripe Strut Rod Vent Glass-Channel Vent Glass.Channel Staballzer Bar Door Handle Door Handle Link Pkg. R L center Post Center Post Door Rear-Panel _ Door Rear-Panel Steering Arm Door Midg. —Stripe Door Midg.—Stripe Steering wheel•Horn Ring Duor Glass Door Glass Steering Shaft-Jacket Rocker Panel Rocker Panel Drag Link Rocker Midg. Rocker Midg. Tie Rod R L Sill Plate SIII Plate Floor I Floor Gravel Shield Quar. inner Const. Quar. Inner Const. Grille Ctr. Quar.-Ext. Quar.-Ext. Grille Side R L Quar. Panel Guar.Panel Grille Mldg. Quar.Midg. —Stripe Quar.Mldg.—Stripe Support R L Cent. Quar.Glass• Reg. Quar.Glass-Reg. Tie Bar Rear Fender Rear Fender Park Lamp R L MISC. Marker Lamp R L REAR Inst. Panel Horn Bumper Ex-New Front Seat-Tracts Bumper Rail Rear Seat Air Cond, Core Bumper Brkl. R L Trim Dehydrator Bumper Gd. R L Headlining Recharge A/C- Gravel Shield ~Top Hood ^ Lower Panel-Mldg. Tire %Worn _ Hood Mldg Floor Hood Orn.• Letters Trunk Lid -Hinges Battery Hood Hinge R L i runk Luck.Miog. Antenna Lock Plate Lower Tail Lamp R L Mirror Lock Plate Upper Back Up Lamp R L Paint 6 Material Rad.Sup. Tau Pipe.Muffler Rad.Core Gas Tank-Neck-Cap SUMMARY Fan Blade Frame-Crossmember _ Fan Clutch —Coolant Axle- Housing Labor�JLl-Irs. ; r tJv Fan Shrowd Hub- Drum-Bearing Parts — Less Fan Beit ( )Hoses _ Control Arms Paint Material Water Pump-Pulley Windshield (C) (T) I Tax — %on Motor Mts. Ft. Rear Windshield Kit Sublet ; Trans. Linkage Windshield Mldg. Advance Charges i Estimate By: -- — TOTAL ; OH - REPAIR - OVERHAUL N NEW R.C. RECHROME X ITEMS MISSED ON GARAGE EST. S STR. Ex EXCHANGE CIRCLED ITEMS INDICATE OLE)OR UNRELATED DAMAGE. ESTIMATE OF REPAIRS Martinez Auto Body Shop 635 ESCOBAR STREET — MARTINEZ,CALIFORNIA 94553 Telephone 228-3689 • ALL WORK GUARANTEED Owner _ ",I / �_- •1 �' Address c' - —Esf. No. Insurance Co. Order No. MA. 7✓ AR YEAR MODEL B Or SJYLE MUIOR NUMBER LICENSE MILEAGE DAIE OF ASSIGNMEM SYMB.I. FRONT LABOR pgR15" SYMBOL LES IABOR PARTS SYMBOL RIGHT LABOR PARTS HOURS HC)UR HOUR FE*,IDER FENDER BUMPED BRKT FENDER SHIELD FEP.DER SHIELD FENDER MLDG FENDER MLDG. BUMPER c.r, HEADLAMP HEADLAMP FRI SYSTEM HEADLAMP DOOR HEADLAMP DOOR FRAfAE SEALED BEAM SEALED BEAM CRO'), MEMBER COWL COWL WHEEL DOOR. FRONT DOOR. FRONT HUB CAP DOOR LOCK DOOR LOCK HUB—& DPUM DOOR HINGE DOOR HINGE KNUCKLE DOOR GLASS DOOR GLASS KNUCKLE SUP VENT GLASS VENT GLASS LR CONI ARM SHAFI DOOR MLDGS. DOOR MLDGS DOOR HANDLE DOOR HANDLE JF CONT ARM SHAFT CENTER POST CENTER POST UOOR REAR DOOR REAR wINUSHIELD DOOR GLASS DOOR GLASS DOOR MLDG DOOR MLDG 'IE ROD ROCKER PANEL ROCKER PANEL SIEEPIr.,G GEAR BUCKER MLDG ROCKER MLDG. STEERING WHEEL SILL PLATE SILL PLATE HORN RINC• FLOOR FLOOR GRAvEL SHIELD FRAME FRAME PARK LIGHT DOG LEG - DOG LEG GRILLE ( GUAR PANEL GUAR, PANEL GUAR MLDG GUAR MLDG. GUAR GLASS GUAR GLASS MISC. INSI. PANEL FRONT SEAT FRONT SEAT ADJ, MIRROR REAR HEADLINING HORN BUMPER TOP BAFFLE. SIDE TIRE BAFFLE LOWER BUMPER BRKT. BAFFLE UPPER BUMPER GD BATTERY LOCK PLATE. LR, GRAVEL SHIELD PAINT �?• ) LOCK PLATE. UP LOWER PANEL HOOD TOP ! FLOOR HOOD HINGE TRUNK LID Leer .�Mrs.0s HOOD MLDG TRUNK LOCK TRUNK HANDLE Mawaft TAIL LIGHT RAD $UP TAIL PIPE ►ARTS , Qom. RAD CORE GAS TANK RADIO ANTENNA FRAME • RAD HOSE WHEEL TOWING A SUBLET REPAIRS FAN BLADE HUB 6 DRUM in� WATER PUMP T0T.4L W�9 V^{ sG.( ; �'�' BOARD ACTION Claim Against the County, or District ) N.OTICE TO CLAIMANT September 11 , 1984 governed by the Board of Supervisors, ) The copy of this document mailed to you is your Routing Endorsements, and Board ) notice of the action-ta&ea �.Ai ycxu: ClalAu oy trie Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and �15. please note. aql "Wa,n1ngs". Claimant: Bryan Joseph Helling , Ba y oe el ling , ris ina c um , Kenneth Richard Hel l i ng and Diana Benita Hel l i ng County Counsel. Attorney: T . D . Bolling , Jr . Bolling , Walter & Gawthrop AUG 0 2 1984 Address: P . O . Box 255200 Sacramento , CA 95865 Martinez, CA 94553 Amount: $3 , 000 ,000 . 00 By delivery to clerk on August 1 , 1984 Date Received: August 1 , 1984 By mail, postmarked on - I. FROM: Clerk of the Board ot supervisors County Counsel Attached is a copy of the above-noted claim. Dated: August 1 , 1984 J.R. OLSSON, Clerk, By Deputy oene war a s II. FROM: County Counsel T0: Clerk of the Board of Supervisors (Check only one) (y;) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: - _3 - a � By: , j7- Deputy County Counsel III. FROM: Clerk of the Board 70: (1) County Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD CIEMER By unanimous vote of Supervisors present This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. P �� ��_� , Dated: i i, j,-,S- L�P&�I, Clerk, By �',,,, ,„ , Deputy Clerk V-- uww WARTM (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. t V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's f action on this claim by mailing a copy of this document, and a memo thereof has been filed 1 and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed t claimant. P ,�'�._�f 11 DATED: // - Clerk, Byj���fl),�4 , Deputy Clerk cc: County Administrator (2) County Counsel (1) (1 .� CLAIM i'. (SPACE BELOW FOR FILING STAMP ONLY) • 1 BOLLING, WALTER & GAWTHROP A PROFESSIONAL CORPORATION 2 7919 FOLSOM BLVD.,SUITE 300 MAILING ADDRESS: RECEIVED 3 P.O.BOX 255200 SACRAMENTO,CA 95865-5200 4 TELEPHONE (916)386-0777 U C, J. R. OLSSON Attorneys for Claimants CLE BOARD OF SUPERVISORS CONTR TA CO g . CO- ............Deputy6 7 8 —000- 9 10 In the matter of the claim of: 11 BRYAN JOSEPH HELLING, NOTICE OF CLAIM AGAINST 12 BABY DOE HELLING, CONTRA COSTA COUNTY, A CHRISTINA SCHRUM PUBLIC ENTITY 13 KENNETH RICHARD HELLING, DIANA BENITA HELLING, 14 against 15 COUNTY OF CONTRA COSTA. 16 / 17 Come now claimants , BRYAN JOSEPH HELLING, BABY DOE 18 HELLING, CHRISTINA SCHRUM, KENNETH RICHARD HELLING, DIANA BENITA 19 HELLING, by their attorney to claim damages against the COUNTY OF 20 CONTRA COSTA, a Public Entity, by reason of the death of Bryan 21 Curtis Helling on or about April 24 , 1984 . 22 CLAIM 23 A. The names and addresses of the claimants are as 24 follows : 25 //// • 26 27 //// • 28 0083E 1742C:sa 1 BRYAN JOSEPH HELLING BABY DOE HELLING 2 CHRISTINA SCHRUM KENNETH RICHARD HELLING 3 DIANA BENITA HELLING 4 c/o Bolling, Walter & Gawthrop A Professional Corporation 5 P .O. Box 255200 Sacramento, CA 95865 6 ( 916 ) 386-0777 7 B. The post office address to which all notices should 8 be sent is as follows : c/o Bolling, Walter & Gawthrop 9 A Professional Corporation 10 P .O. Box 255200 Sacramento, CA 95865 11 C . The date, place and other circumstances of the 12 occurrence is as follows : 13 On April 24 , 1984, Bryan Curtis Helling was operating a 14 motorcycle in a southerly direction on Palm Avenue, which is a 15 . public road in an unincorporated area of Contra Costa County, 16 California, and one Linda Sue Legar was operating an automobile in 17 a northerly direction on said Palm Avenue . Said vehicles collided 18 in or near the intersection of Palm Avenue and Leslie Avenue , which 19 is another public road in Contra Costa County, California . Bryan 20 Curtis Helling died on or about April 24 , 1984 as a proximate 21 result of injuries he sustained in said collision. 22 The collision, and resultant fatal injuries sustained by �3 Bryan Curtis Helling, were proximately caused by a dangerous and 24 defective condition of public property, to wit , the aforesaid �5 public roads known as Palm Avenue and Leslie Avenue, which were 26 designed, owned, controlled, supervised and/or maintained by the 27 COUNTY OF CONTRA COSTA, a Public Entity, and/or negligence of 28 employees of said public entity in the design , ownership, control , -)LLINO,WALTER &OAWMROP PROFESSIONAL -2 CORPORATION 00839 1 supervision and/or maintenance of said public roads . 2 D. A general description of the injury, damages and 3 losses incurred, as far as known at this time, is as follows : 4 Bryan Curtis Helling died on or about April 24, 1984 as a 5 proximate result of injuries he sustained in the above-described 6 collision . BRYAN JOSEPH HELLING is the surviving son of Bryan 7 Curtis Helling, and BABY DOE HELLING is the unborn child of said 8 decedent . CHRISTINA SCHRUM was the putative spouse of Bryan Curtis 9 Helling, and is the mother of BRYAN JOSEPH HELLING and BABY DOE 10 HELLING. KENNETH RICHARD HELLING is the father of Bryan Curtis 11 Helling and DIANA BENITA HELLING is the mother of Bryan Curtis 12 Helling . All of said claimants seek special and general damages 13 from the COUNTY OF CONTRA COSTA by reason of the wrongful death of 14 Bryan Curtis Hellin g, proximately caused by the above-described 15 dangerous and defective condition of public property. 16 E . Claimants do not know the name or names of the public 17 employee or employees responsible for those acts or omissions i8 described hereinabove. 19 F . The amount claimed as of the date of presentation of 20- this claim is the sum of $3 ,000 ,000 .00 . 21 Dated: 22 BOLLING, WALTER & GAWTHROP 23 24 By: �5 T. D. Bolling, Jr . 26 27 28 )LLINO,WALTER &OAWTHROP PROFESSIONAL -3- 0 C 9 CORPORATION 1 3a . CLAIM BOARD OF SDPM7ISORS OF ootTrRA 00STA CM TPY, CALIFORNIA BOARD ACTION Claim Against the County, or District ) NOTICE TO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of th s document ma ed to you is your Routing Endorsements, and Board ) notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: Sean Hoover (a minor) , Kenneth and Joanne Hoover Attorney: R. Lewis Van Blois County Counsel Suite 2375, Ordway Building Address: one Kaiser Plaza AUG 0 8 1984 Oakland, CA 94612 Amount: $700 ,000. 00 By delivery to clerk on Martinez, CA 94553 Date Received: August 7, 1984 By mail, postmarked on August 6, 1984 - I. FROM: Clerk of the Board ot supervisors County Counsel Attached is a copy of the above-noted claim. Dated: August 6, 1984 J.R. OLSSON, Clerk, By Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: By: ��. Deputy County Counsel u III. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDER By unanimous vote of Supervisors present (�() This claim is rejected in full. (/ ') Other: I certify that this is a true and correct copy of the Board's Order entered in its mi Utes for this date. Dated: �' Clerk, By &—..c_., �vZ -1 c� , Deputy Clerk SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this >< matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leav to present a late claim was mailed to claimant. P � DATED: IL4 i i, L/ , Clerk, By� ���,� , Deputy Clerk 3 cc: Canty Administrator (2) County Counsel (1) I ®C8, ?. ► CLAIM 4 _ 1 VAN BLOIS & KNOWLES One Kaiser Plaza, Suite 2375 2 Oakland, CA 94612 3 444-1906 RECEI E D 4 LC.i 1984 5 BOARDSSOU ERVISORS STA CO,6 e u 7 8 IN THE MATTER CF THE CLAIM OF SEAN HOOVER , a minor, KENNETH 9 HOOVER AND JOANNE HOOVER CLAIM OF CLAIMANTS SEAN HOOVER, a minor , KENNETH 10 against HOOVER AND JOANNE HOOVER 11 CONTRA COSTA COUNTY 12 / 13 TO THE BOARD OF SUPERVISORS , CONTRA COSTA COUNTY: 14 a. NAME AND POST OFFICE ADDRESS OF CLAIMANTS: 15 Sean Hocver , a minor, Kenneth Hoover and Joanne Hoover 16 653 Ironbark Circle Orinda, CA 94563 17 b. POST OFFICE ADDRESS TO WHICH THE PERSON PRESENTING 18 LAIM DESIRES NOTICES TO BE SENT: 19 Law Offices of Van Blois & Knowles 20 Suite 2375 , Ordway Building One Kaiser Plaza 21 Oakland, CA 94612 22 C. THE DATE , PLACE AND OTHER CIRCUMSTANCES OF THE OCCURR- 23 ENCE OR TRANSACTION WHICH CAVE RISE TO THE CLAIM ASSERTED : 24 On May 5 , 1984 , claimant , Sean Hoover , was a passenger in a 25 1975 Chevrolet Malibu automobile owned by Paul Hayashi and operat- 26 ed by Matthew Burke. Said automobile was travelling on Warford 00842 1 Terrace approximately 22 feet north of Bates Blvd. , in the unin- 2 corporated area of Orinda, CA, when it left' the road, went down 3 very steep slope, became airborne , landed cn a sloped plateau and 4 then became airborne off a 60 foot embankment and landed at the 5 bottom. 6 Said roadway was in a dangerous and defective condition 7 and was negligently designed, in that there were no guard rails , 8 inadequate shoulders , no signs or warnings of the steep slope 9 or cliff area and other inadequate', improper and dangerous con- 10 ditions which would prevent a vehicle from travelling down the 11 very steep slope or going off the 60 foot cliff. As a. proximate 12 result of the dangerous and defective condition and the dangerous 13 and improper design, the vehicle left the roadway, travelled 14 down the steep slope , became airborne twice and flew off the 15 60 foot cliff, thereby proximately causing serious injuries and 16 damages to claimants . 17 d. NAMES OF PUBLIC EMPLOYEES CAUSING INJURY, DAMAGE OR 18 LOSS : 19 Not known at this time . 20 e. NAMES AND ADDRESS OF WITNESSES : 21 Karren Foppiado 2 Austin Court -22 Orinda, CA 23 Jim Frane 14 Bates Blvd. 24 Orinda, CA 25 Dave Bloodgood California Highway Patrol 26 Martinez , CA 00843 1 Terry Stahr California Highway Patrol 2 Martinez , CA 3 f. THE AMOUNT CLAIMED AS OF THE DATE OF PRESENTATION OF 4 CLAIM, INCLUDING ESTIMATED AMOUNT OF ANY PROSPECTIVE INJURY, 5 DAMAGE , OR LOSS , INSOFAR AS IT MAY BE KNOWN AT TIME OF PRESEN- 6 TATION CF' CLAIM, TOGETHER WITH BASIS OF COMPUTATION OF AMOUNT 7 CLAIMEI%: 8 SEAN HOOVER $500 , 000 .00 . 9 KENNETH HCOVER $100 ,000 .00 10 JOANNE HOOVER $100 , 000 .00 11 12 Dated : August 6 , 1984 13 VAN BLO KNOWLES 14 15 LEWIS BLOIS 16 Attorneys for Plaintiffs 17 18 19 20 21 22 23 24 25 26 QQ � c � DECLARATION OF SERVICE BY MAIL t I declare that: I am a citizen of the United States and employed in Alameda County, State of California, over the age of eighteen years, and not a party to the within action. My business address is Suite 2375, Ordway Building, One Kaiser Plaza, Oakland, CA 94612 . I served the foregoing CLAIM by depositing a true copy thereof in the United States mail at Oakland, California, enclosed in a sealed envelope , with postage thereon prepaid, addressed as follows: CONTRA COSTA COUNTY BOARD OF SUPERVISORS P. 0. Box 511 Martinez , CA 94553 Executed at Oakland, California and deposited in the United States mail on August 6, 1984 . I declare under penalty of perjury that the foregoing is true and correct. Ingrid E . Schroder 0C CXAIM BUM OF SUPEWISORS OFCORM COSTA COUNTY, CALIFORNIA BOAIRD ACTION Claim Against the County, or District ) NanCE To CEAMqAW September 11, 1984 governed by the Board of Supervisors,, ) The copy of this document mMed to you is your 'Rodting,twordements, and Board notice of the action taken on your claim by the Action. All Section references are Board of Supervisors (Paragraph TV, below),, to California Government Codes given pursuant to Government Code Section 913 and 915.4. Please note all *Warnings". Claimant: Pamela Colucci County Counsel Attorney: Jeryco Peterson AUG 0 8 1984 223 North Hartz Avenue Address: P.O. Box 808 Martinez, CA 94553 Danville, CA 94526 Amount: $100,000.00 By delivery to clerk on Date Received: August 8, 1984 By mail, postmarked on August 7, 1984 - I. FROM: Clerk of the Board ot supervisors W: County Counsel Attached is a copy of the above-noted claim. Dated: August 8, 1984 J.R. OLSSON, Clerk, By Deputy Jolene Edwards II. FROM: County Counsel 70: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . Other: Dated: By: Deputy County Counsel M ,F III. FROM: Clerk of the Board TO: County Counsel, (2) County Administrator Clain was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDIIZ By unanimous vote of Supervisors present 00 This claim is rejected in full. Other: I .certify that this is a true and correct copy of the Board's Order entered in its minutes for this date Dated: Clerk, By CL� L )Va44"4 , Deputy Clerk V %kM= (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If You want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board 70: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copyofthis document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. SATED: >/ Clerk, By ► Deputy Clerk ,c: County Administrator (2) County Counsel (1) 00846 CLAIM NOTICE OF SUSTAINING PERSONAL INJURY BOARD OF SUPERVISORS Contra Costa County 651 Pine Street Martinez , CA 94553 Take notice that claim is hereby made pursuant to Government Code §§910 and 910 . 2 for personal injuries against the COUNTY OF CONTRA COSTA. CLAIMANT: Pamela Colucci 420 Hampton Court San Ramon, CA 94583 NOTICES: Notices are to be sent to: LAW OFFICES OF JERYCO PETERSON 223 North Hartz Ave. P.O. Box 808 Danville, CA 94526 DATE OF INJURY: May 17, 1984 PLACE OF INJURY: 9899 Delmar Drive San Ramon, CA NATURE OF CLAIM: Personal injuries FACTS: On or about May 17 , 1984 claimant was walking across the street in front of 9899 Delmar Drive in San Ramon, CA. The cover was off what appeared to be a cleanout and claimant stepped into it. DAMAGE: Due to the foregoing facts, claimant suffered serious injuries including, but not limited to, severe cuts on her right leg with aggravated tearing of tissue and a chipped shinbone, the extent of which has not yet been determined. EMPLOYEE RESPONSIBLE: Unknown RECEIVED AJG 61 1934 J. R. OLSSON CLERK BOARD OF SUPERVISORS NT TA CO. 6 ... .. ...... Deputy 00847 AMOUNT CLAIMED: $100,000 in general damages, medical expenses incurred, loss of wages, future medical expenses and future loss of wages, in an amount yet to be determined and still accruing. DATED: August 7, 1984 J �' PETERSON • L/ 0084 1 PIRDOF OF SERVICE BY MAIL -- CCP 1013a, 2015.5 2 I declare that: 3 I arr, employed in the County of Contra Costa, California. I. am over the aero 4 of eighteen years and not a party to the within cause; my business.adOress - 5 is 223 North Hartz Avenue, Danville, California 94526. 6 On August 7, 1984 , I served the within 7 NOTICE OF SUSTAINING PERSONAL INJURY 8 9 by placing a true copy thereof enclosed in a sealed envelope: %-'lith postace. 10 thereon fully prepaid, in the United States mail at Danville; .California 11 addressed as follows: 12 Board of Supervisors 13 Contra Costa County 651 Pine Street 14 Martinez , CA 94553 15 16 17 18 19 �I 20 21 22 23 I I declare under penalty of perjury that the foregoing is true and.correct, and 24 i that t,'iis declaration was executed on August 7, 1984 at 25 Danville, California. 26 CATHERINE HUGHES (.type or print name) Signature . ( , 'J CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COCwN. CALIFORNIA BOARD ACTION Claim Against the County, or District ) NOTICE RO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of th s document ma ed to you is your Routing Enaorsanents, cax3 ncaru notice of the action taken on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below) , to California Government Coles ) given pursuant to Government Code Section 913 t9�5.�4. Please note all "Warnings". Claimant: Curtis K. Cooper 2701 Crow Canyon Road Attorney: San Ramon, CA 94583 JUL 11984 Address: , Marti►gaz, CA 94553 Amount: $160.00 By delivery to clerk on Date Received: July 31, 1984 By mail, postmarked on July 30, 1984 I. FROM: Clerk of the Board ot supervisors County Ccunsel Attached is a copy of the above-noted claim. ; Dated: July 31, 1984 J.R. OLSSON, Clerk, ByDeputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) (�) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim an ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated:= � By: ter, Deputy County Counsel III. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . 1 IV. BOARD ORDER By unanimous vete of Supervisors present (X) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its mi utes for this date., Dated: , Clerk, By, , Deputy Clerk SING (Gov. Code Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed t claimant. f 40-� j DATED: � 1. ,q,F� "®Ir. E1, Clerk, By -- / zm_z-i , Deputy Clerk cc: County Administrator (2) County Counsel (1) CLAIM O 0 8 o CLAIM TO: BOARD OF SUPERVISORS OF CONTRA CCWX_,krC0Wapp1ication to: Instructions to ClaimantC!erk of the Board .0.Box 911 Martinez,Cal ifomia94553 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 this form. RE: Claim by ) Rese s f`1 'ng stamps RECEIVED Against the COUNTY OF CONTRA COSTA) JIT 3/ X984 J. R. OLSSON 07" DISTRTCT) CLERK BOARD OF SUPERVISORS (Fill In name B C NT O TA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ /� Q • v and in support of this claim represents as follows: ---------------------------------------- --- ------------------------ --- 1. When did the damage or injury occur? (Give--exact date and hour) -----------T--------•�----------2. Where did the damage or ------------------ injury -----------------injury occur? (Include-- tand-c-ou-n-y----- 04r,L/ ee --------------------------=--------------------------------------------- 3. How did the damage or injury occur? (Give full details, use extra sheets if required) w 6;L,U 6 G.t,f v4c-Lc i n.), 4 1, F N �rL C CJ 4'r c1 n L/ a ti 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? t '4• X-A:E G[ X04-- (over) 00851 • : ' *ghat are the names of county or district officers, servants or • j employees causing the damage or injury? --------------------------------------------- -- --- -------------------- 6. What damage or injuries do you claim resu�te�? ZGive full extent of injuries or damages cl imed. Attach two estimates for auto damage) C At., P-,%- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) ------------------------------------------------------------------------- 8. Names and addresses of witn�e�s ses, docto�rJJs,AAa�''and hospita l/s�. ,.q, 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT ictit*icirsiit****�iir�i***ic*i��iit**tk.****�t�tuit**tiir�rxlritstirtiryt***tkltltir**X*�ktk**�It**tk+RtR!'tk**irtktk** Govt. Code Sec. 910.2 provides: "The cla' 'signed by the claimant SEND NOTICES TO: (Attorney) or by e6me e n on his behalf. " Name and Address of Attorney / Q C1 fit' s Signature Address O.J Cq Y Telephone No. Telephone No. 014 2--a - iso 0 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for -allowance- or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " 00852 f - DANVILLE AUTO DETAIL 2156 SAN RAMON VALLEY BLVD.,SAN RAMON,CA (415)838-9254 CUSTOMER CHECK OFF LIST NAME NUMBER ADDRESS f MAKE MODEL YEAR DRIVERS LICENCE NO. DAYS DATE W ITPEN UP BY :INTERIOR DETAIL WINDOWS 3 HEADLINER SHAMPOO ` DASHBOARD INSTRUMENT PANE UPHOLSTERY SHAMPG - DOOR JAMS & PANELS MATS U UK Allti TRUNK EXTERIOR DETAIL BUFFING OUT ALL MINER SCRATCHES , V" POLISHING CAR WITH CUTTING COMPOUND POLISHING ALL CHROME 11, WAXING ENTIRE CAR TIRE DRESS & HUBCAPS ENGINE DETAIL EGINE WASH STEAM CLEAN DEGREASED SPECIAL COMPLETE INTERIOR DETAIL COMPLETE EXTERIOR DETAIL COMPLETE -" COMPLETE INTERIOR DETAIL COMPLETE EXTERIOR DETAIL COMPLETE ENGINE DETAIL COMPLETE WAX JOB - ti COMPLETE TIRE DRESSING COMPLETE TIRE DRESSING (SPOKE RIMS) JAl SIGNED DETAILER THANK YOU 853 DANVILLE AUTO DETAIL CMM BOARD OF SUPERVISORS OF CORTRA COSTA COUNTY 2LnMRN1A BOARD ACTION Claim Against the County, or District ) NprrlCE TO September 11 , 198 governed by the Board of Supervisors, ) The copy of this- document mailed to you is your Routing Endorsements, and Board ) notice or tne *actYon tAKen do your'claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". Claimant: John Sheldon Johnson County Counsel Attorney: Clyde I . Butts , Esq . Marracci ni & Butts (AUG 0 2 1984 Address: 1280 Boulevard Way , Suite 202 Walnut Creek , CA 94595 Martinez, CA 94553 Amount: $50 ,000 . 00 By delivery to clerk on August 1 , 1984 Date Received: August 1 , 1984 By mail, postmarked on I. FROM: Clerk of the Board ot Supervisors aunty Counsel Attached is a copy of the above-noted claim. Dated: August 1 , 1984 J.R. OLSSON, Clerk, Byb Deputy Po ene wads II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that -it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: -- ' By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) Canty Counsel, (2) Canty Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD QRDER By unanimous vote of Supervisors present (�( ) This claim is rejected in full. ( ) Other: I .certify that this is a true and correct copy of the Board's Order entered in its min t for this date. P f�-�6 Dated: //, / Clerk, By P��'(rc.u��� , Deputy Clerk MING (Gov. Cade Section 913) Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. - DATED: i i 9�-y , Clerk, By 0 � , Deputy Clerk cc: Canty Administrator (2) County Counsel (1) 0 0854 CLAIM 1 CLYDE I. BUTTS R ��T T�� LAW OFFICES OF MARRACCINI & BUTTS v 2 1280 Boulevard Way, Suite 202 Walnut Creek, CA 945953Telephone: 415/943-1850 RQ4Attorneys for Claimant R: °`SASRVISORS TRA 5 6 CLAIM AGAINST COUNTY OF CONTRA COSTA Government Code Section 1 7 i 8 To the Clerk of Contra Costa County 9 725 Court Street Martinez, CA 94553 10 pursuant to Section 910 of the California Government Code, claim 11 is presented to the County of Contra Costa, California as i2 follows: 13 (a) The name and post office address of the claimant is: 14 John Sheldon Johnson, 4171 Irene Drive, Martinez, CA 94553 . 15 (b) The post office address to' which the person presenting 16 this claim desires notice to be sent is : Clyde I. Butts, Esq. , 17 Law Offices of Marraccini & Butts, 1280 Boulevard Way, Suite 202, 18 Walnut Creek, CA 94595. 19 (c) The date, place, time, location of the circumstances of 20 the occurrence or transaction which gave rise to claim asserted: 21 Date: May 1, 1984 .22 Time: 4:00 p.m. Place: Contra Costa County Hospital 23 Martinez, California 24 Circumstances: John Sheldon Johnson, who had previously 25 been treated as an In-Patient at County Hospital from April 21., 26 1984 to April 26, 1984 for fracture of vertebrae arising out of 27 an automobile/motorcycle collision that occurred on April 21, 28 1984, returned to County Hospital for a follow-up examination on LAW OFFICES OF MARRACCINI&BAITS 1 1280 BLVD.WAY,STRE.202 O U('j 5r WALNLI7 CREEK CA 94595 1 May 1, 1984. While sitting on a stool in the examination room, 2 claimant was injured when the stool suddenly dropped without any 3 warning, causing claimant to fall and to re-injure his back. The 4 County and its employees are negligent by allowing claimant to 5 use a defective stool and by failing to examine said stool for 6 defects before allowing claimant to use it. (d) A general description of the indebtedness, obligation, 8 injury, damage or loss incurred insofar as it may be known at the 9 time of presentation of the claim: Aggravation of pre-existing 10 back injury, medical and incidental expenses and wage loss . 11 (e) The name or names of the public employee or employees 12 causing the injury, damage, or loss, if known: Unknown. 13 (f) The amount claimed as of the date of presentation of 14 the claim, including the estimated amount of any prospective 15 injury, damage, or loss insofar as it may be known at the time of 16 1 the presentation of the claim, together with the basis of 17 computation of the amount claimed: Medical Expenses, Unknown; 18 General Damages, FIFTY THOUSAND DOLLARS ( $50, 000) 19 I declare under penalty of perjury under the laws of the 20 State of California that the foregoing is true and correct. 21 Executed at Walnut Creek, California on July 27, 1984. 22 LAW OFFICES OF MARRACCINI & BUTTS 23 24 By / CLY I. BUTTS 25 Attorney for Claimant 26 27 28 LAW OFFICES OF MARRACCINI&BLrrTS 1280 BLVD.WAV,STE,202 O Q , WALNUT CREEK CA 94595 2 6 CLAIM BOARD OF SUPERVISORS OF CONT PA COSTA COONTPY, CALIFORNIA �. BOARD ACTION Claim Against the County, or District ) MICE TO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of Ers--d-0565-mie-n-`F-m-a-fled to you is your Routing Endorsements, and Board notice uL uie ac-ticn taKen on your claim by the Action. All Section references are ) Board of Supervisors (Paragraph IV, below), to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all "Warningt0onty Counsel Claimant: Joe Grangnelli Attorney: David S. Thomas AUG 0 1 1984 Rockwell & Thomas Martinet, CA 94553 Address: P.O. sox 129 Antioch, CA 94509 Amount: $150,000.00 By delivery to clerk on July 31, 1984 Date Received: July 31, 1984 By mail, postmarked on I. FROM: Clerk of the Board ot Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: July 31, 1984 J.R. OLSSON, Clerk, ByDeputy Jo ene war s II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) ( ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . ( ) Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) Cam Ccunsel, (2) County Administrator ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD OFUM By unanimous vote of Supervisors present (X) This claim is rejected in full. (( `) Other: I certify that this is a true and correct copy f the Board's Order entered in its min tes for this date. �s�r Dated: J Clerk, By � --e.,c, , Deputy Clerk WNING (Gov. Code Section 913) Subject to certain exceptions, you have only six. (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TO: (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. . + eCC-- rk,DATID: BY E,�� }Yl �,cJ„�, , Deputy Clerk cc: County Administrator (2) County Counsel (1) 00857 CLAIM RECEIVED CLAIM AGAINST THE COUNTY of UL CONTRA COSTA J. R. pLS,pN K BOARD f SUPERVISORS .Pu" To: Board of Supervisors Contra Costa County 651 Pine Street Martinez, CA 94553 Claimant: JOE GRANGNELLI hereby makes claim against Contra. Costa County for the sum of $150,000. 00 and makes the following statements in support of the claim: 1. Claimant' s post office address is 22 East Sixth Street, Antioch, California 94509 . 2 . Notices concerning the claim should be sent to ROCKWELL & THOMAS, Post Office Box 129, Antioch, California 94509 , attention DAVID S. THOMAS , ESQ. 3. The date and place of the occurrence giving rise to this claim are April 24, 1984 , at or about 7:10 p.m. at the intersection of Cypress Road and Knightsen Avenue, in the County of Contra Costa, State of California. 4. The circumstances giving rise to this claim are as follows : At the above time and place, claimant was driving his 1976 Ford pickup in a generally west- bound direction on Cypress Road when his vehicle collided with a "New Jersey Barrier" which was blocking westbound traffic at Cypress Road in connection with the installation of a new bridge on Cypress Road at that location. The construction project was in a dangerous condition due to the failure of the County of Contra Costa to require the installation of adequate warning lights in advance of the New Jersey Barrier, which failure created a dangerous condition, causing claimant serious injuries. 5. Claimant 's injuries are numerous contusions, a broken left arm, injury to the right hand, and injury to the right foot. The full extent of the claimant's injuries are unknown at this time. 6. The names of the public employees causing the claimant' s injuries are unknown at the present time. 7. The claimant' s claim as of the date of this claim is in the sum of $150,000. 00, including special damages in the sum of $1 ,000. 00; wage loss is presently unknown; future special damages and future wage loss is presently unknown. DATED: , "July 31, 1984 ROCKWEL & THOMAS By D ID S . THOMAS Attorneys for Claimant 10 8�8 APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA ODST-k COiT`ITY, GkLIFORNIA BOARD ACTION Application to File Late ) NOTE TO APPLICANT September 11, 1984 Clain Against the County, ) The copy of this document mailed to you is your Routing Endorsements, -and ) notice of the action taken on your application by Board Action. (All Section ) the Board of Supervisors (Paracraph III, below) , references are to California ) given pursuant to Government Code Sections 911.8 Government Code.) ) and 915.4. Please note the "Warning" below. Claimant: Peter Spronken County Counsel Attorney: Alvin E. Tabor AUG 0 8 1984 Ryan & Tabor Address: 680 Beach St. , Suite 324 Martinez, CA 94553 San Francisco, CA 94109 Amount: $1,000,000.00 By delivery to Clerk on Date Received: August 7, 1984 By mail, postmarked on August 6, 1984 I. FRO*": Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Application to File Late Claim. DATED: August 7, 1984 J. R. OLSSON, Clerk, By , Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to 'File Late Claim (Section 911.6) . (X ) The. Board should deny this Application to File a Late Claim (Section 911.6) . V DATED: - JOHN B. CLAUSEN, County Counsel, By ����L u._` . Deputy III. BOARD ORDER By unanimous -vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6) . (� ) This Application to File Late Claim is denied (Section 911.6) . I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED Clerk, By `'J F i P d v , Deputy WARNING (Cov't.C. §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation re- quirement) . See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your applica- tion for leave to present a late claim was denied. You may seek the advice of any attorney of your choice in connec- tion with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1 County Counsel, 2 County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. / , DATED: Clerk, By � -C e� /. Y u� -� ► Deputy -//-�� � V. FROM: 1) County Counsel, 2 County Administrator TO: Clerk of the Board. of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM 00 8 5 9 I RYAN & TABOR Attorneys at Law 2 680 Beach Street , Suite 324 San Francisco , California 94109 . 3 (415) 673-2300 4 Attorneys for Claimant , 5 ` 6 RECEIVE] 7 8 7 J. R. OLSSON CLERK BOARD OF SUPERVISORS CONTR,COSTA CO. B ...... ..&4,(a.V-.Deputy_ 10 PETER SPRONKEN, 11 Claimant , 12vs . CLAIM FOR DAMAGES 13 CITY OF ANTIOCH , ' ANTIOCH AIRPORT, 14 COUNTY OF CONTRA 15 COSTA. 16 PETER SPRONKEN presents his claim for damages., pursuant to 17 Government Code Sections 905 and 910 , as follows : 18 A. Name and address of claimant : Peter Spronken, 71 19 Collins Dr . , Pleasant Hill , CA. 20 B . Address of person to whom notices are to be sent : RYAN 21 & TABOR, 680 Beach St . , Suite 324 , San Francisco , CA 94109 . 22 C. Date , place and circumstances of occurrence : On .2 3 September 17 , 1983 , at approximately 1 : 30 P .M. , claimant was 24 usinga parachute supplied by Bill Jones and the Antioch 25 Parachute Center . Due to the parachute , plaintiff incurred 26 injuries while parachuting . Claimant ' s body became entangled in 27 the parachute lines , causing injuries . 28 RYAN 8 TABOR ATTORNEYS AT LAW 680F BEACH SUITE 321 00860 SAN FRANCISCO, M.O,CA )415)673-2300 1 D . Description of injury or damage : Claimant injured his 2 leg and right shoulder . Patient underwent surgery for his right .3 knee. 4 E . Name of public employee responsible : Not known at this 5 time . 6 F . Amount of claim: Medical bills , total , are unknown to 7 date . There is a Kaiser medical and hospital bill in the amount 8 of $ 14 , 816 . 50 . General damages , based upon the injuries , treat- went and medical. bills is estimated at1 , $ COO , OO.O . 00 . 10 DATED : August 1 , 1984 RYAN & TABOR 11 12 B Y ALVIN E . TABOR 13 Attorney for Claimant 14 15 16 17 18 19 20 .21 22 4 ' 23 24 25 26 27 28 RYAN&TABOR ATTORNEYSAT LAW 0 0 8 6 690 BEACH ST.T.,SUITE 324 � V ..JJiLL SAN FRANCISCO,CA 94109 (415)673.2300 I RYAN & TABOR Attorneys at Law 2 680 Beach Street , Suite 324 San Francisco , California 94109 3 (415) 673-2300 4 Attorneys for Claimant 5 6 n 7 8 9 10 PETER SPRONKEN, 11 Claimant , APPLICATION FOR LEAVE TO PRESENT 12 vs . LATE CLAIM 13 CITY OF ANTIOCH, ANTIOCH AIRPORT , 14 COUNTY OF CONTRA COSTA. 15 16 Claimant PETER SPRONKEN presents his application for leave 17 to present a late claim pursuant to Sections 911 . 4 and 911 . 6 of 18 the Government Code as follows : 19 1 . Name and address of claimant : Peter Spronken , 71 20 Collins Dr . , Pleasant Hill , CA . 21 2 . Address of person to whom notices are to be sent : RYAN 22 & TABOR, 680 Beach St . , Suite 324 , San Francisco , CA 94109 . �3 3 . * Claimant and his attorneys believe that Bill Jones , 24 doing business as the Antioch Parachute Center , was the sole 25 owner and conductor of the parachute business . Claimant and 26 his attorneys were unaware that Antioch Airport was a governmental 27 entity as opposed to a private airport insofar as a private club 28 was using those facilities . It is only now, on information and RYAN 6 TABOR ATTORNEYS AT LAW 6B0 BEACH ST.,SUITE 924 �`fa SAN FRANCISCO,CA 94109 (415)679-2300 I belief , that it is believed that Antioch Airport is a governmental 2 entity . 3 Also , on May 26 , 1984 , an article was published in the local 4 newspaper indicating that there had been a second death at the 1 5 Antioch Airport . This article also gave rise to notice that 6 Antioch Airport may have a connection with the Antioch Parachute { 7 Center . Also , claimant ' s attorney did not know the relationship . 8 between the Antioch Parachute Center and .the Antioch Airport un- 9 til subsequent to the 100 days statute of limitations . Some time 10 within 120 to 160 days , claimant ' s attorney spoke to the owner of 11 Antioch Parachute Center wherein it was indicated that there was 12 a connection between his center and the Antioch Airport . However , 13 the only indications were that he .used those facilities on a 14 regular basis . However , this information was not available nor 15 known to claimant ' s attorney . Claimant and his attorneys had no 16 knowledge of the subsequent injuries , of course , at that center. 17 However , this gave rise to the investigation as to whether or not 18 there had been substantial prior injuries to claimant ' s injury , 19 thus giving rise to a possible cause of action for negligent en- 20 trustment of the Antioch Airport facilities to the Antioch 21 Parachute Center . 22 4 . Pursuant to Section 911 . 6 (b) (1) of the Government Code, 23 claimant requests leave to present late claim . 24 DATED : August 1 , 1984 RYAN & TABOR 25 26 B Y ALVIN E. TABOR 27 Attorney for Claimant 28 RYAN d TABOR ATTORNEYSAT LAW 2 00863 "0 BEACH ST.,SUITE 324 SAN FRANCISCO,CA 94109 (415)673.2300 �s APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COMA COTM Y, CALITMIFNIA BOARD ACTION ' September 11,1984 k-p14caFile Late ) NOTE TO APPLICANT igg=sto ait the County, ) r1he copy of this docuunent mailed to you is your Routing Endorsements, -and ) notice of the action taken on your application by Board Action. (All Section ) the Board of Supervisors (paragraph III, below) , references are to California ) given pursuant to Government Code Sections 911.8 Government Code.) ) and 915.4. Please note the "Warning" below. Claimant: Jesse Bugarin Attorney: Lawrence Mann County Counsel Cooper, Mastromonaco & Mann AUG 10 1984 Address: Four Embarcadero Center, 28th Floore San Francisco, CA 94111 Martinez, CA 94553 Amount: $100,000.00 By delivery to Clerk on Date Received: August 9, 1984 By mail, postmarked on Postmark ; i1Pgible I. FROG": Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Application to File Late Claim. DATED: August 9, 1984 J. R. OISSON, Clerk, By—,V--- � , Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Arplication to Pile Late Claim (Section 911.6) . (� ); The Board should deny this Application to File a Late Claim (Section 911.6) . DATED: 0 IC - SJOHN B. CLAUSEN, County Counsel, By� � ► Deputy i III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6) . This Application to File Late Claim is denied (Section 911.6) . ' I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED< C -V Clerk, By. ,l'j/t�,t,c..u,u , Deputy WARNING (C-ov't.C. §911.8) If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieving you frean the provisions of Government Code Section 945.4 (claims presentation re- quirement) . See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your applica- tion for leave to present a late claim was denied. You may seek the advice of any attorney of your choice in connec- tion with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1 County Counsel, 2 County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this f Claim in accordance with Section 29703. DATED: 9 - Clerk }� Deputy T � BY ����,,.., �..� Pty V. FROM: 1 County Counsel, 2 County Administrator TO: Clerk of the Board. of Supervisors Received copies of this Application and Board Order. DATED: L_LLCounty Counsel, By County Administrator, By APPLICATION TO FILE LATE CLAIM 00864 LAWRENCE MANN 1 COOPER, MASTROMONACO & MANN Attorneys at Law 2 Four Ernharcadero Center, 28th Floor 3 San Francisco, California 94111 Telephone: (415) 421-4591 �0 4 Attorneys for Claimant (� 5 RECEIVED 6 7 J. R. OLSSON 8 CLER BOARD OF SUPERVISORS C NIRA1 COST_A.�C . Deputv 9 10 11 12 ti Claim of JESSE BUGARIN ) APPLICATION FOR LEAVE 13 ) TO PRESENT LATE CLAIM ON BEHALF OF CLAIMANT 14 ) (§911. 4 OF THE Vs. ) GOVERNMENT CODE) ; IN 15 ) THE ALTERNATIVE, CONTRA COSTA COUNTY ) PRESENTATION OF CLAIM 16 ) 17 ) 18 ) 19 ) 20 TO THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, 21 CALIFORNIA: 22 23 24 25 26 Q0�6C� 1 I 2 Application is hereby made, pursuant to Government Code 3 Section 911.4, for leave to present a Late Claim founded on a 4 Cause of Action for personal injuries arising out of a truck 5 accident occurring on November 2 , 1983, for which a claim was not 6 presented within the 100 day period after the accident. However, 7 said Cause of Action for personal injuries did not accrue until on 8 or about mid-July, 1984, in that Claimant had been mislead by 9 agents of the COUNTY OF CONTRA COSTA as to the existence of said 10 claim and it was not until on or about mid-July, 1984 that 11 Claimant became aware of the existence of a claim against THE 12 COUNTY OF CONTRA COSTA. As can be seen from the Declarations of 13 Lawrence Mann and JESSE BUGARIN (which .Declaration will be filed 14 in the immediate future; Application For Leave filed to toll 15 presentation period) , and by the accident report prepared by the 16 Sheriff ' s Department of the CONTRA COSTA COUNTY, JESSE BUGARIN was 17 mislead by the Sheriff' s Department of CONTRA COSTA COUNTY who 18 incorrectly informed Mr. BUGARIN that his accident occurred on 19 private property and not upon a county roadway. It was not until 20 on or about mid-July, 1984 when Lawrence Mann, attorney for the 21 insurance carrier insuring the vehicle owned by Claimant' s 22 employer against property damages informed Mr. BUGARIN that the 23 insurance company' s investigation revealed his accident occurred 24 on county roadway. For additional circumstances relating to the 25 Cause of Action, references made to the proposed Claim attached to 26 this application. 00800 -2- 1 II 2 In the alternative, the failure to present this Claim 3 within the 100 day period specified by Section 911. 2 of the - 4 Government Code was through mistake, inadvertence, surprise and 5 excusable neglect of JESSE BUGARIN, in that he was mislead by 6 agents of the COUNTY OF CONTRA COSTA as aforesaid. The COUNTY OF 7 CONTRA COSTA was not prejudiced by this failure, all as more 8 particularly shown by the attached Declaration of Lawrence Mann, 9 in that on or about January 11 , 1984, Meza Brothers, Inc. 10 (Claimant' s employer) and Enterprise Insurance Company (Claimant' s 11 employer ' s insurance carrier) filed a claim for the property 12 damage arising from the same truck accident occurrence in which 13 JESSE BUGARIN was injured, additionally, at the time of said truck 14 accident, the CONTRA COSTA COUNTY Sheriff's Department was aware 15 that Claimant BUGARIN had been personally injured, as seen by the 16 Sheriff ' s Department Report of Accident, attached hereto. 17 18 III 19 This application is being presented within a reasonable 20 time after the accrual of this Cause of Action, as more 21 particularly shown by the attached Declaration of Lawrence Mann 22 and by the Declaration to follow of JESSE BUGARIN. It was not 23 until on or about mid-July, 1984 that the COUNTY OF CONTRA COSTA 24 was responsible for the truck accident, and it was not until said 25 date that Claimant BUGARIN' s Cause of Action accrued. 26 0086 -3- 1 WHEREFORE, it is respectfully requested that this 2 application be granted and that the attached proposed Claim be 3 received and acted upon in accordance with Sections 912.4-913 of: 4 the Government Code. In the alternative, it is respectfully 5 requested that the attached Claim be deemed timely filed, and 6 filed accordingly. 7 Dated: August 6, 1984 COOPER, MAS OMONACO & MANN 8 9 By• 10 LPLWREIJCE MANN C"Xttorneys for Claimant 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 00868 -4- 1 DECLARATION OF LAWRENCE MANN 2 3 I, Lawrence Mann, declare as follows: 4 I am an attorney at law and an officer of the Court and 5 licensed to practice before all of the Courts of the State of 6 California, and am the attorney for Meza Brothers, Inc. and its. 7 insurance carrier Enterprise Insurance Company, and am the 8 attorney for Jesse Bugarin concerning personal injuries he 9 sustained in a truck accident occurring on or about November 2, 10 1983. 11 In mid-July, 1984, I telephoned Jesse Bugarin, an 12 employee of my client Meza Brothers, Inc. to discuss the facts of 13 the November 2 , 1983 truck incident in which the truck he was 14 driving rolled over. During that telephone conversation, for the 15 first time I informed Mr. Bugarin that the truck roll over 16 incident location occurred upon Contra Costa County property. Mr. 17 Bugarin at that time informed me that he was surprised, in that 18 the investigating Deputy Sheriffs from the County of Contra Costa 19 informed him that the incident occurred on private property. 20 Exhibit A, attached hereto is a true and correct copy 21 (other than for felt pen underlining, the placement of a question 22 mark in the upper left-hand corner of the first page, and circling 23 of data in the upper left-hand corner of the first page, all by an 24 attorney in my office) of the police report prepared by the 25 Sheriff's Department of the County Contra Costa. As can be seen 26 by the upper left-hand corner of the first page of the police 00869 1 report, the Deputy Sheriff s who prepared said report believed 2 that .the truck incident occurred upon private property, and not 3 upon a county roadway. The investigation of Meza Brother' s 4 insurance carrier has revealed that the truck incident in fact 5 occurred upon a county roadway.- 6 oadway.6 The County of Contra Costa will not be prejudiced by the 7 date of filing of Jesse Bugarin' s claim because said county on 8 January 11 , 1984 received a claim by Mr. Bugarin' s employer and 9 insurance carrier for damages to the truck Mr. Bugarin was driving 10 and which damages occurred when Mr. Bugarin received his personal 11 injuries; additionally, as can be seen by the Sheriff Department' s 12 incident report, Contra Costa County at the time of said truck 13 incident was aware that Mr. Bugarin had sustained personal 14 injuries in said truck incident of November 2, 1983. 15 I declare under penalty of perjury that the foregoing is 16 true and correct and that this declaration was executed in San 17 Francisco, California on August 6, 1984. 18 19 LAWRENCE MANN 20 21 22 23 24 25 26 008'70 -2- T1qAfjX4QLCL1Si1ON REPORT SP a•CDHD.roarsO.INJ11R as M a R C'TV JUDICIAL DISTRICT NUMEaR / r/as �e:' "`0 w &A#J I NC-O��T6a E�.vrA r+&t�t NO. KILLED N a a COUNTv Ra►O"TING DISTRICT NEAT r, also. D co v O I ON OCC VwwaD ON YO. OAT Yw. TIME (tMs) NCIC MUYsaR OFFICER 1.0. Se ..is�a,.�_!� ! : of:a3 i gam 4 ::- -_- -- ._--� )..._._ MILS PO ST/M•Ow TION INJURY.SWISOA ON TOW AWAY STAT[HH6"WAV waL1ATITT IRD (J Ia[T OI MILEPOST T[f ON. 0 Taf {d NO 7S LAT IRT[w/ECTION OIT" a��w PHOTOGRAPHS M--::9 R: P I AYE/MILEt Q� 011ppe� RD G D was MO PARTY NAME (FIOST.MIDDLE.LAST) DwNSw'{NAME GAME AS DRIVER ' SEOScg00100010008I, Mrc-Z.A aq, S*Ac- owlVaa STREET ADOxas{ "OMR► O ■ OWNER'S ADDRESS Li SAME AS DRIVEN X ;J , q.-jo VaDas. CITY/STAIR/Zip suSi"aff "ONs DI{POSITION Or Van. ON OwDaRf OF TRIAN JA/Y�R A ` p y S 'Tacr� ❑or►Icaw owlvaw ❑oTHNR PAONSD ONIVEw's LICENSE Nummalt STATEF�. �A' ATK Sax RAC■ DIRE CT10N O► ON/AWWWry(STREET OR HIGHWAY) lopag" LIMIT Van. Va. TRAVELc w -a.s! s �S SICU- van.Tw(K) rAKK(t /MOONL(/)/coaew(f//11 .(f) {TAT cNF use vsMleaa DA Aaa—ExwaNT/LocAT1oN CLIST {II/� ONLY /tea{aL/1T - C.� ICL[TT► PIM DR C5 rODaw ATR D MAJOR TOTAL - AILG.9L-P Oz,T *� ST�ATH 'AA/T •P'! Q I PARTY MAY■ (FIRST.MIDDLE.LAS OwNEw'{NAME SAM[ AS DRIVER 2 DRIVEN STOEST ADDIHa SS NOME PHONE OWNSw'f ADDRESS Lj SAME AS DRIVER C>4.,0 FSOas. CITY/STATE/Zip MUSi"[ft FHONE ISPOSITION OF VSM. ON ONDURS OF TUBA" ❑orrican D DRIVER ❑OTHaN FARKED DR1VOM'f LICENSE NUMSUR ATE a1RTMOATa {Ex WAC■ Olw[CTI OF O"/.CNOfs (STREET ON HIGHWAY) SPS 60 LIMIT VON, MO. DAY VN. TRAVEL wlcY- VEP,vN(s) MAKE(•)/Moos L(sIlCOLOR(S I LICE"SN"O.(f) STATE(S) CHP USE [Mico DAN ASV—E xTU NT/LOCATION CLINT ONLY • - - - VEHICLE TV• MINOR D MODERATE D MAJOR D TOTAL OTHER PARTY NAMEIFIRST.MIDDLE.LAST) OwNSa'S NAPS Lj SAME AS DRIVRR 3 T oR1Vaf SYNKST^Damage NOME F"ON[ OWNER's ADDRESS Lj SAN&AS DRIVER Pa Das- CITY/STATIC/21P skjSINEss PHONE D1SrOSIT1ON Or VEP. ON DODSON or TRIAH DOFFICER D DRIVER 0.1... PARKED Dw1VNR'f LICENSE"UMSER STATE sIRTMDATIR Six RACK OIwG CTID"Or ON/ACROSS INTRUST OR"IOMWAY) PaRD LIMIT IVS". YO. DAY Va. TwAVaL wICT• VE".VR(f) MAKE(s)trooaL(ti/co►ow(s) LICEIHsa"O.(S) STATE(/) CHP USK VaNICLS DAMA611—SxT[NT/LOCATION CLIST ONLY • - VEHICLE TYPE D MINON D MODERATE D MAJOR D TOTAL OTHUw PARTY «AME (►/OST.MIDDLE.LAST) OWNUN'f NAME 0 SAPS AS DRIVER 'oo,vaw fYw K[7 AOOR{fS NOME PHONE OwMa R'S ADDwO{{ U SAME AS OwIVfN I PaoaS• CITT/SVATs ISIP susimuss FHONa olS►ON/TION OF VS.]ON Ow Owns OF TRIAN DOFFICER D ORIVSN D OTMU. &Aw RED DRIVEw's LICSNSS NUrsen SIRTHDATs 1 {TATS SEx RACE DIRECTION OF OH/ACRO{/ (ETREaT OR M10"wAw) io,ERD LIMIT VaM, YO. DAY YR. TRAVEL •ICT. VEP.Vw(f) YAKff(S)/14ODOL(N)/C0LDO(S) L/CKNOR NO.(s) STATS(S) CNP USE VENICLK DAMAGE—OxTa M7/LOCATION CLINY ONLY . . . . . . . . . . . . . . . . . . . . . . . VE"Hua TVP1 D NINON D MODEwwTE D MAJew D TOT&& DTII i w I CHF L7,5—Frye 1 (REV"2)DPI 042 TRAFFIC COLLISION CODING - •+�• I _ DATE OF COLLISION Tlrt ( I.C.0 NIY6tR O aw Lo. HUMOaIt - oZ' 2oa 3� 5 Pio. oir rw. PROPERTY DAMAGE OROCRIPTION Or CAMAO77 OWNSw•MA Mf/A ODw Ett NOTIP tRD Dyet D. VIOLATIONS) •wRTr t ►wllTr 2 PARTY 7 PARTY G CHARGED PRIMARY COLLISION FACTOR *)GMT OF WAY CONTROL 1 2 1 7 14 TYPE Of VEHICLE 1 t 7 A MOVEMENT►RECEDINI IL19T MVMO[R 10)OF PART/ATvAVLTI A CONTROL.PuNCT1oNIM0 A PAGGa Mato CAa/ETA.WAGON COLLISION 6 A VC 66CTION VIOLATION: 0 CONTROLS MOT FUNCTIONING 0 PASSENGER CAN W/TNAILEM A svo FPUD C CONTROLS O6SCunwD IC MOTORCVCLs/GCDOTaw PPOCESDIt•& STRAIGHT w 0 Orman IMPROPER OWNING• D MO CONTROL. Pw[[f NT D .Co..IOR IAM[,TRUCK C MAN OPF ROAD E FICKV•/PAM[L Too W/TRLN D MAKING MISNT TURN C OTNOR THAN OMIVKR• TYPE OF COLLISION I F TNUCK ON TRUCK IIIACTOA E MAKING LUPI TURN DUNKNo WN• A MEAD-0N C TRK/TRK TRACTOR W/Tnl.w F MAKING V TURN WEATHER MARK 1 TO I ITEMS) 0 SIDRGWIPR H SCHOOL.Pu[ C eACKIMO A CLEAR C Ra A"END 1 OTMSw DUG M[LOWING—STOPPING 11 CLOUDY O MROADSIDIS J GENCT VEHICLS I PASSING Orman Va./CLI C MAIMING E MIT Osia CT K HWY COM OVIPM6NT J CHANSONS LANES O$"*wefts F Ovwnrwn Mao L OICv CLa K PARKING MANSVWKM E PDG C AuTo(►a Df BTRIAM M OTmaN V[MICLa ENTERING TRAFFIC P.C. F oTNaR•: N Orman•: N PEDESTRIAN SmOULDEw.MRDIAN. L G Wlwp O MoltO PARKING .TMP on 1.16MTIN6 MOTOR VEHICLE INVOLVED WITH PRIVATE OSIVS A OATLIONT A MOM-COLL1110N 1 2 1 l THEM ASSOCIATED FACTOR M OTKas UNSAPE TURHIND 9 DUSK—DAWN 0 PEDESTRIAN 1MARK I To S ITRMSI N a1NG INTO OFIOGING LANE C OARK—STafaT LIG MTB C OTHER MOTOR VEHICLE A VC SOCTION VIOLATION: O PANKfD D DANK—NO STN6[T LIGHTS D MOTOR Va".ON OTHER ROADWAY P monsoon 6TOi6T,IONTO NOT E PA*KfO MOTOR VEHICLE 8 VC GOCTION VIOLATION: O♦oavf LlWG WoONO W.,- DAN N_ Plum CTIO04 INS .Y- DAMN— FVMCTIOMINS• F TRAIN R*THE*': P DICYCLf C vC SECTION VIOLATION: ROADWAY SURFACE N ANIMAL: 1 2 7 G SOeR1ETY—OMu6— A Dow D VC GSCTION VIOLATION: PHYSICAL 0 War I PIKao OaJa CT: (MARK I TO I ITEMS) C SNOWY—ICV E Vla1011 Oaacu REMENTS: I A HAD NOT GaaN DRINKING D SLIPPSOV )MUDDY.GILT.ETC.) J O/T.9A OMJSCT: 0 H90—UNORM INFLUENCE �1•1 �� F IMATTa NT10N I C"100—NOT UNDER 1NPLU.• ROADWAY CONDITIONS r..STOP SI 60 TRAFFIC 014110—IMPAIRS16NT YNKN• PARK 1 TO I ITKMIJ PEDESTRIAN'f ACTION M ENTanlma/LEAVING "AMP E UNOaR DRUG INFLUa HCG• A MOL6S,DOE►IVUTG• K A NO Pa De GrwIAN IMVOLVSD I ►Nf VIOUS COLLISION FIMIAtR M[MT—PMT SICAL• -DSV MATS*IAL ON ROADWAY• CROSSING IN CROSSWALK J VNPAMILAAR WITH"GAD 0IYPAI11016NT NOT KNOWN s C GRGTRtICTIDN Om ROAOW AVP AT INTM n[s CTION K D[Ia CTM VaM.EOUIP.; N NOT A►KICA GLt D CONSTAUCTIOM-NRPAIft SONG CNOSSI046 IN CROSSWALK—NOT { (Lai lr(I ATICUfD t aG6u Cab ROADWAY WIDTH C AT/NTKRSSCT/ON L umtHvoLVao va H%c La F•,601180• O CROSSING—MOT IN CROSSWALK M armsa•: 1 1 s G SPECIAL 1NPOMYATION 4 OTKaft Pt E IN ROAD—ImcLu Dft SHOULD&* - N NONE APPAMf NT A Hwa.woout MATEN1A►S• M NO UNUSUAL CONDITIONS F How IH ROAD O RUNAWAY VamICLa E P/OU tNVOLVED• G APP"DACMIWa/LOAVINO SCHOOL Owe C Tont DSPSCTIVAILVnS- SRSTCH MISCELLANEOUS 0 IWDICATO NORTH PHYSICAL DESCRIPTION OF PARTY WUMa6R HAIR evenHEIGHT W6NMT t MO. OAT I.D.NUYEE■ MO. DAT vM. ME V16 rE A'G NAME vR. LI`'Y`'�'`i� s� g8zh tl cz 83 Ihh 6421 OPI O;? _ 4 G116 E:pl6tn to natiut 00872 c INAMED/WITNESSESMASSENGERS SEES42 OATS oP COLLISION —_ IME (sass) &CIC NYrS2w OPPICsw I.00� lfduw;vftDAY o Vw. 7-6 11 EXTENT Or INJURY (Cheek one) INJURED WAS(Cheek ohe) PARTY IIITNEEPASSMNO[" Aot SSE. WOUND 07"20 VIPIRLe CONPLAINTONLTT ATAL IN+YwY ORIVRR PAss. Ps O. ICVCLI/T OT"En N01sTOwTSO r2YSsw /MlYwlEsO/ IA/❑ ❑ ❑ NArs TAKEN TO (1w4Uw Ro ONLY) AOow2Es TELEPND"s SES V- PC,/ t� NAME TAKEN TO INJURED ONLY AODRSSs T26tp"ONs ❑ ❑ ❑ OM ❑ ❑ NAME TAKEN TO(INJ0020 ONLY ADDw2s* TELEP"OM2 D ❑ D ❑ D ❑ D ❑ I D I ❑ I ❑ NAME TAKEN TO (INJURED ONLY ADORE" TELE►"ONR — 01 ❑ D D ❑ ❑ ❑ 1 ❑ 1 ❑ 1 D ❑ "Ars TAKEN TO (INJunED ONLY) &Downs* TSLs P"ONs "AME TAKEN TO(INJURED ONLY) AIM2N T2LSP"ON■ ❑ D ❑ ❑ D ❑ 1 ❑ I ❑ ❑ NA TAKEN TO (I/IJURRO ONLY) ADBIEN . TRLn►NONE D ❑ ❑ D ❑ 1 D I ❑ ❑ 1 ❑ NAMES TAKSN To (INJUwRD ONLY) ABBWnN TnL2r"owE ❑ ❑ ❑ ❑ ❑ 1 ❑ I ❑ ❑ ❑ kAstf TAKSN TO (IN+Uw ED ONLY) &Dfmw TEL 2 P"ON 2 ❑ ❑ ❑ Cl I O I ❑ 1 D ❑ Fff I/AssS TAKEN TO INJYwEO ONLY) wDBMts* VULEPNONE IrITW�Rs PAsf[wlSw EXTENT OF INJURY (Cheek One) INJURED WAS(check one) PARTY DOLT ONLY SCESER SE1JERE WOUND DTNS"VISIBLE COMPLAINT ATA►IMJYwT owlYsw PAft.' PS O. BICV Cl1S OTwt■ NVr■sw Dls7owT2e rsrREw Rs+Uw1aS OP PAIN onsJyNWw's NArt I.D.NYMIs■ r0. DAY Tw. wsVls Wn N's"Aids r0. BAY Va. Ta q 1 I 20 CNP 56L-fSp 31Rvv 6.821 0Pl 042 t • • , . SSSS., FACTUAL DIAGRAM PACK L OAT[OF COLLISION71r[/(as") jftCIr 11111,16111111111,161111C[R�Ij.O. MVr�IR �j re. \ pAv OA��[[S vw. ' 4o0 43 Li.: 9 i <= / f� ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE .NOICATS t•' NORTH p' 2' 2' l 1 �1 4. SEn Sof ,. Ro Aa 5 ( s• s• t ' • h . r s• Ci PReSS fZa f �.. s.. �.. 4.. f.. �.. 7.. f I PR[PAR[w'S NAM[ S.D.NYrDRw r0. DAT TR. IftevolturgIl's NAM[ 0(1 7ro. sA• •w. b.L.. yoJ64 STO q8� �I zo V CHP 555—Pape 4 (Rev 6-62)OPI 042 atio�u�Av z�mr r_ars •� •• S' C CA-CA eggs CMUCM'—s WAR'$4tIVE/SUPPLEM ENTAL NARRATIVE D SUPPLEMENTAL ® COLLISION REPORT D OTHER: DAT<;DP ewI.INALAMCIDPtftT> TIME (LIN) NCIC NUMBER OPPICSw I.D. "u...Sw 11 DAV VS. 11.00 CITY/COUNTY/JUDICIAL DISTRICT Rf►e RTIN.OISTNICT/.UAT CITATION ggU si.Sw LA CATION/S Y N U CT t. 1 T AT :. DSCI-54G AT ltf!fQ ftgS- 4# E,J PRS A iJ E • FEACTLAIL 7. /Z ' tt 1 x W ► co -4 Ti ao IVC, To rL " it. IDIA f0b IIJT- t- T o C-7 o - t... f D T Tti o Aa&,L;. . 7 R F Fo �► . �1 �E2 I D-1 � 1 r Ir L.,j A 15 1 o S A Au Oce i -P-3 &FPILIC:Ix ' o ND AP3 r=Ars OF C-0441:!j ►N ► nD nI► }O T • - ig 71> JJAVIAtilO wt V E H 1 .RS.ARfw'.MANie.NY/I.fw fi0. DAV VO. INSVOSWIIN'S NAME 2 eA♦ Tw. a.`, y o�tJ V 5� 5 2[0 1 2-0 CHP 668(Rev 4.83)OPI 042 Uo p►evioue editiom until depleted. 00875 eNreN owE ewrew owr NARI;ATIVEfSUPPL'�MENTAL NARRATIVE ❑ OUPPLZMZNTAL IN COLLIEIGN ME.CRT ❑ TNER: SAVE d► ONIBINAL INCIDENT •�rr.N..)) "CIC wurrrw OFFICER Le. NUMBER re. ' SAT 0 Vw.. 1 -co r% Z� Z tea/ •f- 1 CETT/COUwTV/JUDICIAL oIBTw ICV RB►OOT/NB RUVOICT/BEAT CITATION wwwomm LO CATION/NEJE CT t. A c'� •J Go G �., wA hjASj 04m jj Is QT S tD o LL o v W-7z . 6 LZ A b,-J a 464 q Pa 6C'S le A 1 DF4E S =S - e^P . ts. S E D L E 1 � JJ �• �•. t TZ 1 = PA V 6M> bo P-7I I o..1 F =&eILSIA fe&CX �I O 1115. S ACC-1 D U X-a A1D ,,4 A Dw 0 2 QjjML IT_ 00876 ArFAwrw•B SArr I.o.wurSBw re. SAT Vw. wrvlESEw•B NA 000. SAT Vw. p. o��� S� S$ 11 Lo OL CN► (Aw 443)OPl 042 Lw previous editions until depleted. C J T E. iJ'-(--*l- 2 3 J `_'4:• t C 5 1-.1-C.t h 7:f.:, 6 cl I v:1 IV 9 Cc r Cc L,,-u,-:i 10 V 11 4L 12 r ut F"-!j Tl,�--!-,­tT,J� n"I I 2:'l T,,.k 13 t. t I 141'C15 c i: A i. 1. .._ C.-. U r t y C. 16 L F, 1C.:lu 6 t c 17 18 U1`.' , I. i) c: t I C.T.-h C T-, 19 o t t c r. o c. c: C.I: F, il A--U t 20 a- v;1!i C) t t C r*r;,-. I C r. , t ht:t i i t 21 --1 C 1 L !.r t 111( IC I C.-VOr iFIC i GL U*Z% Lil 22 cc-u:. 3'C (A-17.7 i: ?!C" iiCIL t'l-C mr (f j. I 23 thulreaitui- r. cul d 'Lhl-i.". i,l- r, 1'E I Fc. el": 'LAtoync-', to J 1i< tll-: truuk rcll ovOl. 24 ri�. i f:r c. i! vu 25 26 ol th,.� 0087' ------------------- � � ►tea y 1 thr_t ti,i._. r,:.t_cr e:r.:; c -.E cut<_-Cz irq Los 2 _ 47,(_i CczJ DC7. . t f,i i uctl'.::t 3 9i4 . 3 - 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 00878 -5 '-' CLAIM FOR DAMAGES AGAINST THE COUNTY OF CONTRA COSTA, STATE OF CALIFORNIA TO: THE BOARD OF SUPERVISORS, COUNTY OF CONTRA COSTA, CALIFORNIA PLEASE TAKE NOTICE that claims is hereby made against you . on behalf of JESSE BUGARIN. A. Name and Post Office Address of Claimant: Jesse Bugarin 1548 Canal Farm Lane, Apartment 8C Los Banos, California 93635 B. Address to Which Notices Are to Be Sent: Lawrence Mann, Esq. Cooper, Mastromonaco & Mann Four Embarcadero Center, Suite 2840 San Francisco, California 94111 C. Facts and Circumstances Giving Rise to This Claim Insofar as Known to Claimant: On November 2, 1983, on the Jersey Island Road, Contra Costa County Road #8774, 5. 1 miles north of Cypress Road, Jersey Island, Contra Costa County, California, due to the negligent ownership, operation, maintenance and failure to warn concerning vehicle weight tolerance on the aforesaid roadway, approximately 8 to 15 inches of said roadway broke off,- proximately causing the - freightliner - 2-axle tractor and two semi-trailers driven by Mr. Bugarin to roll over, causing him severe and disabling personal injuries. D. Name of Any Public Employees Involved: The names of any public employees involved .are unknown to claimant at this time. E. Amount Claimed on Behalf of Claimant: 77 The amount claimed by claimant is $100,000. 00 in general damages. Claim is also made for medical expenses and lost wages which are continuing at the present time. Dated: August 6, 1984 C04 TROMONACO & MANN N E MANNneys for Claimant 00879 CLAIM FOR DAMAGES r AGAINST THE COUNTY OF CONTRA COSTA, STATE OF CALIFORNIA TO: THE BOARD OF SUPERVISORS, COUNTY OF CONTRA COSTA, CALIFORNIA PLEASE TAKE NOTICE that claims is hereby made against you on behalf of JESSE BUGARIN. A. Name and Post Office Address of Claimant: Jesse Bugarin RECEIVED l 1548 Canal Farm Lane, Apartment 8C Los Banos, California 93635 B. Address to Which Notices Are to Be Sent: Lawrence Mann, Esq. C',Er' BOARD OF SUFERVISOt`_. , Mastromonaco & Mann Cooper, f CONTRA C.. TA ':'S(�.Deputy TTA. -CO. P BY..� 1� Four Embarcadero Center, Suite 2840 y.^�f: San Francisco, California 94111 C. Facts and Circumstances Giving Rise to This Claim Insofar as Known to C aimant: On November 2, 1983, on the Jersey Island Road, Contra Costa County Road #8774, 5. 1 miles north of Cypress Road, Jersey Island, Contra Costa County, California, due to the negligent owneKship, operation, maintenance and failure to warn concerning vehicle weight tolerance on the aforesaid roadway, approximately 8 to 15 inches of said roadway broke off, proximately causing the freightliner 2-axle tractor and two semi-trailers driven by Mr. Bugarin to roll over, causing him severe and disabling personal injuries. D. Name of Any Public Employees Involved: The names of any public employees involved are unknown to claimant at this time. E. Amount Claimed on Behalf of Claimant: The amount claimed by claimant is $100,000. 00 in general damages. Claim is also made for medical expenses and lost wages which are continuing at the present time. Dated: August 6, 1984 COOPER., ROMONACO & MANN By• RENCE MANN Attorneys for Claimant C'0880 COOPER, MASTROMONACO&MANN ATTORNEYS AT LAW FOUR EMBARCADERO CENTER,28th FLOOR SAN FRANCISCO,CALIFORNIA 94111 (415)421-4591 RECEIVED August 20 , 1984 J. OLSSON CL Rr BOARD OF SUPERVISORS C NTR -COSTA CO. Jolene Edwards, Deputy Clerk B est Board of Supervisors Contra Costa County P.O. Box 911 Martinez , CA 94553 Reference: Jesse Bugarin v. Contra Costa County et. al. Dear Ms. Edwards: On August 9 , 1984, we filed with you an Application for Leave to Present LateaClaim; attached thereto was a copy of a Declaration of claimant Jesse Bugarin. Enclosed please find the original of Mr. Bugarin' s Declaration, which we request that you attach to the original Application For Leave to present late claim. So that we may confirm that you have received the original Declaration, would you please return to us the enclosed copy of the Declaration of Jesse Bugarin stamped received by your office. Thank you very much for your assistance. Very t my yours, W ENCE MANN LM/ss Enclosure I 1 DECLARATION OF JESSE BUGARIN 2 3 I, Jesse Bugarin declare as follows: 4 I reside at 1548 Canal Farm Lane, Apartment 8C, Los 5 Banos, California 93635. 6 On November 2 , 1983 , I was employed by Meza Brothers , 7 Inc. , a trucking company. On that date, I was driving their truck 8 and working for them on the Jersey Island Road, approximately 5. 1 9 miles north of Cypress Road, Jersey Island, Contra Costa County. 10 At said time and place, the roadway collapsed and gave way 11 underneath my truck, causing my truck to roll over. 12 On the date of said truck incident, Deputy Sheriffs of 13 the Contra Costa County Sheriff ' s Department informed me that the 14 incident occurred on private property and not upon a county road. 15 I relied upon said representations by Contra Costa County, and did 16 not file a claim for my personal injuries within 100 days after 17 November 2, 1983. 18 It was not until mid-July, 1984, during a telephone 19 conversation with the attorney for Meza Brothers, Inc. and its 20 insurance carrier, which attorney is Lawrence Mann, that I first 21 learned that the site of the above truck roll over incident was on 22 a county roadway, and not upon private property. I immediately 23 thereafter requested that Mr. Mann represent me as an attorney to 24 recover for my personal injuries sustained in the truck roll over 25 incident. 26 I declare under penalty of perjury that the foregoing is 00892 ♦ ,r1 p 1 true and correct, and that this declaration was executed in Los 2 Banos, California on August 1984. 3 4 5 6 JESSPUGARIII/ 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 00883 -2- 1\ CLAIM f BOARD OF SOPERPISORS OF COMMA COM OOURrY, CALInO wm BOARD ACTION Claim Against the County, or District ) NOTICE TO CLAIMANT September 11, 1984 governed by the Board of Supervisors, ) The copy of this document ma ed to you is your Routing Endorsements, ana mora 'hotic* or the action raKen or- your claim cy the Action. All Section references are ) Board of Supe� asors (Paragraph IV, below) ,, to California Government Codes ) given pursuant to Government Code Section 913 and 915.4. Please note all 'Warnings". Claimant: Cadillac Ambulance Service, Inc. Attorney: Gary Hursh 6825 Fair Oaks Blvd. , Syuite 103 Address: Carmichael, CA 95608 _Amount: $84,171.28 By delivery to clerk on July 30, 1984 .,tt Date Received: July 30, 1984 By mail, postmarked on a I. FRom: Clerk of the Board ot Supervisors County Counsel Attached is a copy of the above-noted claim. Dated: July 30, 1984 J.R. OLSSON, Clerk, By t-c--a- 6,0 Deputy Jolene Edwards II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check only one) y) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3) . / ( ) Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: (1) County Counsel, (2) County r ( ) Claim was returned as untimely with notice to claimant (Section 911.3) . IV. BOARD ORDER By unanimous vote of Supervisors present (�) This claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its mi utes for this date. Dated: 1 I , Clerk, By EREM&M&" , Deputy Clerk MRNYNG (Gov. Code Section 913) :Subject to certain exceptions, you have only six (6) months from the date of this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. V. FROM: Clerk of the Board TD:' (1) County Counsel, (2) County Administrator Attached are copies of the above claim. We notified the claimant of the Board's action on this claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. ( ) A warning of claimant's right to apply for leave to present a late claim was mailed to claimant. PE{ ,,� p DATED: G 1L� y Clerk, By ve - I . , , Deputy Clerk cc: County Administrator (2) County Counsel (1) CLAIM 00107 CLAIM TO: BOARD OF SUPERVISORS OF CONTRA "*, rFRWRVappiication to: • _ Instructions to ClaimantClerk of the Board 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 his form. RE: Claim by )Res z e f ttct r ing stamps CADILLAC AMBULANCE SERVICE—INC.' 4601 Nevin Avenue ) Richmond, CA 94805 JUL 3v, 1964 Against the COUNTY OF CONTRA COSTA) J. R. OLSSON CLE 80ARD OF SUPERVISORS or DISTRICT) B "'� Tco. fRA putt' (Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 84_171.28 and in support of this claim represents as follows: I. When did the damage orn3ury occur? (Give exact date and hour] AUGUST 1, 1983 through December 27, 1983 --- SEE ATTACHED �. Where did tie damage or injury accur? (Include city and county) Contra Costa County --- SEE ATTACHED 3. How did the damage or in3ury occur? (Give �u�S 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 _. ,sEilaxat��r�.]._cantrac ==-SEE ATLAL��-------=----------------- - 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) 00108 5. What are the names of county or district officers, servants or -employees causing the damage or injury? Unknown, but SEE ATTACHED 6. xnl�iat damage or injuries do you claim resu�te�? ZG�ve dull extent of injuries' oi damages claimed. Attach two estimates for auto damage) Loss of Income --- SEE ATTACHED ------------------------------------------------ ------------ -- 7. Bow was the amount claimed above computed? Include the estimate amount of any prospective injury or damage. ) The private ambulance rates in effect on the date of the requested service less any payments received. ------------- �< Names and addresses of witnesses, doctors and hospitals. Employees of Cadillac Ambulance Service, Inc. , 4601 Nevin Avenue,. Richmond, California 94805 --- SEE ATTACHED � List the .expenditures you made on account of this accident or injury: DATE ITEM AMOUNT AUGUST 1, 1983 through AMBULANCE TRANSPORTATION COST OF DOING BUSINESS DECEMBER 27, 1983 Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney Claimant's ignature GARY HURSH 4601 Nevin Avenue 6825 Fair Oaks Blvd. , Suite 103 Address Carmichael, CA 95608 1 Richmond, CA 94805 Telephone No. (916) 481-9426 Telephone No. (415) 231-0190 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents forallowance or for payment to any state board or officer, ' or to any county, town, city district, ward or village board or officer", authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony." 00109 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 08/01/83 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 50.00 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- 00110 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- 00111 NAME DATE OF SERVICE AMOUNT PEDROTTI, WILLIAM 08/07/83 $ 216.50 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 WILLIAMSON, 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- 0011.2 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- 00113 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- 0011.4 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 RUN 08/20/83 50.00 DRY RUN 08/20/83 50.00 WRIGHT, Prola 08/20/83 193.00 DRY RUN 08/20/83 50.00 -6- 00115 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 SCHWERIN, 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- 00116 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- 00117 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 08/29/83 211.510 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- 00118 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 09/02/83 241.50 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- 0011.9 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 SHEPARD, 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, 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- 00120 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 09/05/83 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 09/07/83 189.50 -12- .. 00121 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- 00122 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- 00123 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 09/13/83 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 MARRABLE, 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- 00124 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 EDWARDS, Arthur 09/19/83 194.50 TIMMONS, TAMMY 09/19/83 159.50 -16- 00125 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 PHEA, 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- 00126 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- 00127 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 MCDONALD, Timothy M. 11/08/83 59.90 -19- 00128 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- Q 1.2W9 CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM 1 ` UNIT AUTHORIZATION a _. `) CFILL IN APPROPRIATE SPACES DATE. p j ' .1 e__�____-_-__ FF TIENT'S NAME15)A/ `1 ❑ M El COMPANY 0 ADDRESS _ _._. _ AGE STATE _.. . ._ . ZIP _. DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S D;dVER'S LICENSE# PHONE NATUHE OF DISPATCH 1&�. DD TYPEOFTRANSPORT AMBULANCE OTHER❑ '( INCIDENT LOCATION RESPONSE COLE REQUESTED BY TIME - (24 HOUR CLOCK) TO SCENE - 'PS O _._- . CALL RECEIVED ❑ PD. TIME 10 8 1 PATIENT DESTINATION FROM SCENE ❑ FIRE -_ _____ TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 1. END _ _.._-_ ___ _... TIME 10-98 -- DOCTOR __ PMD/ER START—_.._-__.- —_. —_ TIME 10-22 HOW CHOSEN TOTAL -_-�_ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER _ _ WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY: n II PT AMBULATORY? PATIENT TAKENTOAMBULANCERESPONSE ZONE ( , ❑ YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION DRIVER Lt�J 14A Aj EMT-tA TECHNICIAN _.. TY / ���_ PARAMEDIC Hx ----- ------ - - ---- - DISPATCHER: -t- ----- / -�1'=------------jam CHIEF COMPLAINT: ._- ___..___. .._____-._, DRY RUN 4�1 YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE UNLV)_ - �1/ PATIENT REFUSED SERVICES (SIGNATURE) X i' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS. SS a ----- - --- --- - / PRIVATE INS.CO.:_ -.___ - __.- BASE RATE: KAISER a: __— _.--._ __ MULTIPLE PTS BASE RATE BLUE CROSS a: _.. —_ TOTAL MILES: _—__—_—_— X MEDICARE a __ E O B. ATT ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19:00-07 00) CCHP/PPRP#: - _. EMERGENCY RUN: -- MEDI-CAL a: — —_______— 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) ___—_.__�_ STATE _ __ZIP:__.__..___ C-COLLAR: (IF NOT REPLACED) CITY:_-__._ _ PHONE: _— WORK PHONE DRY RUN: (AUTHORIZED) EMPLOYER. _. OCCUPATION. __..__. ... ___ OTHER' ADDRESS.--- = ----- - - - -- - -- - - ----- - - CITY: _ STATE.-------ZIP: -- - -- ----- - --- - - - -- COMMENTS - - PATILNT F+1 Ca IVLD fSY X CONTRA COSTA COUNTY '� AMBULANCE PRE-HOSPITAL CARE FORM ! �� UNIT AUTHORIZATION N � CHECK OR FILL IN APPROPRIATE SPACES _.- DATE: PATIENT'S NAME , �aD f ( r I ❑ M 11 F COMPANY N z-% d) t ADDRESSiL_L �'j��j nl AGE 'Z)_ ! I � r CITY___ STATE ZIP O Sn M T,O W O Th O FaiT ; P s•—� DRIVER'S LICENSE k ___ PHONE — TURE OF DISPATCH \\ E>J I T-(-sff TYPE OF TRANSPORT: AMBULANCE El OTHER O _ STATION 1(A)_.2(B)_3(C)_4(D)_5(E) (�.'.�� I IINCIDENT LOCATION: / �N 6�{ RESPONSE CODE: RE�ESTED 8Y: TIME-(24 HOUR CLOCK) , ) �7�,/ n ^ TO SCENE- L'S.O. CALL RECEIVED G Li�� 1`,) i=�t 1 "I :3 ❑ P.D. TIME 10-8 1-2 �©c.!I:3 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 ,(.1K_ _ �� 3 c r �/ ❑ PSAP TIME 10-49(A MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10.98} .,w •1Q.`.�"! DOCTOR _LGL\`y PM /ER START l 12 TIME 10.22 :err HOW CHOSEN: TOTAL • 0 STANPOY TIME r •�' ❑ NEAREST ❑ FAMILY ❑ TRANSFER/ WAIT TIME PATIENT ❑ DIRECT ❑ OTHER ( % CALL BACK N: AMBULANC MPANY: PJi/AMBULATORY? PATIENT TAKEryfO AMBULANCE: 5 v RESPONSE ZONE f YES ❑ NO ❑ WALKED 9 GUERNEY ❑ OTHER !� PATIENT CONDITION: DRIVER t Q I7 `��0KUTAA r""'••► (I -, TECHNICIAN ( Hx: _�f7`�Q�7 1 S DISPATCHER: V S CHIEF COMPLAINT: LTJ 1�:e�t ZI DRY RUN: ❑ YES NO REASON FOR DRY RUN .. ,; AUTHORIZATION R DRY RUN(EMS USE ONLY) ) L PATIENT REFUSED SERVICES: (SIGNATURE) X — r MEDICAL,COVERAGE: INDUSTRIAL O YES O NO NO.OF PATIENTS: � S.S. k_ i - � .� �L�•�— -.. I � •• ,,��^^I ',,���� PRIVATE INS. CO.:.. BASE RATE: KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: X SF•av - MEDICARE k: E.O.B. ATT. ROUND TRIP: OYES O NO O YES ❑ NO. NIGHT: (19:00•07:00) ax 4z. CCHP/PPRP k: EMERGENCY RUN: MEDI-CAL k: CODE 2,3 L Y OTHER: OXYGEN: (PEb TANK) / 6.0.E. STICKER O YES ONO NEONATAL: (INCUBATOR) nrr DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) qq NEAREST RELAT1IVE/RESPON�IBLE PARTY: I.V.: (PER ADMIN.) X '� DRUGS: (PER ADMIN.) X NAM Tj fi�=- 1�WLATIONSHI n E.O.A.: (IF NOT REPLACED) -� y ADDRESS: T �� ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) P�E:t WORK PHONE: r). - DRY RUN: (AUTHORIZED) EMPL6J `:� T �x M`nbCCUPATIO ._ZL`1. OTHER- ADDRESS: THER ADDRESS: CITY: ��1 I �1 STATE: ZIP* - COMMENTS: TOTAL-72:9f_ �.....r�.� PATIENT RECEIVED BY:X 00131 , , (SIGNATURE) Provider rata White rd Pt'n; ropy Retur" Ye'llw' krP? t• FXF when bil-inp n• Oa-1 CONTRA CO2TA ZZUNTY ,y�11 AMBULANCE PRE-HOSPITAL CARE FORM I ` UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: 3 _. PATIENT'S NAME ? /��Iv nn I Of L. ff A ❑ M COMPANY N�('�1 2 (��BC� ,r r ADDRESS Z �J.'-1 I E?I'-iJ r. AGE ' � �` ' `i" CITYn�ICI STATE _, (� ZIP S I p T' �O S 9 - o���.. 0 13W E3 Th OF OSS-.l DRIVER'S LICENSE# __^ ___ _ PHONE Ti- ��v�NA TURF DI g�T�� ("�U ( N�� TYPE OF TRANSPORT: AMBULANCEp OTHER❑ .-______ --. ATION 1 20-30-40-50— INCIDENT LOCATION: RESPONSE CODE: RE0UE5TfD BY: TIME- (24 HOUR CLOCK) TO SCENE- CALL RECEIVED I 1 ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 �• ❑ PSAP TIME 10-49 - 1 '�1•. � '4 MILEAGE: ❑ OTHER/PVT TIME 10-7 END 73.5 TIME 10-98 DOCTOR T(f 7 PMDR START 7 �� TIME 10-22 HOW CHOSEN: R TOTAL ��- STANDBY TIME _❑_ NEAAE T O FAMILY 13 TRANSFER WAIT TIME -- ATIENT ❑ DIRECT ❑ OTHER <_.�i� CALL BACK N: AMBULANCE COMPANY: - MBULATORY? PATIENT TAKEN RESPONSE ZONE ® S 13 NO 11WAL'CEQ� GUERNE OTHER PATIENT CONDITION: 3 L�f S DRIVER VY)(�;� a 7J F T to ( , TECHNICIAN -•+^�� .�7T PARAMEDIC Hx: ` DISPATCHER: 4 H�EF COMPLAINT: Pre-` (r DRY RUN: ❑ YES kyal REASON FOR DRY RUN e. t�ti l<L< ` 11( I I —_ UTHORIZATION FOR DRY RUN(EMS USE ONLY) ) I PATIENT REFUSED SERVICES: (SIGNATUREr Mf-MC L CO R{C��:` �_ _ ITN�DUSTT Ll0`YES NO. F PATIENTS: �U 1S'^p� (� \N RIVATE INS. CO.: � BASE RATE: KAISER N: ( • !( I". A MULTIPLE PTS. BASE RATE BLUE CROSS k: '� J TOTAL MILES: X ___K---co — (, MEDICARE K: 'E.0.Et ATT. ROUND TRIP: ❑ YES ❑ NO , r , -� , ❑ YES ❑ NO NIGHT: (19:00-07:00) I~ �MEDI-CA #: JEMERGENCLY RUN:C? 7• t' l � �'�� -_ �� CODE 2!3 ER: OXYGEN: (PER TANK) -- i P.O.E. STICKER ❑ YES ja 0-- NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X NO �( DRUGS: (PER ADMIN.) X NAME.��}O(`J fj k A T I i j}A`RELATIONSHIP: O E.O.A.: (1F 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: STATE: ZIP: ` COMMENTS: 1A) %U se O AOA%1& _ V� SrfaS�S r_r�[ ariS rn�(JI-C Al v TOTAL:/,/,'�r' C)D ' AIS 1 iQ LA C11 C N-API PATIENT RECEIVED BY:X 0013;- (SIGNATURE)Provider retain Vhitr ;Y' ni, -,,pp . Ret.m Ye",L' ^n;y t• M!, uksn Fina CKS-1 CONTRA COSTA COUNTY , '. AMBULANCE -7 (j PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIO N JJJIII - CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S PATIENT'S NAMkC� A7 7 CSC;�''lC L { '(�� LtT L--- ❑ F COMPANY N � ���/�� � I ADDRESS 1C]_SIL` 11 C1 AGE L� P� �•... STATE ZIF�yJ '� KM CITY C7r�l? � r-- ���(� Df`O�B���C�]I�L'U�❑ Sn OT OW OTh 0F 0 SDRIVER'S LICENSE a ____ PHONEkv 1 11�.(_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ _ -- - STATION 1(A!_21e1_3(CI-4(D)_5lE►_ -v.,.-•.! INCIDE T LOCATION: RESPONSE CODE: QUESTED BY: TIME- 24 HOUR CLACK 1 �j / 1 TO SCENE- S.O. CALL RECEIVED C Y 7 /�v tft— ❑ P.D. TIME 1D-8 • ? '. -� �I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 •: ��•-- J��/ j 13 PSAP TIME 10-49; a ''�� l ��L'T'_F'• MILEAGE: 13OTHER/PVT TIME 10•7 END TIME 10-98 �. Z DOCTOR �i�`•h PMDe START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME • NEAREST O FAMILY ❑ TRANSFERI WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY UIT S "� PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5O RESPONSE ZONE_ YES 0� NO O WAL'CED 9.GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A 44I TECHNiCiAN ';�' ' PARAMEDIC. Hx: �`r:i'c+�\u` =�r ✓�1ki5 DISPATCHER: �l(. CHIEF COMPLAINT: 7� q/2 IT P-Aal DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 PATIENT REFUSED SERVICES: (SIGNATURE) X_ - L 1 MEDICAL COVERAGE: DUSTRIAL 13YES 9 NO NO. OF PATIENTS: .� S.S. a_ S - �l — 41 PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE 1 BLUE CROSS N: _ TOTAL MILES: X 6-. a MEDICARE N; J =� 1" JLI E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO fD YES ❑ NO NIGHT: (19:00-07:00) -••� CCHP/PPHP N: EMERGENCY RUN: MEDI-CAL„�"�C.U�i �'�� �I,UUa,C) CODE 2 l`3_ , 7 W OXYGEN: (PER YANK) 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 r NAME:Cnn ` L C 1 r ll RELATIONSHIP�Ldhl E.O.A.: (IF NOT REPLACED) '- ADDRESS::A. {-VIR kL,r 1 L- IL „ ORAL AIRWAY: (IF NOT REPLACED) '�- /,� / CITU:�,t4S STATE.-ZIP: C-COLLAR: (IF NOT REPLACED) 1��r PHONE:`��� L 5LMF WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: S--��(• ADDRESS: _-- C /� .r CITY: STATE: ZIP:_ -2, COMMENTQ- -`� __1 ,j(,r CONTRERAS PFT3 • - C7609555764930 TOTAL: . 208e3P47M 0® 1 �� PATIENT RECEIVED BY:X .1 - ( Pmnider ntai.. White a' (SIG T RE) 015.1 lr ` .rd rr .gyp,, .QetLrn Yo'tr4• ^n�. •. n.^ �:kwn )..*I*..•q i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N av :5 CHECK OR FILL IN AIPROPAIATL JPAC[S DATE: • U J PATIENTS NAME O M ❑ F COMPANY A _ ADDRESS ) AGES ' CITY - STATE ZIP DOB ❑ Sn M O T /❑�W O Th OF ❑ S DRIVER'S LICENSE 0 _ - - PHONE NATURE OF D SPATCH� TYPE OF TRANSPORT: AMBU LANCEf OTHER❑ STATION 1(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOCATION: i RESPONSE CODE: BY: TIME- (24 HOUR CLOCK)TO SCENE- S.O. CALL RECEIVED 2�EQUESTEO P.D. TIME 10-8 PATIENT DESTINATION: FROM SCEN O FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: 13OTHER/PVT TIME 10-7 END TIME 10-98 r ISOCTOR_ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME F-.•_ ❑ NEAREST_ _ ❑ FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBUL NCE C PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 7og� Ca PATIENT CONDITION: z� DRIVER / r �0 ,5 e) 77,a-"'- rrl� TECHNICIAN 1 L �f�� PARAMEDIC HX: / DISPATCH CHIEF COMPLAINT: DRY RUN YES ❑ NO REASON F R DRY RUN 11" Y 4-j (Oy AUTHORI FOR DRY RUN(EMS USE ONLY) W0'r4<(C. 90-25°AAe— C�r PATIENT REFUSED SERVICES:(SIGNATURE) X 1 J MEDICAL COVERAGE: INDUSTRIAL 13 YES ❑ NO NO. OF PATIENTS: S.S. `( PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N:' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP 0: EMERGENCY RUN: MEDI-CAL N: CODE OTHER: OXYG . (PER TANK) P.O.E. STICKER ❑ YES ❑ NO ONATAL: (INCUBATOR) ' DATES BILLED: STANDBY: (OVER 15 MIN.) \ E.K.G.: (PER EPISODE) v' ---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:,f52,SC'-' _ - PATIENT RECEIVED BY: X __._ 00134 n•,,i.lar . .. + .. ,• (sin NATORF.) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N (a 7 CHECK OR FILL INA PFROMATE SPACES DATE: -5, Z/ /& j P PATIENT'S NAME_._ �E L ��/%/� ❑ M --- �.. _—N_f� �� K F COMPANY N ADDRESS 5 S' 3�;'/�N/Y S% - AGE CITY C ti STATE C�>'[ • ZIP__. DOB4v3 ❑ Sn #kM ❑ T ❑ W ❑ Th ❑ F E3 DRIVER'S LICENSE is _ _._._.__..__ PHONE._.._—_.-___—.—_ NATURE OF DISPATCH 1S0X7.1Z TYPE OF TRANSPORT: AMBULANCET OTHER❑ _- ,.,__.._`_ .. STATION 1(A).k2(B)-3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) , TO SCENE- ❑ S.O. CALL RECEIVED f —��— /�. ❑ P.D. TIME 10-8 PATIENT DESTINATION: / FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 ,AILEAGE: 14 OTHER/PVT TIME 10-7 END �9 S TIME 10-98 DOCTOR �' PMD/ER START .�� I -M• �'� TIME 10.22 HOW CHOSEN TOTAL . L STANDBY TIME ❑ NEAREST ❑ FAMILY A.TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULC CE_?OMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: {� RESPONSE ZONE YES ❑ NO ❑ WALKED X GUERNEY ❑ OTHER / �( PATIENT CONDITION: DRIVER _'�LYS1614'I2 TP _��/ EMT-1A TECHNICIAN �✓� C�T I `'. PARAMEDIC Hx DISPATCHER: � { T f 1 �' G CHIEF COMPLAINT: �� C7 ,C T��Sf�� .ZS; DRY RUN: ❑ YES '0-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: 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: EDI-CAL 1� 7e!3_� �,5� -�U-3 CODE 2/3 OXYGEN (PER TANK) ' P.O.E. STICKER ❑ YES ANO 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) ORAL AIRWAY: (IF NOT REPLACED) CITY. ..`________.__... ..__ _:_ STATE__ZIP:___— C-COLLAR: (IF NOT REPLACED) PHONE. WORK PHONE: DRY RUN. (AUTriORIZE(D) EMPLOYER: OCCUPATION: OTHER: I � . ADDRESS: CITY. STATE: ZIP:_►' ' COMMENTS: f 5's-y S �/V%� i�✓C: ��� Hyl i .7 TOTAL:—s.��'yy _ PATIENT RECEIVED BY:X I - Z) (SIGNAT REI z CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N `�- CNECI(OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME I O M 13F COMPANY* '�" G p ADDRESS -1- LI Z''T 14 o� P AGES {, CITY ( STATE ZIP DOB ❑ Sn 1�'a OT O W O Th OF O S DRIVER'S LICENSE N _ I PHONE _ NATURE OF DISPATCH U 10 �� 4 TYPE OF TRANSPORT: AMBU HER — STATION 1(A)_20_3(C)-4113)^5(E)_ C y7 INCIDENT LOCATION: S�rAT_ (!W RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOJc) _ TO SCENE- .0. CALL RECEIVED �_ -'S'7 38- ❑ P.U. TIME 10-8 51"1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 `~1 ❑ 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 O FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT 13 OTHER CALL BACK N: AMBULANCE O�PY. c PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES,,O NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER `` //EMT-1A TECHNICIAN O_��� �ARAMEDIC �f Hx: ' " DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES Cl NO RE�OZS8N FOR DRY RUN (a -Z 2 pvt C C AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ON S S h . PATIENT REFUSED SERVICES: (SIGNATURE) X 999 .. . . . MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 �) �/ PRIVATE INS. CO.: J BASE RATE: KAISER#'• ' MULTIPLE PTS. BASE RATE BLUE CROSS 0: - i TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N:') ' EMERGENCY RUN: MEDI-CAL p: CODE 2/3 (^l OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '- NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:'- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP: C-COLLAR: .(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) ) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: - STATE: ZIP: COMMENTS: 00136 PATIENT RECEIVED BY X ' CONTRA COSTA COUNTY �(..'�. AMBULANCE PRE-HOSPITAL CARE FORM I \ UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME. OM ❑ F COMPANY N - ADDRESS ` "� /.L ` _%i���t I/�//1-�-�j /�J-�/ AGE \ , 7-5PIA .._. CITY i f/h ili STATE (�^� ZIP l fU DOB—.-- O Sn M ❑ T ❑ w C3 T?hE3 F 0 DRIVER'S LICENSE a .________ .. ___.___ PHONE_ _ ��_��' NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ _ STATION 1(A)_2(B)-3(C)._4(D)_5(E)._ INCIDENT LOCATION: 1` /�. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLO K) K) TO SCENE- � S.O. CALL RECEIVED P.D. TIME 10-8 � •� PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 - n �J O PSAP TIME 10-49 �. MILEAGE: ❑ OTHER/PVT TIME 10-7 .-. : END TIME 10.98 DOCTOR PMO/ER. START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME Cl NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: t PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO O WALKED O GUERNEY O OTHER _ PATIENT CONDITION: DRIVER eql TECHNICIAN PARAMEDIC ! Hx: _ DISPATCHER: /. CHIEF COMPLAINT- i DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 1 I THORI ION FOY RUN E E LY) r� PATIENT REFUSED SERVICES: (SIGNATURE) X Q ��L —• MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. e PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE --• BLUE CROSS M:_ TOTAL MILES: ax MEDICARE p: E.O.B. ATT. ROUND TRIP: O YES ❑ NO �- I r(B� ❑ YES ❑ NO NIGHT: (19:00-07:00) " CCHP/PPRP#: EMERGENCY RUN: _ MEDT-CAL#: CODE 2/3 OTHER OXYGEN: (PER TANK) r 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 . 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: 6.Cl �. PATIENT RECEIVED BY:X Provider reta:r. Vhite crd Fin: ropy keturm Ye'lm, ropy t, VfS when bii"ing (SIGNATURE) ^ � ' � R CONTRA COSTA COUNTY \ , AMBULANCE r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK ON fltL IN APPROPRIATE SPACES • , - DATE: PATIENTS NAME ❑ M ❑ F COMPANY N / —5 J 2! � : ADDRESS AGE CITY STATE ZIP __ DOB--_ O Sn J�V OT ❑ W ❑ Th ❑ F O S . r 1v DRIVER'S LICENSE N _ _ ____` PHONE_—___—�__ NATURE OF DISPATCH — TYPE OF TRANSPORT: AMBULANCE 13 OTHER❑ __ _—_ —_ STATION 1(A)_.2(B)_3(C)_4(D)_5(E)_ INCIDENT L CATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ' 1 •. v Pj� C� TO SCENE - Xf-970. ,__ CALL RECEIVED i '- ❑ P.U. — TIME 10-8 L PATIENT DESTINATION: FROM SCENE-iC� ❑ FIRE — TIME 10-97 V ❑ PSAP TIME 10-49 , I 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 O OTHER CALL BACK N: AMBULANCE COMPANY: i 1 PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: `jlJ RESPONSE ZONE ❑ YES O NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER L� PATIENT CONDITION: DRIVER // t '^EMT-`IA TECHNICIAN (, 6 PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES O NO iiEASON FOR DRY RUN _ _JTp ZATIO FOR DRY RUN/EMSUSE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X _ ' �c �J ^L�l `_ Y MEDICAL COVERAGE: INDUSTRIAL ❑ Y ❑ NO NO. OF PATIENTS: ss. 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 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 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�l ) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) —1Z—O EMPLOYER: OCCUPATION: OTHER: I ADDRESS: CITY: STATE: ZIP: COMMENTS: — } �__._.. TOTAL: ---- 00138 PATIENT RECEIVED BY. CONTRA COSTA COUNTY ` AMBULANCE 1 • PRE-HOSPITAL CARE FORM I '' UNIT AUTHORIZATION M � c) CHECK OR/ILL IM APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N ¢" slo 4 ' ( I ADDRESS AGE CITY STATE ZIP DOB___ ❑ Sn )irM ❑ T ❑ W``O Th ❑ F ❑ S DRIVER'S LICENSE M ___ _ -_—_ PHONE—_._ .._____._._ NATURE OF DISPATCH Me C C Y>t� • TYPE OF TRANSPORT: AMBULANCEID OTHER❑ ____—___._—__. ___._ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOCK) `r TO SCENE - O. CALL RECEIVED v 1 �1 `L)-L)- .�. '❑ P.D. TIME 10-8 r f PATIENT D STINATIO : FROM SCENE - ❑ FIRE — TIME 10-97 ;T— ❑ PSAP TIME 10-49 �_ �_ MILEAG . It OTHER/PVT TIME 10-7 END TIME 110-9-8 DOCTOR PMD/ER START TIME 10.2 HOW CHOSEN: TOTAL I 7 Y '-STA TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE C(lyPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL-<ED ❑ GUERNEY ❑ OTHER n^, . PATIENT CONDITION: DRIVER- EMT-IA) TECHNICIAN ��k'� ' MEDIC ^ DISPATCHER: LL'•� � � � r i� " I r (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: 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: --- - TOTAL'-------- --" 00139 PATIENT RECEIVED UY X -- ----- ------ rroviaer-reca.r,-�nrce�.ra-P'r*K cope—F¢tum Ye:Iwr :�npv t+9M5 uhen Eil-Ing ' �°1 �- 0014g0 7 CONTRA COSTA COUNTY AMBULANCE e I'' PRE-HOSPITAL CARE FORM I I E UNIT 1y AUTHORIZATION R dU= - .. CHECK OR FILL INAPPROPRIATE SPACES DATE:.�� T 11- oA16 r�Fil- L0 PATIENT'S NAME_ J A M ❑ F COMPANY d ADDRESS 0 FI(-In R r AGE CITY ' R ) STATE C 14• ZIP 9 Y ( DOB 1 2--Z 7'yZ O Sn yU u M O T OW O Th O F O S MLS} Q �i . , I DRIVER'S LICENSE* _ -L-' PHONE -v7�7 NATURE•OF DISPATGhV��T� �� n Fd octiv— TYPE OF TRANSPORT:. AMBULANCE OTHER❑ _ — STATION 1(A),_2(B)_3(C)_4(D)._5(E)___.. INCIDENT LOCATION: RESPONSE CODE: �tEOUESTED BY: TIME- (24 HOUR CLOCK) _. j TO SCENE- 2 K S.O. CALL RECEIVED �(J /(�• R�CI� J ❑ P.D. TIME 10-8 R^ PATIENT DESTINATION: FROM SCENE -� ❑ FIRE TIME 10-97 - O PSAP TIME 10.49 a� y MILEAGE. O OTHER/PVT TIME 10-7 F- END (J 2 _ TIME 10.98 DOCTOR VZRIG 11 C L START 09' TIME 10.22 ` ' HOW CHOSEN TOTAL �� STANDBY TIME ❑ NEAREST Cl FAMILY. ❑ TRANSFER WAIT TIME 12(PATIENT 13DIRECT ClOTHER CALL BACK k: AMBULANCE OMPANY: -.. PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE _ !�YES ❑ NO ❑ WAL'<ED �(GUERNEY ❑ OTHER _ PATIENT CONDITION. DRIVER_�f 4L /?E iA w,f14 TECHNICIANGL/V/S -�N C-N AM F AVC K a V Fcy 065E(-,r ro c G'A'F-DISPATCHER: P- L '1 CHIEF COMPLAINT: 14 kRP pA),(, DRY RUN: ❑ YES YNO REASON FOR DRY RUN — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) J CIC -i PATIENT REFUSED SERVICES: (SIGNATURE) X ....1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES KNO NO. OF PATIENTS: L -f7 —4� 7_40 - illy PRIVATE INS. CO.: BASE RATE: ��-� j KAISER x: MULTIPLE PTS. BASE RATE / BLUE CROSS k: TOTAL MILES: 3 X e, 5U ,�•�--- MEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 0.015 © - r i 13 YES ONO NIGHT: (19:00-07:00) 20. . - CCHP/PPRP k: EMERGENCY RUN:) CODE 2 r/3 ..__J OTh ER: OXYGEN: (PER TANK) ,P.O.E. STICKER '0 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 NAMETAUI-C i fF 9A*(+Fl-GI FT RELATIONSHIP!'yl FIY E.O.A.DRUGS: (IF NOT REPLACED) X ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) i� CITY: _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) - �>t+?� PHONE:),3 5 L/0 WORK PHONE: DRY RUN: (AUTHORIZED) 5� —1 EMPLOYER: OCCUPATION: OTHER: - --- ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTSti� C/ 0 /�va(tpBL� ;Or _9 TOTAL:.;��. 5� -�_ PATIENT RECEIVED BY:X Provider retain• VAite and PF Aecurn Ye'2vw -nR, t• EMS when bit-inp ( IGNATUREI EMS-I 00141 1�• C �' i 1� .C•�q, I CONTRA COSTA COUNTYAMBULANCE 'j �z• �' I PRE-HOSPITAL CARE FORM 1 u �. QTHCRIZATION r 9 CHECK OR FILL IN APPROPRIATE SPACESPk 6 �o PATIENTS NAME 4M ❑ F COMPANY• �} �\ADDRESS �."�} .M O AGE Z t Z .. �Q DOB�'�( ❑ Sn �M OT.13W ❑ DF CITY - STATE ZIP� _ � {�1 r� t Ott -k DRI ER'S LICENSE sr — PHONE NATURE OF DISPATCH 40 G - TYPE OF TRANSPORT:. AMBULANCE HER 0 _ STATION INCIDENT LOCATION: RESPONSE COD I R OUESTED BY TIME•–(24 HOUR LOCK) C,f 7 � •C, TO SCENE�2 OA:LO. CALL RECEIVED �t �J L" 3 P.D. TIME 10-8 ;.2 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10 97 1 1 L ` 1 O PSAP T RTIME 10-49 A1I A 61 _J_m rA +'1 MILEAGE: ❑ OTHEWPVT":;.• TIME 10.7 r; END-- ,TIME 10.98 f DOCTOp �e`� S kDO 1�' PM ER START r I TIME 10.22(Aq •�aL HOW CHOSEN: TOTALS STANDBYIME /S+ ftlEAREST O FAMILY O TRANSFER - ' WAITITIMEE�"� ` : ��TIENT O DIRECT ❑ OTHER CALL BACK N: AMBO PT. AMBULA ORY? PATIENT TAKEN TO AMBULANCE; RESPONSE,ZON 'S 13 YES_P'IQO ❑ WALI<EO GUERNEY OTHER I 15et.�La PATIENT CONDITION: DRIVERt3p�, EMTOA' ;~ TECHNICIAN 1FO PARAMEDIC`r�:� t 7 Hz:KTT_t V-5 0IV{ DISPATCHER: 5 0 - w ll CHIEF COMPLAINT: _ DRY RUN: ❑ YES - NO . REASON FOR DRY RUN (� T� AUTHORIZATION FOR DRY RUN(EMS USE ONLY), PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS:. G`... + S.S. # n :. PRIVATE INS. CO.:L7(?���.� V��-• �� ' BASE RATE: KAISER N: .MULTIPLE PTS.BASE RATE14� nTtL"?M BLUE CROSS N: TOTAL MILES: X •1: Q; ? - f { MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ; ❑ NO ❑ YES '•D NO NIGHT:(18:00.07:00) ZR8 ^J 36Ua i ' CCHP/PPHP C EMERGENCY RU ��I�7q�4pi MEDT-CAL N: CODE 21 rJ I OTHER: OXYGEN- (PE TANK) „ f P.O.E. STICKER ❑ YES 13 NO NEONATAL: (INCUBATOR) ;`- v DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: "' I.V.: (PER ADMIN.) I DRUGS: (PER ADMIN.) NAME: RELATIONSHIP• E.O.A.:(IF NOT.AEPLACED) `�`—'"± ADDRESS. ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED). PHONE: ORcK PRONE: `3 -�D7 TH a DRY RUN' (AUOf�IZED) R 17 EMPLOYER.Da"' 5 ��` LbGCUPA'A6N_ a 'u y' OTHER-"" '_ .._.__"-: ADDRESS: O�µ� � (V/�t� • �GLl?�_�l �S•G+�� � CITY:==�,� -STATE-.Dl ZIP= . COMMENTS: TOTAL: / _ ;..1.��►+..� ia+� PATIENT"RECEIVED B ►1 .,w(SIGNATURE) Provider retain Vhite card Pink copy Aeturn Ye:Zov rapt' t! at who" bit:{np Wl,i o o i I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I C UNIT AUTHORII�ZATION N CHECK OR FILL IN APPRO RIATE SPACES DATE:-o f3 PATIENTS NAME � M ❑ F COMPANY N I ADDRESS AGE12 1 CITY STATE ZIP_ _ DOB—`_ ❑ Sn kM OT OW ❑ Th ❑ F O.S DRIVER'S LICENSE NPHONE NATURE OF DISPATCH M Fly/ CA i TYPE OFTRANSPORT: AMBULANCE❑ OTHER❑ __-_ __._._—._-.___._. STATION l(A) 2(8)-3(C)-4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) / C Y -1 /o / � / � rJ�� TO SCENE - � S O CALL RECEIVED P.U. TIME 10-8 • � � PATIENT DESTINATION: FROM SCENE ❑ FIRE _— TIME 10-97 _ ❑ PSAP TIME 10-49 MILEAGE: 13OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 % l HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY; PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE .1 ❑ YES ❑ NO O WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER N��— `'"' EMT-tA TECHNICIAN G w�LL 1/a i✓1 r ;C r Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN-(n YE ❑ NO REASON FOR DRY RUN I)SA L AUTHORIZATION FORARY RUN(EMS USS OI Y) ���(� PATIENT REFUSED SERVICES: (SIGNATURE) X 141 _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N �l PRIVATE INS. CO": BASE RATE: KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N:- E.O.B.ATT. ROUND TRIP: O YES ❑ NO O 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 O YES ❑ NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) sZSG_ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: l TOTAL. -._----- _ __. . .__. PATIENT RECEIVED BY X ,•:r 1,.. ;� (SIGNATURE) - Iti I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATI N w 79 CHECK OR/Ill IN APP rr srAcrs DATE: r PATIENTS NAME OM OF COMPANY N n c -3 ADDRESS'' i AGE~ l - n` ROA CITY STATE ZIP DOB- - ❑ Sn Om OT Ow O Th ❑ F OS DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH 44717 A� ` TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION. l 1 RESPONSE CODE: REOUED BY: TIME— (24 HOUR CLOCK) �/'� G7 TO SCENE- O. CALL RECEIVED � V (/ 1�nT�f, O P.D. TIME 10-8 PATIENT DESTINATION: -- FROM SCENE - ❑ FIRE TIME 10-97 - O PSAP TIME 10-49 ?rn✓• ii ! MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 1D-98 S OOC:TOR' PMD/ER START TIME 10 22 6v HOW CHOSEN: TOTAL STANDBY TIME �')•j _O NEAREST,,: O FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER L""T h /- EMT-1A TECHNICIAN ! ©� d PARAMEDIC y00 Hx: DISPATCHER" b L/��� DISPATCHER- 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: PRIVATE INS.CO.: BASE RATE: KAISER•: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YES ONO ❑ YES •❑ NO NIGHT: (19:00-07:00) GCHP/PPHP 0: ` ' EMERGENCY RUN: MEDI-CAL M: 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: 43 r ' PATIENT RECEIVED BY: X _ (9IONA 1 UnFI r• . � rVvl CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION N 's ' � CHECK OR FILL INAPPROPRIATE SPACES DATE: �"- ` 2 - ]'" -1 PATIENTS NAME 7 ❑ M O F COMPANY N ADDRESS K GI I.1 - AGE C R I CITY STATE----,-- ZIP DOB -O Sn ❑ O W O Th OF O S DRIVER'S LICENSE N PHONE _ ' _ NATURE OF DISPATCH —4 41 ;,tG''AAA-2 TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ — STATION 1(A)-_2(B)-31C1-4(D)-5(E)— INCIDENT LOCATION:, RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) pp TO SCENE .0. CALL RECEIVED _ n� C/Zb T.r�`��EP I[ h(a, 13 O P.U. TIME 10-8 13 PATIENT DESTINATION: " FROM SCENE$_ 11 FIRE TIME 10-97 A R Y ❑ PSAP TIME 10-49 T MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 - DOCTOR ' I 1 PMD/ER START TIME 10-22 HOW CHOSEN: - TOTAL STANDBY TIME ❑ NEAREST, :', ❑ FAMILY ❑ TRANSFER ( WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER /` CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5;IU RESPONSE ZONE ❑.YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: i DRIVER 14J Ac JZ TECHNICIAN R l b,a 9 +7n PARAMEDIC Hx: DISPATCHER: 50 E1- CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN /c-21- I' �2oo>tYrt. AUTHOR1 ATION FOR DRY RUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES O 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: O YES O NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP C 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) R-EAREST 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) r•C - EMPLOYER: OCCUPATION- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -' TOTAL: ,,u Jar --- _ 0014-41 PATIENT RECEIVED BY" • .,,I,r... 0.... ISinNA11114F) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATES ACES I DATE: r.J PATIENT'S NAME O F COMPANY 1 S ADDRESS _h A �-- i: CIT _-? �� =� STATE ZIP DOB ❑ Sn O f'❑W�O`Th��FL Q I DRIVER'S LICENSE# ____.____-.-___.._.—___-_-_ PHONE '233- 3/ �! NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CK REQ y/j� TO SCENE i CALL RECEIVED ' ❑ P.D: TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �' E11PSAP TIME 10-49 � � _ MILEAG ❑ OTHER/PVT TIME 10.7 END TIME 10-98 f LAP-_ 1.C��--2�' ��;eq R _ PMD/ER START TIME 10.22 HOW W15-HOSE : TOTAL I ` STANDBY'TIMEi ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COA 7 1 • v PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i 15/0 JRESPONSE.ZONE-7,d) ❑ YES C3 NO ❑ WACIED 13GUERNEY ❑ OTHER =J PATIENT CONDITION: DRIVER 1 2'7E T-1A •' IY � TECHNICIAN 2 RAMEDIC Hx: _�Trt —_ _ dA�11�(AISPATCHER: � CHIEF COMPLAINT: RY RUN- YES ❑ NO REASON FOR DRY RUN or AU OR ATION F DRY RU 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 O NO11..,.E i t ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: 'EMERGENCY RUN: �(f l MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) '(');:`j 3(J '✓r X w--- -J I {� P.O.E. STICKER ❑ YES NO NEONATAL: (INCUB OR) /I } vDATES BILLED: STANDBY: (OVER 1 MIN.) '0 E.K.G.: (PER EPISOD ) M, ,�__ NEAREST RELATIVE/RESPON IBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) !- X � I NAME: RELATIONSHIP: E.O.A.: (IF.NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT RE LACED) I CITY: _ STATE- ZIP: C-COLLAR: (IF NOT REP ED) ~� ! PHONE: WORK PHONE: DRY RUN:_(AUTHORIZE EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: - ZIP' COMMENTS: _... TOTAL: i .F^ PATIENT RECEIVED BY:X Provider retain. White Lmd Pink copy Return ye::ov copy t+ DNS when bi1:£ (SIGNATURE) np 0 0 /� '>QtS- CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 Z CHECK OR FILL IN APPROPRIATE SPACES DATE: l.T Z- PATIENT'S NAME'i / lw��.1-��T6� ��J1M ❑ F " COMPANY M ADDRESS l�( 7�Rt"SSE L L c� AGE CITY X0 STATE CAC- E- ZIP 7 7O 3 DOBr-� ❑ Sn O M�WT ❑W O Th Dn F O S DRIVER'S LICENSE a -- ------------------ PHONE L L�Gc3 _ NATURE OF DISPATCH Sf w�tj �...:. t TYPE OF TRANSPORT: AMBULANCE Ur OTHER❑ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_' I INCIDENT LOCATION: RESPONSE CODE: R,..,,EOLUESTED BY: TIME- (24 HOUR CLO�C) ! ' C TO SCENE- 1 5.0. CALL RECEIVED 7 L n J —D ❑ P.D. TIME 10-8 IS 20 Z�� PATIENT DESTINATION: FROM SCENE-,�- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �S l M MILEAGE: i ❑ OTHER/PVT TIME 10-7 � -'•� END� ' TIME 10-98 ,Z :11 � •`� DOCTOR _.z"�'V`J�R_ PMO/ft START 5L TIME 10 22 - I HOW CHOSEN: TOTAL C, STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER li )�= � CALL BACK k: AMBULANCE COMPA PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: i RESPONSE ZONE YES ❑ NO ❑ WAL'CED GUERNEY ❑ OTHER ~ PATIENT CONDITION: DRIVER L/ p 0 EMT-/A I t nn TECHNICIAN t-G� " U -5 PARAMEDIC ' f 2�<J'_� DISPATCHER: I3E LF.17 L.E 0014 CHIEF COMPLAINT: 5 f/ 7- F DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— t MEDICAL COV RAGE: /� p INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. a l:j - to U'- I �y q PRIVATE INS. CO.: ;JO IJ BASE RATE: KAISER a: — MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: 'I MEDT-CAL a: CODE 2/3 _ (� OTHER: OXYGEN: (PER TANK) ^I� I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) -- I' I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X /�� p DRUGS: (PER ADMIN.) X NAME:C 1�5 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONEQU" � J // DRY RUN:.*(AUTHORIZED) EMPLOYER:(AGtS wt3T OCCUPATION: OTHER_' '''��J�,,,,LS -7 V �� :.� .,.!.- �c71/J � ADDRESS % CITY: L ��E£E:� STATE: ZIP: - COMMENTS: - �9 ;- TOTAL: PATIENT RECEIVED BY:X Provider 7Ytu_r. White rd Pt'n�. corp . Aoturn w 1u4 �npp t' p4:- uhta ot1"Ing AAU RE Dlf-1 r 'l 1 CONTRA COSTA COUNTY AMBULANCE C PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR Flll IN APPROPRIATE SPACES ( DATE:._._ jl ^ 4 2 PATIENT'S NAME_—_.._.�..._-.. "1� ❑ M ❑ F COMPANY a ._ � ADDRESS —___.. AGE 1 (>I� h� • I CITY STATE __ ZIP—.._-__._.. ._ _ DOB.--.-_._ ❑ Sn ❑ M T ❑ W ❑ Th ❑ F ❑ S r DRIVER'S LICENSE a ....____ PHONE NATURE OF DISPATCH'.)&41-4-,/4"t-6 -�I TYPE OF TRANSPORT AMBULANCE❑ OTHER❑ tJ INCIDENT LOCATION: RESPONSE CODE EOUFS TED BY: TIME — (24 HOUR CLOCK) 4 6 TO SCENE so _ ._ .. CALL RECEIVED 1_ — ���� `� !_�._ 1-16�,.� 0P - - -.---- TIME 10-8 PATIENT DESTINATION: FROM SCEN ❑ FIRE .._.._ —.._ TIME 10-97 ❑ PSAP TIME 10-49 --- /U C0 i�_����_z MILEAGE: ❑ OTHER/PVT TIME 10-7 _ END._ - _ _ _ —_—_ TIME 10-98 DOCTOR __. PMD/ER START_.._ . ._ _—__—__—__ TIME 10-22 U� y L� HOW CHOSEN. TOTAL —_ __— _ _._--_____,—. STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER _._.__ _ WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK It: AMBULANC GO PANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: yIi'� RESPONSE ZONE— D ONE❑ YES ❑ NO -O WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER__ __ �?��__1s�1 t_i_ u -?'� ' / TECHNICIANPARAMEDIC ! % Fix: -------- -- -- --T -- DISPATCHE f t. CHIEF COMPLAINT: __' _�`�'-___`___�_�._�� _�_Ll_ ___. DRY RUN' 9,YES ❑ NO REASON FOR DRY RUN AUTHORI WFOR DRY RUN(ELAS USE UNLY) PATIENT REFUSED SERVICES (SIGNATURE) MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S PRIVATE a— -- - --- --- --- PRIVATE INS. CO.:___ ---_----- — BASE RATE: KAISER x. —_ MULTIPLE PTS. BASE RATE i BLUE CROSS#: TOTAL MILES: __._...._ ___.___.__.____— X _ Y MEDICARE a: __.—E.O B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19 00-07.001 1 CCHP/PPRP a: —_ --� EMERGENCY RUN: MEDI-CAL a:_ CODE 2/3 OTHER: _.. OXYGEN: (PER TANK) P O.E. STICKER ❑ YES ❑ O NEONATAL: (INCUBATOR) — DATESBILLED: STANDBY: (OVER 15 MIN.) _— E.K G.: (PER EPISODE) NEAREST RELATIVE/RESPON 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: EPLACED)PHONE: WORK PHONE.-----,-.---,--. DRY RUN: (AUTHORIZED) — EMPLOYER: _ OCCUPATION:--- OTHER: ADDRESS. —...— --------------.. --. ^'- --- - - — CITY: __ _—.— STATE:-----.__ZIP:_..._---- ..-- ----- --- --------------------- — COMMENTS: -- —----- --------- - -- ------- -- ----......._ TOTAL - -- PAI 1FNT RFCEIVI"D BY X ®0.147 r� 1•r. ni•r.•r rrr.,. 4'L• ' ("JLNP111RE) `2 } / CONTRA COSTA COUNTY AMBULANCEO ,:'. 1 PRE-HOSPITAL CARE FORM I UNIT / AUTHORIZATION K t i CHECK OR illi INAPPROPRIATE SPACES DATE: ry PATiENT•S NAME ❑ M ❑ F COMPANY N rLpE / r ADDRESS AGE ( ! )' CITY STATE ZIP DOB—.__ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M _ _ __ PHONE____—_.��_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Ll OTHER❑ — _—.._____ .__ STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ 1 INCIDENT LOCATION: •, RESPONSE CODE: REQUESTED BY. TIME — (24 HOUR CLOCK) C Z TO SCENE- CT S.O. CALL RECEIVED / /l �/ �_ l t-�-��tc� -� ❑ P.D.— TIME 10-8 - r PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 :T— 1 ❑ PSAP TIME 10-49 i i C, MILEAGE: ❑ OTHER/PVT TIME 10-7 —4— END END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 `l _ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER 1. 1 WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER / CALL BACK k: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: v: RESPONSE ZONE Cl YES ❑ NO ❑ WALNED ❑ GUERNEY ❑ OTHER V I1 I PATIENT CONDITION: DRIVERS !.L. (I S ' EMT-1A TECHNICIAN PARAMEDIC i1 ^• PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN I( AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE T BLUE CROSS M: TOTAL MILES:-- X MEDICARE R: E.O.B. ATT. ROUND TRIP: O YES ❑ NO y� ❑ YES ❑ NO NIGHT: (19:00-07:00) t CCHP/PPRP 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) 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: t CITY: STATE: ZIP: COMMENTS: _ _ TOTAL: -- 00148 PATIENT RECEIVED BY: X Provider rntair whit; ..rl !•i•: Srt,,n : (SIGNATURE) tr t. �t CONTRA COSTA COUNTY AMBULANCE 7. PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: .___.____ PATIEN S NAME ___-- , __---. --_ -- ❑"M ❑ F COMPANY# ADDRESS AGE _ CITY_-- STATE-_. — ZIP___—._.___ DOB__._. ._—_- ❑ Sn ❑ M ❑ T ❑ W ❑ Th 0 ,1F/`❑ S DRIVER'S LICENSE # __.._.._ . . PHONE . _....._ AZURE OF DISPATCH'S�ii TYPE OF TRANSPORT AMBULANCE CTHER❑ INCIDENT LOCATION: RESPONSE CODE. EOUFSTED BY TIME - (24 HOURLOCK) / . -} D TO SCENE C. -____._.___. CALL RECEIVED 1 --- -- ❑ P D. - - TIME 10-8 PATIENT DESTINATION: FROM SCENE_- _ ❑ FIRE -_-__ TIME 10-97 ❑ PSAP TIME 10-49 I l _ MILEAGE: — ❑ OTHER/PVT TIME 10-7 i END. TIME 10-98 DOCTOR _ _— _ PMD/ER START _ -__ TIME 10-22 LL_ :LL_ HOW CHOSEN. TOTAL _ _ _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �� CALL BACK #: AMBULANC E OMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �y�;'�. RESPONSE ZONE r ❑ YES ❑ NO ❑ WAL',ED O GUERNEY ❑ OTHER —_.- PATIENT CONDITION. DRIVER___<yii_i�' Sly'_ �_'' +iT-tA � TECHNICIAN PARAMEDIC _ Hx: J11 {-y�t�lC__ I' �_Li� -1.�. 'ice DISPATCHER: - CHIEF COMPLAINT: I,I�__-.-_' �.--__.______.___. __-. DRY RUN: YES ❑ NO REASON FOR DRY RU f S �ae c�iPsiri AUTHORIZATION FOR DRY RUN (EMS USE ONLY)_ %T tL ✓ t- _. PATIENT REFUSED SERVICES (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS' SS. # — --- ---------- PRIVATE 11467,1',Q,— BASE RATE: KAISER #: MULTIPLE PTS. BASE RATE BLUE CROSS#'— TOTAL MILES: ___-___- X — MEDICARE#. --- --E.0 B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (1900-07.00) — CCHP;PPHP#: _ _-_______ —__ EMERGENCY RUN: - MEDI-CAL#: ._ -_.--____ _— CODE 2/3 OTHER: _ _. OXYGEN: (PER TANK) P O.E. STICKER YES ❑ NO NEONATAL: (INCUBATOR) — DATES BILLED: - STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST 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) 4M EMPLOYER: _.- OCCUPATION. -_—. OTHER: ADDRESS: CITY: STATE:_—ZIP: COMMENTS: - ----- --- ---- -- -- - - G`o -- ---- --- -- - --- TOTAL -- - - - 00139 PATIENT RECEIVFr)BY X P,•.•r i.i,•: r. r.rr• .�;;., r . L.. (SIGNATURE)- ' CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT r /1 ] AUTHORIZATION 0 jr CHECK OR i1LL IN APPROPRIATE SPACES DATE: I I PATIENTS NAMEJ�1s�l1Ll-L� _ -� — C}�d ❑ F COMPANY k 1.,5 , ADDRES 6-_ ZL416,_ AGE44t CITY ` STATE ZIP_ BD _ DOB7_a%'.:/j ❑ Sn ❑ M T ❑ W ❑ Th F ❑ S DRIVER'S LICENSE N _ _0.. ��.�_ PHONE -3_ �7 Vi]dATURE OF DISPATCH L�EZj�l TYPE OF TRANSPORT: AMBULANCE} OTHER❑ INC10_ ENT LOCATION: ,I RESPONSE CODE: RE ESTED BY. TIME- (24 HOUR PLO'C'K) CR n /^� � tl TO SCENE- 2 �O. — CALL RECEIVED L :, V, A,,I -7— ❑ P.U. TIME 10-8 Q �_ ) PATIENT DESTINATION: FROM SCENE ❑ FIRE -- TIME 10-97 3z _ ❑ PSAP TIME 10-49 MILEAGE. AGE: O OTHER/PVT TIME 10-7 END�LTIME 10-9 8 E T c ' " (` �-1 TIME 10-22 "'DOCTOR -' t� AAA— PM /ER START�..�Q— I HOW CHOSEN: TOTAL STANDBY TIME DEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- `❑ PATIENT ❑ DIRECT O OTHER CALL BACK p: AMBULANCfA�NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S JO RESP ONSE ZONET D YES O O WAL',ED UERNEY ❑ OTHER f --- PATIENT CONDITION. DRIVER_G � _S r) —e-9.1A _ TECHNICIAN _ MEDIC HX: DISPATCHER_( h )5 5 CHIEF CO PLAINT: —�t2>� DRY RUN: ❑ YES O REASON FOR DRY RUN /q-3 ! _ AUTHORIZATION F R DRY RUN (EMS USE ONLY) 1 . , PATIENT REFUSED SERVICES: (SIGNATURE) X,_. _ 777 P MEDICAL COVERAGE: j[JDUSTRI Y; NO NO. OF PATIENTS: S.S PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS C 4 TOTAL MILES: �j X - ✓ .;U VE ICAR W: ( E.O.B. ATT. ROUND TRIP: 13 YES ❑ NO r ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRPM.�f �`�0. l�,�J\�Cr/ EMERGENCY RUN: MEDT-CAL N:L2 7/c.7 015' 3 5' 3 CODE 2/3 OTHER:- OXYGEN: APER TANK) cJ-JU 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: (1F 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 RLCI:IVI1)fly X ' IS n'tl��t1d�/! 001150 `! CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT F—ri,----1 AUTHORIZATIONN��- , -• CNECIt OR FILL INAPPROPRIATE S/ACES DATE: v" `� j 6� M ❑ F COMPANY N j %iPAT(ENTS aim �//�!�- v� S ADDR S1m IJRC�Vt- -S� AGE 31-21 L) I"� 1 CITY§9p&z!:�Y STATE CA ZIP L i_ .DOB 1_ 2y 1 ❑ Sn ❑ M T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE• PHONE__!t2 NATURE OF DISPATCH TYPE OF TRANSPORT:r AMBULANCE OTHER57 STATION I(A)_2(B)_.3(C)_4(D)_5(E)A '.! INCIDENT LOCATION: i , RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C O K) 1I � -4'T w: TO SCENE- cX`� ❑ S.O. • CALL RECEIVED .. . 13P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 3 1l 31 D ❑ PSAP TIME 10-49 3 } �� ) MILEAGE:'?C7 OTHER/PVT TIME 10-7 1 END_.x...22—' TIME 10-98 RDOCTOR r +? I PMD/ER START 09- TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME , yi+X_❑ NEAREST-2 O FAMILY TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER j CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: H 4�} RESPONSE ZONE_ YES ❑ NO ❑ WALKED &GUERNEY ❑ OTHER r 1 PATIENT CONDITION; - DRIVER , �Ay� I(-^) ( EMT-1,) TECHNICIAN -'r- T� z�o PARAMEDIC Hx: DISPATCHER: UR113E'_ �i�,r7 CHIEF CO(YPL�AINt�T: ^� �`�IL- DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN J [����/t t�Jt✓ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 ,ti A_ U0 PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: ..-- INDUSTRIAL 13YES ❑ NO NO. OF PATIENTS: S.S. 0 ! PRIVATE INS. CO.: BASE RATE: KAISER N: r MULTIPLE PTS.BASE RATE OSS N; I TOTAL MILES: *J X t44 —_nr� %J EDICAR . c oyya 1�r=�/� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C =I I EMERGENCY RUN: 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-34F-4UA=4-((bRELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) '---CITY: tSTATE_ ZIP: C-COLLAR: .(IF NOT REPLACED) PHONE: -`- 3 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP: —COMMENTS: �L TOTAL: .3 S 0 � PATIENT RECEIVED BY: Provider wain White xd Pink oPY . ketur, Ye'iau t ea; uhen Di i:ir,d (SIGNATURE) 0 V tNs-I ((fit 15 CONTRA COSTA COUNTY AMBULANCE . PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES • DATE: U PATIENTS NAME—2_1J�7 nne,,r PGMC_k� ❑ F COMPANY 0 ADDRESS ��3(4 )Ct Yl lit n4b/1/ AGE 3CJ 0.0 , CITY.(,-3.', C STATE ZIP - DOB a_ s O sn O M OT J�W- O Th,,O F.Q_ lCD DRIVERS LICENSE k HJ�q ±'� PHONE NATURE OF DISPATCH TYPEOFTRANSQORT: AMBULANCE OTHER❑ STATION 1(A)_2(B)_3(C) I -- INCIDENT LOCATI RESPONSE CODE: QUESTED BY: TIME-(24 HOUR�C,L`OCK TSCENE-. C '�( 7 0 rnO SCENE-. 25.0. CALL RECEIVED 1 it � t-�` �-'``\sck- � ! � ❑ P.D. TIME 10-8 i L Z �t =�` .• C2S 1 PATIENT DESTINATION: FROM SCENE,- Z � ❑ FIRE TIME 10-97 —�fJ�`t L ❑ PSAP /TIME.10.4RJX! ! . cCLN �:�'•. ` C �1A PP MILEAGE: ( 2 O OTHER/PVT TIME 10-7 �� ? END "'v.' ; TIME 10-981Aq DOCTOR L+lc PMD/ER START TIME 10.22 HOW CHOSEN: TOT STANDBY TAME ❑ NEAREST ❑ FAMILY O TRANSFERWAIT TIME + 13PATIENT 13DIRECT n`/� OTHER Q P jeQ7-U- CALL BACK 0: AMBULANCCOMPANY; ,( :1 1(, PT MBULATORY? PA )ENT TAKEN TO AMBULANCE: -- 'I 50 'RESPONSE ZONE YES 11 NO PA ❑ GUERNEY 13OTHER T.' r �'r• PATIENT CONDITION: DRIVER EMT=1A ^�-� TECHNICIAN PARAMEDIC ��•s 9`.'` " Y I Hx: �-' DISPATCHER: ' 1 r. CHIEF COMPLAINT: - W •LDRY RUN: ❑ YES 0 REASON FOR DRY RUN -....l�.., ' AUTHORIZATION FOR DRY RUN(EMS USE.ON�t'J '•'� : �`: PATIENT REFUSED SERVICES: (SIGNATURE) X �ti�n .sv MEDICAL FOY RAGE: INQUSTRIAt 13 YES NO NO.OF PATI_E_NTS: ._ - •:,:. S.S. N �} w PRIVATE INS. CO.: BASE RATE: -- !L.-�_::;•, KAISER M: - -MULTIPLE PTS.BASE RATE tib j •.7 '�.' BLUE CROSS N: TOTAL MILES.'_)( •E�- "' MEDICARE C E.O.B.ATT. ROUND TRIP: YES O NO N7:c.At� ❑ YES -0 NO NIGHT: (19:00-07:00) �1M'3oA0 , CCHP/PPRP B: EMERGENCY RUN: V,11 QWAr:&i TXa 7 C ' MEDI-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) J{ Tt*iv15W 31%lr'cT.-DX �} P.O.E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR) t 4 DATES BILLED: STANDBY: (OVER 15 MIN.) " s _ _ . .. . 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: EMPLOYER: OCCUPATION: ' ' OTHER: ADDRESS: ; CITY: -STATE• ZIP COMMENTS: TOTAL: 00152��° U &0 V( ( PATIENT BY)X Provider retain White (-d Pink copy Return le_Zw ro t, (IGNATURE) py ENS vhen bil:inp OIE-1' 1 CONTRA COSTA COUNTY 1` AMBULANCE PREHOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: J PATIENTS NAME 1C. ❑ M ❑ F COMPANY M I S-2 ADDRESS AGE CITY -jTATE ZIP DOB ^❑ Sn ❑ M ❑ T CXW ❑ Th O F 0 S DRIVER'S LICENSE.# _ PHONE —` NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE:LN OTHER _ __.--.—_.._ . STATION 1(A)_2(8)_3(C)_4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) `G�ce,i ' W-3-pe<) TO SCENE-3/� O S.O. CALL RECEIVED —() 7 ..;3 ❑ P.U. TIME 10-8 0 -7 33 PATIENT DESTI ATION. FROM SCENE/- ❑ FIRE TIME 10-97 rj i V 11PSAP TIME 10-49 'br {� n 'L �Q_S 1'r'1 MILEAGE: ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 �.DOCTOR PMD/ER STAR TIME 10-22 HOW CHOSEN: I TOTAL STANDBY TIME c' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C,A S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER t iI PATIENT CONDITION:; ( DRIVER sGrNc�.�,d �'J EMT-1A 1 _ TECHNICIAN I"`Tr �S PARAMEDIC y V Hx: J0?7 Al A�'" bel Q01 f"IVIv611 a2CIkt, DISPATCHER: D / D CHIEF COMPLAINT: T DRY RUN: RYYES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l 5� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# PRIVATE INS.CO.: BASE RATE: KAISER 0: 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 0: EMERGENCY RUN: n MEDT-CAL#: 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) �c �� PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) Coe* EMPLOYER: OCCUPATION: OTHER: S ADDRESS: CITY: STATE: ZIP:— COMMENTS:' IP:COMMENTS:' TOTAL: 00153 PATIENT RECEIVED BY: X r.! (SIGNA URE) CONTRA COSTA COUNTY `1, AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION • CHECK OR FILL IN APPROPRIATE SPAAIII - DATE: PATIENTS NAME y: ❑ M uJ F COMPANY If ADDRESS �l I NA �U "�-� AGE"_Z ( rr /7 CITY W G STATE LAS- ZIP C� _._ DOB3__'_ ❑ Sn ❑ M O T (2(W O Th ❑ F ds DRIVER'S LICENSE N PHONE__._� -�.�1�-NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANC;:Q9 OTHER❑ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: 1, RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 'Z�L "-T t "LI TO SCENE --3 I�S O. —_ CALL RECEIVED rA'/ �d ❑ PD. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE 2 ❑ FIRE - TIME 10-97 ❑ PSAP TIME 10-49 1 (' MILEAGE: ❑ OTHER/PVT TIME 10-7 1 ` END TIME 10-98 DOCTOR �`e rf PM D/IlpSTARTL:ila`.LSC_j: TIME 10-22 HOW CHOSEN: TOTAL -JA. STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY: CA S T AMBULATORY? IENT TAKEN TO AMBULANCE: RESPONSE ZON I., YES ❑ NO xE:,,,,:��t AL KED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER W ( I EMT-IA TECHNICIAN "<Z 0 G PARAMEDIC N G- HK: 10, S c DISPATCHER: 1 CHIEF OMPLAINT: ,) G DRY RUN: ❑ YES NO REASON FOR DRY RUN t^ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) ro PATIENT REFUSED SERVICES: (SIGNATURE) X C v'L J MEDICAL COVERAGE: INDUSTRIAL ❑ YE NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: SER x �--L4 15-0MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) / CCHP/PPRP R: EMERGENCY RUN: ) `' MEDI-CAL R: CODE 2,/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ANO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E K.G.: (PER EPISODE) NEAREST @ELATIVE/RESPONSIBLE PARTY: I.V.: tPER ADMIN.) X -*�-- CJ r Ol C7 DRUGS: (PER ADMIN.) X I NAME: I n "C' RELATIONSHIPbE.O.A.: (IF NOT REPLACED) ! F� ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE.0 ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: r OCCUPATION: OTHER: i (• II/ /] ADDRESS: /r''• `� J( CITY: STATE:—ZIP:— COMMENTS: TATE: ZIP:COMMENTS: of 00- -- -- - . TOTAL PAIIFNT RECEIVLD IJY X. ..G!` ll L v A.,vilir rvtalc Vl:r r. .i t.. (SIGN��IIHF) fnt-I t�. CONTRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I �, UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: ( 3 - PATIENT'S -PATIENTS NAME 1/ ` ❑ M ❑ F COMPANY# ADDRESS AGE- CITY GE CITY STATE ZIP DOB_ O Sn OM OT 4W O Th OF OS DRIVER'S LICENSE# _ _ _ PHONE NATURE OF DISPATCH f 1n�/ To ✓-1 e C 17 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 CLOCK) �{ n TO SCENE- S.O. CALL RECEIVED kP.D. TIME 10-8 L ' PATIENT DESTINATION: FROM SCENE- 6 13 FIRE TIME 10-97 � ❑ PSAP TIME 10-49 u MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 1 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: A. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: U U RESPONSE ZONE -- ❑ YES ONO ❑ WALKED O GUERNEY ❑ OTHER — [ PATIENT CONDITION: DRIVER LAN,�s/fq/ti ,r' EMT-1A TECHNICIAN G CIP 1ti t l.A M J p qNj f� Hx: __ ` DISPATCHER �' ) C. '1 I CHIEF COMPLAINT: f' 1 1 (� DRY RUN: ❑ YE�❑ NO REASON FOR DRY RUN /4" 114- 'y ( (I I I 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#: 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/RE PONSIBLE 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: ' CITY: STATE: ZIP: COMMENTS: TOTAL` r�- - PATIENT RECEIVED BY: X__._..__V____._ 00 .55 i�•ii.ior rvl l'.. ��:i 1•. , n;.: .. ISIGNA PURE) ! zt'l o i � j CONTRA COSTA COUNTY AMBULANCE IOJ PRE-HOSPITAL CARE FORM I (UNIT AUTHORIZATION If CHECK OR ILL INAPPROPRIATE SPACES DATE: 7 7 PATIENT'S NAME _ �:._c�f11 ._- ��. �❑ M OF COMPANY a- � ADDRESS ------ ---- AGE CITY-____.- -__.-- STATE-_-_--____- ZIP DOB .._______ ❑ Sn ❑ M ❑ T ❑ W '❑ Th ❑ F ❑ S DRIVER'S LICENSE a PHONE ... __..__ NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER❑ ICtDENT LOCATION RESPONSE CODE. UDUF.STED BY: TIME- (24 HOUR CLOCK) 4 TO SCENE - 5 O. . .._ _. . CALL RECEIVED Qy..L._. .- ----- __. P.D. _._ .__.._..... TIME 10-8 PATIENT [pESTINATION. FROM SCENE - ❑ FIRE ____. ...... TIME 10-97 D ` ❑ PSAP TIME 10-49 CJ •\(i ------- MILEAGE: -- ----. ❑ OTHER/PVT TIME 10-7 --- .-- 3 END.---------.-- ---. --------__ . TIME 10-98 DOCTOR _-_- PMD/ER START___--__ �_-__—_ TIMEj10-22 HOW CHOSEN: TOTAL -_-_.— STAABY TIME — ❑ NEAREST ❑ FAMILY ❑ TRANSFER __-__-- WAIT TIME — ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE �--_-- ❑ YES ❑ NO ❑ WAL':ED GUERNEY ❑ OTHER -- PATIENT CONDITION DRIVER....__._.__ Sf _. TECHNICIAN__ n 4 // _. __-. L�PARAMEDIC. Hx: --- -------- -- --------- DISPATCHER CHIEF COMPL.AINT __..___-.___.. .__.._.____.___-______. DRY RUN: YES ❑ NO REASON FOR DRY RUN +�_ AUTIlORIZ TION FOR DRY RUN ELAS USE UNLYI___-__.--___-- I PATIENT REFUSED SERVICES: (SIGNATURE) _ I ' MEDICAL COVERAGE: INDUSTRIAL Cl YES NO NO. OF PATIENTS: SS a - ---- -------- --- PRIVATE INS CO.:- _ -__ -_-_ BASE RATE: ---- ---- KAISER a: .__ . __--_--.-.._-- __---_ MULTIPLE PTS. BASE RATE BLUE CROSS a ---_-- - TOTAL MILES: _-.- X MEDICARE a' ___-_---__-- _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES 0 NO NIGHT (1900-07:00) l CCHP;PPHPa --_______ -.�__._-_--- 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 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. . . _ _ DHY RUN. (AUTHORIZED) - - EMPLOYER _-_._.._...-_. OCCUPATION -.-. _.-_.____ OTHER: ADDRESS:._ -- -------------- --- -- -- --- ----- 1 CITY. - -- - STATE:--- ZIP---- - ---- --- - - ---- ----- COMMENTS---- --- ..... . --------- - -. ------ - . -------- ---------- - --- - - - _. TOTAL..I-P_ -- -- -_ 015 6 P-^ III NT RECEIVED 11Y X --.-- ---..__-_- --- ._.. !?•rri�7rr r�•:.::� .. ... (SIGNATURE) F.h i. • l ,•, .► /:-1( 7/5 1 CONTf1A COSTA COUNTY AMBUL NCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: _ PATIFNT'S NAME bl�f.W�1 ti_«���t L _ M ❑'F COMPANY a_ t ADDRESS —I? L� <.CJ .- -1" ��- -._ A�'' AGE -Z b 0 I CITY.__.- L C^'� STATE ZIP \-e' 1 -_ DOB �I�`� O Sn ❑ M O T W O Th 13 F O S DRIVER'S LICENSE 4 _ __._.._.-- __,. `' PHONE _ ` .`__ -_— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE D OTHER❑ INCIDENT LOCATION: RESPONSE CODE: vs. UESTED BY: TIME- (24 HOUR CLOCK)_TO SCENE O. CALL RECEIVED :5 ❑ P.U. TIME 10-8 5 s PATIENT DESTINATION: FROM S ENE- ❑ FIRE -- TIME 10-97 ) -� ❑ PSAP TIME 10-49 1.•1✓ __.Y_.� _..._ --.____ __ MILEAGE: /�.• 11OTHER/PVT TIME 10-7 Z END 7 TIME 10-98 DOCTOR _J �LLTJ�_�� PMD ER START yl!L) TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME NEAREST ❑ FAMILY O TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER "?. CALL BACK a: AMBULANCE COMP PT AMBULATORY? PATIENT TAKEN TO AMBULANCE RESPONSE ZONE----/— D ONE❑ ES ❑ NO O 'AL':ED ❑ GUERNEY O OTHER _E�L Jto/c C :1 //�� PATIENT CONDITION. DRIVER—_--_ t1 S4oEMT-1A_T TECHNICIAN J..l f LlI(.oA 12Z 34 PARAMEDIC Hx . _-_ DISPATCHER: D CHECq �AINi:� e �L_ '9—l.C/_QU DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 4 __/_.._. AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PAT14 REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE. INDU TRIAL ❑ YES tNUNO NO. OF PATIENTS: S.S. a .---S_"_rV---J7-- S - - -- PRIVATE INS. CO.:. _ _ - BASE RATE: KAISER x: _� _ MULTIPLE PTS. BASE RATE BLUE CROSS a'__./ 1�: •r.' ` '� %' TOTAL MILES: X '<J J MEDICARE a:__ ' " '= E.O.B. ATT. ROUND TRIP: 11 YES ❑ NO C •❑ YES ❑ NO NIGHT: (19:00-07:00) �� d ' CCHPIPPHP a:L? `,_�-'_1.'S �r� y �� o —_ EMERGENCY RUN: t- MEDI-CAL#:__l"jo CODE 2/3 ' OTHER,--.__ _____ __ OXYGEN: (PER TANK) P O.E. STICKER ❑ YES ❑ .N0 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: ��t_Q�.__ !_�— RELATIONSHIP:_�k.d E.O.A.: (IF NOT REPLACED) ADDRESS ORAL AIRWAY: (IF NOT REPLACED) CITY _, . 1 .. STATE-.,ZIP:—.__- C COLLAR: (IF NOT REPLACED) PHONE _ _. — WORK PHONE DRY RUN: (AUTHORIZED) EMPLOYER: _ OCCUPATION: _ OTHER: ADDRESS: CITY: _ STATE: ZIP: COMMENTS:—_ /Q �J — TOTAL - - 15 7 PATIENT RECEIVED BY: X f'r.widcr rr,:ir whit. r.:,.; ..�f;l .. t:.r+: Y.�'.:a• •;rr. F.+l." uh�n til f:� (SIGNATURE) O7S-1 CONTRA COSTA COUNTY r� , AMBULANCE PRE-HOSPITAL CARE FORM I , UNIT © AUTHORIZATION OR AI JS 23 CHECK OR FILL IN APPROPRIATE SPACES DATE:1J l' PATIENT'S NAME ���(1•-CZC1�`�ALZ -am OF COMPANY ADDRESS 501I ��l�L<�-LcxrC C1, AGE S CITYaS�122Z&\OQ__. STATKI '' - Zi DOfl ❑ Sn OM IRT OW ❑Th OF O S DRIVER'S LICENSE a PHONR3D_aiZa_c�_ NATURE OF DISPATCH t:-y Alco TYPE OF TRANSPORT: AMBULANCE9 OTHER❑ _ - STATION 1(A)_2(B)_3(C 4(D)_5(E)_^-- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-- (24 HOUR CLOCK) TO SCENE- VS.O. CALL RECEIVED �3 C-L. 7 �1� •�.`�_t k- c+L ❑ P.D. TIME 10-8 2- PATIENT DESTINATION:' FROM SCENE- ❑ FIRE ^__ TIME 10.97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 .3 END 60 1 1 TIME 10-98-. - DOCTOR M®ER START TIME 10-22 HOW CHOSEN: TOTAL f_qSTANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME - O PATIENT ❑ DIRECT OTHER CALL BACK 0: AMBULANCE COMPANY: r- -- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 19YES ❑ NO `<WALNED ❑ GUERNEY Cl OTHER n/� PATIENT CONDITION: DRIVER 600 EMT=1A of , .-.1 TECHNICIAN O�`L Q PARAMEDIC , DISPATCHER: (-:u-) CHIEF COMPLAINT: l� pG�� 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 'j NO NO. OF PATIENTS: ` S.S, II PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL K: CODE 2/3 OTHER: _ OXYGEN: (PER TANK) P.O.E. STICKER 11 YES ❑ NO NEONATAL: (INCUBATOR) ) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) INEAREST 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:('*�? CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION r CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME ` OM ❑ F COMPANY 11 ADDRESS AGE CITY STATE ZIP DOB— ❑ Sn OM ❑ T ❑ WW gTh ❑ F ❑ S , DRIVER'S LICENSE r _ PHONE __.�,� NATURE OF DISPATCH_ TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _ --- STATION 1(A) _2(B)_3(C)-4(D)_5(E)^ I ` INCIDENT LOCATION: S /' RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE] ❑ S.O. CALL RECEIVED / 01 J ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 : �, l 11PSAP TIME 10-49 y �J NMILEAG ❑ OTHER/PVT TIME 1D-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK r: AMBULANCE C MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: - RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER // _ I PATIENT CONDITION: DRIVER.�L Ltlj:f�, �fi � -�� EMT-1ATECHNICIAN « PARAMEDIC Hx: DISPATCHER: s c: / CHIEF COMPLAINT,: fy I b/ DRY RUN: YES ❑ NO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE-ONLY) PATIENT RE USED SERVICES: (SIGNATURE) X_ I (1 MEDICAL COVERAG INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: I S.S. r PRIVATE INS. CO.: BASE RATE: ' KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS r: TOTAL MILES: X I MEDICARE r: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP r: EMERGENCY RUN: MEDI-CAL r: 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) Vv EMPLOYER: OCCUPATION: OTHER: ADDRESS: I CITY: STATE: ZIP: COMMENTS: cy TOTAL:— __. PATIENT RECEIVED BY: X – — Prouidor "ta-n whin, xd Pi: „ , 1 (SIGNATURE) _ S +' CONTRA. I TAA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT n� AUTHORIZATION N 3 -a 9� L i ry"3 C►jt� .�INAHROMUTf 3RACf3 DATE: PATIENTS NAME ti 0 E C SA I)I C' ❑ M" �QF COMPANY If � ? 7-�- ADDRESSS 3)Q pyG AGE_L_L—_ CITY-111 CIS Mo'Ld STATE cA- zi d /DOOL -B��1y-0 ❑ Sn O M ❑ T ❑ W ;(Th13F O S DRIVER'S LICENSE k PHONE NATURE OF DISPATCH co/ CAL t' TYPE OF TRANSPORT:,AMBULANCEOTHER O — STATION 1(A) (8),3(C)-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) G F -" TO'SCENE- 3 KS.O. CALL RECEIVED 410 J (4UU.SFVriL� /0 ;t.R/C'/�. .'�'•' : • '.' ❑ P.O. TIME 10-8 Z)-Q '_3—I PATIENT DESTINATION: FROM SCENE-3 O FIRE TIME 10-97 i�o%� C (� -�) _ ❑ PSAP TIME 14.49 c3'.r.l �•J' I' '" I MILEAGE: ❑ OTHER/PVT TIME 10-7 _ END h b• 9 TIME 10-98 ADOCTOR PMD40 START TIME 14.22 HOW CHOSEN: -. _� TOTAL y STANDBY TIME NEAREST- ., O FAMILY O TRANSFER WAIT TIME _— ❑ PATIENT O DIRECT O OTHER 3 CALL BACK k: AMBULANCE OMPINY: EoT BO TORY? PATIENT TAKEN TO AMBULANCE: SfoRESPONSE ZONE��JJNO O WALKED GUERNEY O OTHER'• 1 vi PATIENT CONDITION:; "' i DRIVER_hIC L.(AM S •� EMT-1A TECHNICIAN GU kL L,4N G HAn� Z3 q�A}pt�C /7d HR: CAAQ114G ;#yOFRTEN!/o,.. e' DISPATCHER: Q I dI o n CHIEF COMPLAINT:' I 5/•/.16 f 0E BFLEA T Ft _ DRY RUN: ❑ YES. CNO REASON FOR DRY RUN hh AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r✓ %'•' PATIENT REFUSEO SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL OYES NO NO.OF PATIENTS: S.S.k ! - PRIVATE INS.CO.: BASE RATE: KAISER k: ' MULTIPLE PTS. BASE RATE BLUE CROSS k: _ TOTAL MILES: -3 X 21- E.O.B.ATT. ROUND TRIP: O YES ❑ NO L ✓' F_ . .� O YES E3 NO NIGHT: (19:00-07:00) — CHP/PPRP k:• I I EMERGENCY RUN: MEDT-CAL k: CODE 2/3 ?, OTHER: I " OXYGEN: (PER TANK) %' e) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) 9 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: E05 UP- A-2 '" "' RELATIONSHIP: uN E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -` CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 3 2.- n 2) WORK PHONE: DRY RUN: (AUTHORIZED) —EMPLOYER: OCCUPATION: OTHER: ADDRESS: l!. ,e-, r� �. /✓• C! /-' ('—CITY: "' STATE' ZIP: — COMMENTS: "M'FO/CAR f PSR h �vR/L�B�at TOTAL:_i y'% ,T' `I. DD n016!1! PATIENT RECEIVED BY: X Pi-vider retain Whit, ,nd /'ink ..npi hetur" 1'✓" c •npy t F.N.' uhvn I iI'ina �— CONTRA COSTA COUNTY AMBULANCE ; PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION k r , 9, DATE: OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME yl1 _ 0,A) ❑ M ❑ F COMPANY M Z(0 7_� ADDRESS AGE CITY STATE ZIP DOB____ ❑ Sn ❑ M ❑ T ❑ W ❑ Th PF ❑ S DRIVER'S LICENSE M' PHONE_—___— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: tl l-4 RESPONSE CODE: R UESTED BY: TIME- (24 HOUR CLOCK) �` — TO SCENE=� S.O. —_� CALL RECEIVED -4061I P.D.- TIME 10-8 ' PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 - ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 I END TIME 10-98 DOCTOR PMD/ER START_ © _ TIME 10-22 lJ� HOW CHOSEN: TOTAL — STANDBY TIME 11NEAREST 13FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT ❑ DIRECT ❑ OTHER r CALL BACK 4: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SIO RESPONSE ZONE ❑ YES ❑ NO ❑ WAUED ❑ GUERNEY ❑ OTHER It PATIENT CONDITION: DRIVER) _ __L�✓ EM - t Y TECHNICIAN _ 27 DIC Hx: DISPATCHER: I J CHIEF COMPLAINT: ' DRY RUtZ><ES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) JV14.0PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL 11 YES 13 NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: t KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE 1i: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: 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) J1L— EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ---_ TOTAL:�� � - U0016L PATIENT RECEIVED BY (SIGNATURE) �.. . CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ff� AUTHORIZATION I< CHECK OR fill IN APPROPRIATESPACES DATE: O V /�/v_�_ PATIENTS NAME ❑ M '❑ F COMPANY N 14 " 1 ADDRESS AGE CITY STATE ZIP DOB _ ❑ Sn ❑ M ❑ T ❑ W X Th ❑ F ❑ S DRIVER'S LICENSE PHONE—.____—__—.-- NATURE OF DISPATCH ' TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: Rt.QUESTED BY: TIME— (24 HOUR CLOCK) ` / TO SCENE- S.0. — CALL RECEIVED —' t 2112- Ab �1' T l r _ l ❑ P.U. TIME 10-8 y. 'PATIENT DESTINATION: r FROM SCENE-O ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 � 2- 9�z MILEAGE: ❑ OTHER/PVT TIME 10-7 ' r 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: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J lO RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'(ED ❑ GUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER_,/�lL j��,1J 1 0 AT-1A ) TECHNICIAN 6 ?-00 PARAMEDIC t -�o by lco Hx: �� """" DISPATCHER: �L7 J _ T � CHIEF COMPLAINT: � _Aen4? i(./< 'CDeJ�DRY RUN:SWYES ❑ NO REASON FOR DRY RUN N���/Vt e/.�v �Il(r t AUTHORIZATION FOR DRY RUN (EMS USE ONLY) � �• ( 1 � •'r-`• ', PATIENT REFUSED SERVICES: (SIGNATURE) X_ — MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �1St1' y S.S. a PRIVATE INS. CO.: BASE RATE: 1 KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: 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) — Uv PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �— EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: LL — TOTAL: PATIENT RECEIVED BY: X 0 Provider r¢tair: Air (SIGNA'URE) r ;��d Pin:: ropb Frr4rn �� '�,;. n, ,.•h.•. 1 i 1'.�;� Etic-1 CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT . 2 ' AUTHORIZATION R �� 2_q ti L r , I ILT` CHECK OR FILL(N APPROPRIATE SPACESQATE: lis- 4_4 _ PATIENTS NAME 1 �-Sc`1 t, Te f f'--{ al� O F COMPANY R ADDRESS AGE~N y1 CITY - ' STATE ZIP DOB � O Sn OM OT O W Mi OF ❑S DRIVER'S LICENSER _ _ PHONE NATURE OF DISPATCH S E! I - TYPE OFTRANSPORT: AMBULANCEV OTHER STATION 1(A)_2(B)_3(C) 4(D)_5(E)— J INCIDENT LOCATION:! RESPONSE CODE: REO ESTED BY: TIME- (24 HOUR CLOCK) / TO SCENE- NfS.O. CALL RECEIVED f Zco l Q ,.ie�' p�G�e t,r (�I , O P.U. TIME 10-8 PA TINATFOFI r FROM SCENE ❑ FIRE TIME 10-97 Z� ❑ PSAP TIME 10-49 pMILEAGE: 13OTHER/PVT TIME 10-7 TT(o ( 7 J M NiL I••4 / U 1_ �JC� END TIME 10-98R ' f I PMD/ER STAR TIME 10 22 . d� HOW CHOSEN: TOTAL STANDBY TIME c1.:' ❑ NEAREST :, O FAMILY O TRANSFER r WAIT TIME _ ❑ PATIENT ❑ DIRECT O OTHER CALL BACK R: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE:, 5.`c) RESPONSE ZONE ��¢¢ YES 13 NO O WALKED 13GUERNEY ❑ OTHERET 1 PATIENT CONDITION: DRIVER �l �1SSo n EWf-jA TECHNICIAN ol:�5 (S 50 PARAMEDIC Hx: DISPATCHER: 05 n J3 CHIEF COMPLAINT: DRY RUN: W YES ❑ NO REASON FOR DRY RUN S h t`p (/ 1 AUT RIZATION FOR DRY SE USE ONLY) PATIENT REFUSED ERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF ATIENTS: S.S.R PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS R: TOTAL MILES: X MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C • EMERGENCY RUN: MEDI-CAL R: 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 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) -5v CrC� EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS.` TOTAL:�h ' 00T63 PATIENT RECEIVED BY- X—___ `. .il.•� -. r (SIGNAIIIRF) rw • k CONTRA COSTA COUNTY AMBULANCE G PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: - � - OE PATIENTS NAME ❑ M ❑ F COMPANY p 1 ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑W 9-Th ❑ F ❑ S ) DRIVER'S LICENSE M+ _ PHONE—_._______,— NATURE OF DISPATCH �- TYPE OF TRANSPORT: AMBULANCE❑ INCIDENT LOCATION: N+ RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ., p� TO SCENE- 2 — CALL RECEIVED 11�� L✓ �[/��/ ❑ P.U. TIME 10-8 0 L � � PATIENT DESTINATION: �— FROM SCENE- ❑ FIRE TIME 10-97 0\113PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 r DOCTOR I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �f O RESPONSE ZONE. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER. I0O EMT-1A 1 I i _ TECHNICIAN y��p, PARAMEDIC 42 / "�- DISPATCHER: �f L�� �7 nO - _ CHIEF COMPLAINT: t J 4 Z DRY RUI�i S ❑ NO REASON FOR DRY UN?21^-'s Le f /(J(1 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) / / 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 M: 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 ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) + E-K.G.: (PER EPISODE) NEAREST RELATIVE/RES PO 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: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) 1 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: 1 ADDRESS: 1 CITY:- - STATE: ZIP:- COMMENTS: IP:COMMENTS: - TOTAL.5D A I C� PATIENT RECEIVED BY X P1•'ui fn. rte'.. tn;:•. .., (SIGNATtME) + . CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION#GO I CHECK OR FILL IN APPROPRIATE SPACES DATE: n PATIENTS NAME -DR ❑ M ❑ F COMPANY# S 1 l p IV ADDRESS AGE CITY STATE ZIP-- DOB—_- - ❑ Sn ❑ M ❑ T ❑ W Th ❑ F �/❑ S DRIVER'S LICENSE# _ I PHONE-------------- NATURE OF DISPATCH �t��C •C QX^f/ TYPE OF TRANSPORT: AMBULANCE EVOTHERID INCIDENT LOCATION: RESPONSE CODE: REQ STED BY: TIME- (24 HOUR CLOCK) / TO SCENE- S.O. CALL RECEIVED 0. L� ,J ❑ P.U. _ TIME 10-8 — :— z PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 k ❑ 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 c ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE�MRA�NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 51C) RESPONSE ZONE o� rT- ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER�I ��s�S(001 135 EMT-1A TECHNICIAN C"��C* Z15 "-PARAMEDIC Hz: _ DISPATCHER�ESE3 o7 J I CHIEF COMPLAINT: DRY RUN: NO REASON FOR DRY RUN aC -Q�1 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) e 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 ❑ 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) 5-1 G EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: - - TOTAL'1'9-� cZ► V----- -- --.---_____---------•-.--- PATIENT RECEIVFD BY X -- ,.. ... ,. .. (SIrNA t1IRE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORMAI UNIT AUTHORIZATION N < t CHECK OR FILL IN APPROPRIATE SPACES DATE. PATIENT'S NAME . 15r_r<Od L)`�� 5I - , M ❑ F COMPANY M l ADDF PG� —4'-3 AGE 11 f 4/ i CITY . . STATE-' -. ZfP_-____ DOB.7/4.A/ ❑ Sn ❑ M ❑ T ❑ W>$Th ❑ F 0 S DRIVER'S LICENSE a _.___ ._. __. PHONE l(w.- � NATURE OF DISPATCH A) TYPE OF TRANSPORT: AMBULANC�5 OTHERO INCIDE T LOCATIO�- RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C},OCK) 1 C TO SCENE- S.O. - CALL RECEIVED 1L , ❑ P.U. ---- TIME 10-8 :r PATI NT DESTINATION: FROM SCENE -2 ❑ FIRE _ TIME 10-97 - IA03 6s IF y -- /----- _ ❑ PSAP TIME 10-49 r/ MILEAG ❑ OTHEFL'PVT TIME 10-7 END��C _6 TIME 10-98 DOCTOR __._. lam _—. PMD START.c��--7— TIME 10-22 HOW CHOSEN TOTAL, STANDBY TIME 1 NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMj!!V COMPANY: PT AMBULATORY? PATJENT TAKEN TO AMBULANCE. 5101V RESPONSE ZONE ES ❑ NO SVAL':ED (7 GUERNEY ❑ OTHER Q� , PATIENT CONDITION. DRIVER ' ��EhaT-1A I TECFINICIAN .jam, PARAMEDIC ;t r Hx. L r��_ jU_C('cIC'_ �'1'�- . =�(�r /7!_ t L___ -_ DISPATCHER: CHIEF COMPLAINT: -__.. _ -_._- - DRY RUN: ❑ YES%g NO REASON FOR DRY RUN +. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: NDU T IAL ❑ YES'j;jrNO NO. OF PATIENTS: S S *• - - -- -- 1 PRIVATE INS. CO.: 2- �.JZ/l1__ __ BASE RATE: ao KAISER u: _-_. - -_ -i MULTIPLE PTS. BASE RATE BLUE CROSS#:J TOTAL MILES: y X 6�.j MEDICARE V: _-- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ' ❑ YES ❑ NO NIGHT: (19.00-07:00) G CCHP/PPRP tl: __-_--___ _ EMERGENCY RUN: i MEDI-CAL r+: CODE 2/3 J OTHER: ___ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: __._-__ STANDBY. (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.' (PER ADMIN.) X Ell(�t_lu)A[ / _ DRUGS: (PER ADMIN.) X NAME: L 7 A) FJJJ'��)1.�HELAT10NSHIP4/1 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: OCCUPATION: _ OTHER: ADDRESS: CITY: -._.__..___ STATE:_ ZIP:_-__ COMMENTS: 166 PATIENT REdEIVED BY:X ® S` Frrvider r�ra:- ai r.:r (SIGNATURE) Lr' r7'. . . •'r.L :.r^ - N^ L:}Ah r:, f••] LMS-I \� I,U1N f, itI 1011") USi'(i / CON IFIA COSTA COUNTY 1 AMBULANCE L� 1 l PRE-HOSPITAL CARE FORM ( () UNIT AUTHORIZATION - ��,8 3 ✓J CHECK ON Flll IN AaPROPRUTE SPACES DATE: ..-�.. PATIENT'S NAME –� 1 VM `❑ F COMPANY A ADDRESS L `iL I\7 t 1"14_�.�- AGE J` , CITY _ STATEZIP DOB O Sn OM OT OW tom, OF P 8-►-- DRIVER'S LICENSE a ___– PHONE— LL4_�—_ NATURE OF DISPATCH—`-' TYPE OF TRANSPORT: AMBULANCE❑ OTHER W-_ _ --- STATION 1(A)_2(B)_3(C)_4(D)_5(E)` INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) �i� TO SCENE- 3 9 S.O. CALL RECEIVED � ❑ P.D. TIME 10-8 s3 Q � PATIENT DESTINATION: FROM SCENE J2 FIRE TIME 10-97 •: PSAP TIME 10-49 1� l MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 1D-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME -- ❑ NEAREST ❑ FAMILY ❑ TRANSFER h WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER J CALL BACK C AMBULANCE COMP�IN L �I PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE W ❑ YES O NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER n _.1 PATIENT CONDITION: DRIV G'U ``O EMT-1 A -`1 TECHNI IAN �! e-1� 2,95 PARAMEDIC i>( Hx: J 1l�I T DI AT HER: add E. L I l CHIEF COMPLAINT: •1- C-'°� 1 YES O NO REASON FOR DRY RUN RIZATION FOR DRY RUN(EMS USE PATIENT REFUSED SERVICES: (S(Gr G ATI X J MEDICAL COVERAGE: INDUST IAL YES N NO. OF PATIENTS: S.S. q _ ---1 PRIVATE INS. CO.: BASE RATE: 1 / KAISER#: MULTIPLE PTS. BASE RATE /--. BLUE CROSS TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO r-f J c ❑ YES ❑ NO NIGHT: (19:00-07:00) " •, �: 1 1 ( C CCHP/PPRP N: EMERGENCY RUN: _ 1 �ld _MEDI- CODE 2/3 OTHER: �~ OXYGEN: (PER TANK) :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: •-DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (1F 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: h"' PATIENT RECEIVED BY:X G Prwidcr retai: HkitP ,.d Pi n�� cafum Yt'low c'nP� t, M7 whin bil'inp (SIGNATURE) al-I N � CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N O f0 CHECK OR TILL IN APPROPRIATE SPACES DATE: PATIENTS NAME _L ..T!`�-�- M ❑ 'F COMPANY# / �' L/ `J ADDRESS .� /GAGE V 3L 1 STATE ZIP DO '� ❑ Sn ❑ M ❑ T ❑W )t'Th ❑ F ❑ S DRIVER'S LICENSE# _ PHONE�J.�� _�_}�SI NATURE OF DISPATCH U�0ONSLIJOLIS ^ _33 a-tel Sr13 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATIO : RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) oi/m pv� TO SCENE - S.O. __ CALL RECEIVED � T 7 O P.U. TIME 10-8 PATIENT DESTINA ION: FROM SCENE- 7� ❑ FIRE TIME 10-97 = ��1 J0, ❑ PSAP TIME 10-49 J ':i. ✓ MILEAGE: ❑ OTHER/PVT TIME 10-7 4`, END TIME 10-98 DOCTOR {" PMD START-1.1 TIME 10-22 HOW CHOSEN: ��jj TOTAL 2 ' STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER r CALL BACK#: AMBy COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: '510RESPONSE ZONE-(-._- ES ❑ NO ❑ WAL`:EO�GUERNEY ❑ OTHER t ���� � �.�,�/ «r PATIENT CONDITION: DRIVER-Mi CfA EMT-tA- 9T I - TECHNICIAN L�___ 4_ PARAMEDIC _ Hx: _ DISPATCHER: CHIEF C MPLpAI�NT: � DRY RUN: ❑ YES NO REASON FOR DRY RUN �� 7aY � ►V/��T AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAG1 S RIAL ❑ YES p NO NO. OF PATIENTS: S.S.# . RIVATE IN �MUQU e tJA_r-"J'�L- U F� BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE _ B _ #: TOTAL MILES: 1 X MM DILA -20 �� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) HP/PPHP#: EMERGENCY RUN: ' MEDI-CAL#: CODE 2/3 J OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES '❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: (/ 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) EMPLOYER2 OCCUPATION: OTHER, _ . ,.._ •J ; ADDRESS: - - - - CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL' Z DC7 ---. . . 00168 - - --=- ----------- - .. PATIENT RECEIVED BY. X - 1 CONTRA COSTA COUNTY AM13ULANCE 2 � ' •)[j�� G PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# _ �C CHECK OR FILL IN A"PROPRIA T[SPACES DATE: 81 � � s� 3 PATIENT'S NAME 1.4.4 &1:5e9__.___.________._ ❑ M `ZI F COMPANY p /2 /c3 ADDRESS ._ .^-_ 1 .. -UL , AGE CITY _ 11 Sn ❑ M ❑ T�. ❑ W �Th 13 F CIS -__ _.` —. DRIVER'S LICENSE a _.-_ __..- - .-__.- -- PHONE 33.- NATURE OF DISPATCH GEn u_?us y. TYPE OF TRANSPORT: AMBUL-ANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR Cr,OCK) 1\` TO SCENE - .0. — CALL RECEIVED ❑ P.U. _ TIME 10 8 PATIENT DESTINATION: FROM SCENE - 13FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 _ ? MILEAGE. ❑ OTHER/PVT TIME 10-7 : I -` �- END 6? TIME 10-98 DOCTOR �1� `P_ /ER START461z_- TIME 10-22 HOW CHOSEN: TOTAL,— STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER --� WAIT TIME PATIENT ❑ DIRECT ❑ OTHER 1 CALL BACK a: AMBULANCE COMPANY: IRS PT AMBULATORY PATIENT TAKEN TO AMBULANCE. In RESPONSE ZONE YES ❑ NOvAl:ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER�"..'v�V�'J �2 -�5,-� EMT-tA / 1 �C t Ff� ` l C TECHNICIAN j5 ? � PARAMEDIC (. Hx: lJ_ LIIG�_.T_L_____F�.-1 !L DISPATCHER: -4--cc -eel Q OO4 1 CHIEF COMPLAINT: DRY DRY RUN: ❑ YES 'd,NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X — �s�� ` MEDICAj/COV RAGE I�USTRIAL 11YESXNO NO. OF PATIENTS: ` S.S. a_? � - C� c - — PRIVATE INS. CO. _ BASE RATE: KAISER#: _— MULTIPLE PTS.BASE RATE BLUE CROSS#: — TOTAL MILES: X � J MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) D 1 CCHP/PPHP#: _ _ EMERGENCY RUN: o MEDI-CAL#: CODE 2/3 OTHER_ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) IJ 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—__ _._ RELATION �.._1 ._ E O.A.: (IF NOT REPLACED) ADDR�SSCO_Y_ � Cl- __. ORAL AIRWAY: (IF NOT REPLACED) CITY �� C_..f` STATE ..__- ZIP:_. .. C-COLLAR: (IF NOT REPLACED) pHONE' WORK PHONE._ _ DRY RUN:. (AUTHORIZED) EMPLOYER: OCCUPATION: -- OTHER: ADDRESS: CITY ______ __.._..— STATE:_—ZIP:_____— \CO(OMMENTS:J.o_J�/,5_.. TOTAL: PATIENT RECEIVED BY: X 00169 I'!'•'„ii:r'! . +r�i 'rL •.,.. „ (SIGNATURE) • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 3 CHECK ON FILL IN APPROPRIATE SPACES DATE: 1•I /`t At> I i ,fit AA RAT _.7 c t�j t, u� ❑ PATIENTS NAME M �F COMPANY N ADDRESS,+ ' I -R'Ly �T -1-�0� AGE _ r -1 CITY µ� STATE ^ ZIP DOB9�—t!M-4q5 ❑ Sn ❑ M ❑ T ❑ W VTh ❑ F Os DRIVER'S LICENSE N _ _ PHONEZ?$ ..� .`�— NATURE OF DISPATCH 1-261 C - TYPE OF TRANSPORT: AMBULANCE OTHER❑ -- - --- STATION I(A)_2(B)_3(C)_4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOPK) ;4j A3� TO SCENE- Z ❑ S.O. CALL RECEIVED L I I I 4 R µTZ 13P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 •1/�, C� Q 2 11PSAP TIME 10-49 MILEAGE: 91 OTHER/PVT TIME 10.7 -� (Q��--''__ Ir ENDS rc'rw.-r 7�9 TIME 10-98 `.DOCTOR PMD4f5 START_ 7S' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME i ` . ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER `� ) CALL BACK N: AMBULANCE COMPANY- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: +�- RESPONSE ZONE 2 l n ❑ YES 4 NO ❑ WALKED [�(GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER. ' ` &T-CEREMT-tA ) 1) TECHNICIAN �-1�� �_I.17 ARAMEDIC HX: � I�S1�•� r DISPATCHER: �aR'.B�_ it r CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR 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: KAISER N: MULTIPLE PTS. BASE RATE !METOTAL MILES: XDIRE�CA3�0 IO 137 A E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO YES ❑ NO NIGHT: (19:00-07:00) r/ CHP PNP N: SSG 14 EMERGENCY RUN: '•/ I-CAL N: CODE 2/3 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 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: —CITY: STATE: ZIP: - COMMENTS: TOTAL: --- I 6017 0 PATIENT RECEIVED BY: X.___ ..._ _•i'_.1_��� )��i� �� Provider mt0jr., White r.d M., ,•,,I,p hut�rn Yr':. (SIGNATURE) ) {: I Of': LA.n IiI by CMS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM IUNIT r AUTHORIZATION Na ��z g-� CHECK OR FILL IN APPROPRIATE SPACES DATE: 7 PATIENT'S NAME�L1� /_l_�C� X14'' S l� ❑ M F COMPANY# 1 9 `' -7 ADDRESS I S l AGE-i `�(' f1 h �- StATE(----%. ZIP �', DOB Z r `S7 ❑ Sn O M E3 T O.W Th O F O S DR ERS LICENSE# ------ -- — PFJONE J 1 NATURE OF DISPATCHC4–'L TYPE OF TRANSPORT: AMBULANCE OTHER❑ ' ' — - STATION 1(A)_2(e)_3(C)_4(D)_5IEI_ .•.-.. INCIDENT LOCATION; RESPONSE CODE: Oti STED BY: TIME- (24 HOUR CLOCK) _. 0. �._ CALL RECEIVED : TIME 10-8 1-47 PATIENT DESTINATPbN: FROM SCENE- ❑ FIRE TIME 10-97 1 �` r � ❑ PSAP TIME 10-49 MILEAGE 13''�� ❑ OTHER/PVT TIME 10-7 :-)-` EN71 D___�a__LL TIME 10 98 �I=I . : t > DOCTOR L= f PM ER START-.1_L TIME 10-22 - HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ! ' , CALL BACK N: AMBUL NCE COMP PT. AMB AT RY? PATIENT TAK N AMBULANCE: ��Q RESPONSE ZONE ❑ YES ❑ O ❑ WAL'(ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER ZQQ MT-1A TECHNICI 45 PARAMEDIC Hx: Cus' DISPATCHER: IZ,4' I'LL' - I IrO CHIEF COMP INT: VIDEO IGt DRY RUN: ❑ YES 'L) 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: Js1c'. S.S. # C L / PRIVATE INS. CO.: BASE RATE: l KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X ' .. �' MEDICARE#: '> �� `� � ' � �' E.O.B. ATT. ROUND TRIP: El YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) O` CC►iPtP #: EMERGENCY RUN: ' EDI-CAL#: - �!cCODE 2/3 UTRTll OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 13 NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �j DRUGS: (PER ADMIN.) X NAME' 1<� �'"�" _��RELATIONSHIP: �� 77 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: 4-4-17 L �S_S c' .✓ TOTAL: 'd - __- PATIENT RECEIVED BY. X I TUtaEI • CONTRA COSTA COUNTY AMBULANCE A ��,_/�l\•./ ,/(/ PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 V l CHECK OR FILL INA PPROMATE SPACES DATE:f I / •+�/lj•%L- ! i / PATIENT'S N_AMEI -d M 0 F COMPANY M ADDRESS 1� ; i AGE CITY ' —_ STATE—� ZIP DOB"BLL—' �) O Sn OM OT O W .J Th OF O S DRIVER'S LICENSE# _._____. . PHONE. _ y.L1�l� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ -- STATION 11A)�S,2(B)_.31C)_4(D)_5(E)._ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- O S.O. CALL RECEIVED O P.D. TIME 10-8 0 PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10-97 0 PSAP TIME 10-49 ` �-- ' MILEAGE: q,I 7 LTJ OTHER/PVT TIME 10-7 L END— TIME 10-98 0 .�S DOCTOR PMD/EP. START (I �� �� TIME 10-22 HOW CHOSEN: TOTAL 1� .' STANDBY TIME ❑ NEAREST ❑ FAMILY [ TRANSFER WAIT TIME /I ) 0 PATIENT 0 DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY:/ �- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: LJ !� RESPONSE ZONE 0 YES ONO 0 WALItED 0 GUERNEY 0 OTHER n PATIENT CONDITION: DRIVER ��4i �!Y'` 1 , ' EK(T-.lA\ TECHNICIAA �� „ f 1 r ' �� 1�2 PARAMEDIC Hx: _IJ I DISPATCHER- CHIEF CHIEF C MPLAINT:_.i: 1� DRY RUN: 0 YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X—_ MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: S.S PRIVATE INS. CO;: BASE RATE: c'/ .77 . KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: X "z LL�� ,M€DICARE '> ( E.O.B. ATT. ROUND TRIP: O YES ONO / .; OYES ONO NIGHT: (19:00-07:00) 1 CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL u: - CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER 0 YES 0 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 ir NAME: I I RELATIONSHIP:)( E.O.A.: (IF NOT REPLACED) ADDRESS 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: _ _ Tf1TAl • I OQ -- 0 01'7 2 PATIENT RECEIVED BY: X Provider rrta:r Vhitr "r, n „app drt� r':r:` tv ,•.ti; (SIGNATURE) r .. J. CONTRA COSTA COUNTY AMBULANCE 3 3 Q -7 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M g / CNCCK OR FILL IN A►PROPRIATE SPACES DATE: PATIENT'S NAME M o2TZ�.;� (ZAN/0 AL-L, YM ❑ F COMPANY ADDRESS _ 7��B R A ti/ 1 A � l T �/c AGE�-U — �ll' ` � ) �-Ti, CITY A ITZ STAT, CAL- ZIP�Z'Z( DOo'Z1L5'"❑ Sn ❑ M ❑ T o w O Th XF OS DRIVER'S LICENSE 0 N �!. yL�_ PHONE�'z�-1 6 S�.._ NATURE OF DISPATCH �e Z v� . TYPE OF TRANSPORT: AMBULANC "OTHER❑ __ STATION 1(A),2(B)-3(C)_4(D—5(E_ INCIDENT LOCATION: / L` RESPONSE CODE: ;rsp. UESTED BY: TIME- (24 HOUR CLOCK)i 6 /S,�/� 4 5_}_ TO SCENE 3 .O. CALL RECEIVED ✓✓ /� �'( I U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - 2 ❑ FIRE _ TIME 10-97 'l ❑ PSAP TIME 14.49 Lu ' MILEAGE: ❑ OTHER/PVT TIME 14.7 LL4_ :4 END 7 S TIME 10-98 LLa _ .",DOCTOR — ! �� PMD/ R START 3, 3 TIME 10-22 HOW CHOSEN: TOTAL 2- ' '57 STANDBY TIME . ❑ NEAREST, AMILY O TRANSFER WAIT TIME ❑ PATIENT ii✓//✓✓✓❑ DIRECT ❑ OTHER _J.I CALL BACK#: AMBULANCE COMPANY:^^ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: `J t RESPONSE ZONE �f' YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER SCA-e( 6 -'''- TECHNICIANW- 7 L.A i J 17, 5 Fic IZfs�IyV y PARAMEDIC — Hx: S ej ZV r S DISPATCHER: r ' 9 + " LEI.) CHIEF COMPLAINT:. / 4C DRY RUN: O YES NO REASON FOR DRY RUN L/Cltl �— AUTHORIZATION F R DRY RUN(EMS USE ONLY) f q :; ;• PATIENT REFUSED SERVICES: (SIGNATURE) X- -MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: )" S.S. K —P.A -7 � I _ PRIVATE INS. CO.: r `'d-e-1 NO CARD BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: ✓ X U ` 7 MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: 1 u' u MEDI-CAL N: '"Itl9lz - CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) ( p DATES BILLED:ED STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME>��-2nnnn`1 SI PL.JR j h•RELATIONSHIP, L^�` E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: M T L STATE—C—&ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WO�IRK P`dOE: DRY RUN: (AUTHORIZED) EMPLOYER: L CORN/T1�!OCCUP ON:�T MCN T OTHER: ADDRESS' r r S r CITY: F STATE:ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY. X Pro,43or ror,r.': L'h••, (SIGNA It IRE) a ' CONTRA COSTA COUNTY AMBULANCE ff,, ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION - CHECK OR nLL IN APPROPRIATE SPACES _ DATE: 'PATIENTrSNAME" -' OM ❑ F COMPANY 0 ADDRESS I AGE ` 1•{ CITY -STATES_ZIP�___!_ DOB ^ ❑ Sn ❑ M OT OW O Th ❑ F OS DRIVER'S LICENSE M -, ' PHONE ,- NATURE OF DISPATCH -r� j 2 L11 J' TYPE OF TRANSPORT: AMBULAN OTHHEEjR'❑ -. STATION 1(A)-_2(B)_3(C)_4(D)_5(E)_ ` INCIDENT 4OCATION JI- 'j+" RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL, �K) / i TO SCENE- �(S.O. CALL RECEIVED b ❑ P.D. TIME 10-8 ATIENT DESTINATION:- FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 ' MILEAGE: ❑ OTHER/PVT TIME 10.7 jj END TIME 10.98 �+"DbC7Clf�"=' '�'' Lam— PMD/ER START ' TIME 10-22 _ HOW CHOSEN: _._ TOTAL STANDBY TIME ?Ty, O NEAREST;-) O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT 13 OTHER J CALL BACK N: AMBULANCE,C�KFANY: PT.'AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY 13 OTHER q:;":`. PATIENT CONDITION: DRIVER !1 1 ` MT-1A_ TECHNICIAN OARAMEDIC Hx: �li�` v" DISPATCHER: ✓ G C CHIEF COMPLAINT: DRY RUN:-,;OYES 13 NO REASON FOR DRY RUN f 53 A OAIZATIO F U S USE ONLY) CLl q q A�,I I I i.PATIENT REFUSED SERVICES: (SIGN— 'tt -! MEDICAL COVERAGE. . _. ... INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N �- . PRIVATE INS. CO.: BASE RATE:- KAISER 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) CCHPMPHP N: I ( r EMERGENCY RUN: 71 MEDI-CAL N: _., CODE 2/3 OTHER: 1 OXYGEN-1 (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:-' 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) UGC) -EMPLOYER: - OCCUPATION: OTHER: ADDRESS: --CITY: -STATE* - ZIP: - "--COMMENTS:-•- - TOTAL: 00174, - -- PATIENT RECEIVED BY:X ,q..yi.frr rr•.(.. W (S�GNA1 URF) COt!TRA C(.5.7.A COUNTY ( AMBULANCE / ' PRE-110SPITAL CARE FORM, I -3., 6UNIT AUTHORIZATI N1t ( CHECK JR F1L1 W A:'� .OFRIATE SPACES DATE: s A;, PATIENT'S NAME__ D p 7t COMPANY ADDRESS AGE I_ l�h _ AGE_ �"o �. tQ! S ,CITY_��1_ — STATE_(- f / (-/ ZIP DOB s Z ❑ Sn 11 M 13 T ❑ W 13 Th• F ❑S DRIVER'S LICENSE# L`_�Ll 5�-r _7._� L I PHONE/_ J NATURE OF DISPATC TYPE OF TRANSPORT: AMBULANCE: : BOTHER❑ INCIDENT LOCATION: `0 1 RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLO/CK).- 1 e TO SCENE- .O. CALL RECEIVED P.D. . TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 VZ) -�' 7 3� ❑ PSAP TIME 10-49 E—_.. _ MILEAGEr ❑ OTHER/PVT TIME 10-7 X=_ END �( � TIME 10-98DOCTOR - ._ — PMD/ START__(;L' TIME 10-22 40,11! HOSEN: TOTAL —Z STANDBY TIME '7NEAREST ❑ FAMILY ❑ TRANSFER i WAIT TIME ) /0 PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE C ---77-) Y: PT. A%1 ULgTORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WALKED GUEP,NEY ❑ OTHER PATIENT CONDITION srt3�-,LC DRIVER 0 _ OWSC TECHNICIAN U N G PARAMEDIC Hx: LC DISPATCHER: / 'r�^ j' CHIEF C0':1PLAINT: DRY RUN: ❑ YES O 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: S.S. # � PRIVATE INS. CO.:�r_.•�� •'` ��.( � BASE RATE: ` KAISER#: — __._ MULTIPLE PTS. BASE RATE �^ BLUE CROSS M: —_ TOTAL MILES: X MEDICARE N: —E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO i 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) CHP/PPRP k: EMERGENCY RUN: 1 MEDT-CAL# _ CODE 2/3 i OTHER:—_.. _ OXYGEN: (PER TANK) c�� J �7 P.O.E. STICKER C YES XNO NEONATAL: (INCUBATOR) I DATES BILLED. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �— JJ 4// NEAREST RC-LATIVE/RESPONS!13LE PARTY: I.V.: (PER ADMIN.) X t DRUGS: (PER ADMIN.) X NAME I Z"1G U v 15 i,_4 r T RELATIONSHIPE.O.A.: (IF NOT REPLACED) — •--- ADDRESS.._ `�'��( (�_ �-7_ _ _ ORAL AIRWAY: (IF NOT REPLACED) CITY: .-1� .__ __ STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: __. _ WORK EP fQ,NE:, DRY RUN: (AUTHORIZED) \ EMPLOYER. �L= C Le %I T 1Ce-'1 T 1C OCk TIb7 r (J T OTHER: • � � ./ .. is � �..� ADDRESS: _. CITY: �' �_ �__ STATE:C ZIP: COMMENTS: TOTAL: 77, _A�PATIENT RECEIVED BY: X F'.^nu%d�•r rr t,:'. .ni•, ,xd r;..:� Rctur '2c�• copy <<•. when h�:Fi•�g '� CONTRA COSTA COUNTY AMBULANCEI PRE-HOSPITAL CARE FORM I UNIT P� AUTHORIZATION 1 73- 13 09-2 CHECK OR FILL IM APPROPRIATE SPACES 1 DATE: PATIENTS NAME�1"� O M O F COMPANY M ADDRESS AGE t CITY STATE ZIP DOB O Sn ❑ M OT ❑ W ❑ Th ❑ F OS DRIVER'S LICENSE N _ _ _ PHONE NATURE OF DISPATCH 117-9 - TYPE OF TRANSPORT: AMBULANCE[ -S.OTHER❑ E INCIDENT LOCATION: RESPONSE CODE: FIEqfJESTED BY: TIME— (24 HOUR CLO K) � Q Y7 �j25 ��� I"1 TO SCENE 3 S.O. CALL RECEIVED _S2 � _ I C —.L '`� _ ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE —_ TIME 10-97 ❑ PSAP TIME 10-49 ' MILEAGE ❑ OTHER/PVT TIME 10-7 1J END TIME 10-98 I DOCTOR PMD/ER START TIME 10-22 —L HOW CHOSEN: TOTAL STANDBY TIME I ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBUL NG MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 50 RESPONSE ZONE-q— ❑ YES ❑ NO O WAL:<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_Mf_6_0P4_(&QA1--C tl/ FIAT-IA— TECHNICIAN u(--)�� '� AHED co, Hz: DISPATCHER:- �� �fy -DL 'A19 CHIEF COMPLAINT: DRY RUN:)J YES ❑ NO REASON FOR DRY RUN I2 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#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X _ MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP A: 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) _ga PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: �— ---- — - --- TOTAL: -- ----- 001761 f AIWNT nrrr)vrn RY x _. .__.__ %:urll.rimrj- t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION M (! ,r '.. - •,,', , ` /q � CHECK OA FILL IN APPROPRIATE SPACES DATE:-_�� 'PATIENTS NAME 1 i 1 OM ❑ F COMPANY N 1 ADDRESS AGE ^ CITY STATE ,ZIP__�_ DOB ❑ Sn ❑ M ❑ T ❑ W 13Th *F 13S , 1 - DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH S-e.41 (:S TYPE OF TRANSPORT:,AMBULANCE 18 OTHER 0 STATION 1(A 2(B)_3(C)_4(0)_6(E)_ INCIDENT LOCATION: C,N RESPONSE CODE: UOUESTED BY: TIME— (24 HOUR CLO,CK) '� C 7 )5)< i, TO SCENE-rI S.O. CALL RECEIVED _L :L l ` n1 Q ; J_ ❑1 P.D. TIME 16.8 .�1�pf : .� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 T i ❑ PSAP TIME 10-49 MILEAGE OTHER/PVT TIME 10-7 ENO TIME 10-98 i.DOCTOR�_� 1 PMD/ER START TIME 16.22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST.L ❑ FAMILY ❑ TRANSFER WAIT TIME -- O PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULAN?C�NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 U RESPONSE ZONE ❑ YES ❑ NO.,.. ❑ WALKED ❑ GUERNEY ❑ OTHER 'fi f l PATIENT CONDITION: DRIVER �� r 330 TECHNICIAN Kelp-�� D PARAMEDIC Hx: DISPATCHER: ?53 C, CHIEF COMPLAINT: DRY RUN: YES In NO REASON FOR DRY RUN EerE (�✓ f Loll AUTHORIZATION FOR DRY RUN(EMS USE ONLY) L}L�� fE r=.,. PATIENT REFUSED SERVICES: (SIGNATURE)X q 15� MEDICAL COVERAGE: 1 INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.M PRIVATE INS.CO.: L BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS C 1 TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: 119:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDT-CAL C r ' 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/RESPONSISLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) r "'CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: k CITY: STATE' ZIP: ` COMMENTS: TOTAL•20 y.. 17 rry PATIENT RECEIVED BY: X Pmv(der rota(, Ait• r"f M-.: �„ (SIONArURE) . S CONTRA COSTA COUNTY AMBULANCE �l PRE-HOSPITAL CARE FORM I UNIT ' a AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE:s J - rPATNTS NAME OM OF COMPANY/�M (� ADDRESS 4.a': AGE CITYSTATEN ZIP DOB - ❑ Sn ❑ M D T 13W ❑Th CJF O S DRIVER'S LICENSE - PHONE NATURE OF DISPATCIJQ ICL o\,(cq� TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ -- STATION I(A)_2(B)_3(C)V4(D)_5(E)._ INCIDENT LOCATION:i ~~ j RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CIQGK) ��, TO SCENE- ljS.O. CALL RECEIVED (/`1 :�/(�� C �'l.�1X03 C' r , ❑ P.D. TIME 10-8 td_.0 :F-f-- PATIENT DESTINATION: FROM SCENE- / ❑ FIRE TIME 10-97 PSAP TIME 10-49 y�y� MILEAGE: ❑ OTHER/PVT TIME 10-7 W�� ✓ _ )1; END TIME 10-98 �ObCTOR `S..fl h _ I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL, STANDBY TIME 13 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: Ca-o PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE S ❑ YES, p NO _ 11 WALKED D GUERNEY ❑ OTHER ) PATIENT CONDITION:' - DRIVER A� � '�[� EMT-1A✓ Mr a i TECHNICIAN S.� � PARAMEDIC Qn Hx: DISPATCHER: -7��1 L T? C14 4� jJ " CHIEF COMPLAINT: ! DRY RUN:AYES ❑ NO REASON FOR DRY RUN�Q'a`3, 1 /�(J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `-/ '] A ..'J!Jc I PATIENT REFUSED SERVICES: (SIGNATURE) X (75 2 MEDICAL COVERAGE: i INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N .ti ! / 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 �y O YES ❑ NO NIGHT: (19:00-07:00) CCHP)PPHP N;I' ! EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: I I OXYGEN:' (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —NEAREST RELATIVE/RESPONSIBLE PARTY: '` I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X —'NAME:---' ' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) - 'CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) —EMPLOYER: `" OCCUPATION: OTHER: ADDRESS: CITY: STATE* ZIP: ~� COMMENTS:' �.._ ._ . . TOTAL: �^J Q _.___ PATIENT RECEIVED BY: X ___ 001 ! IS CONTRA COSTA COUNTY AMRUI_ANCE ,2 /- PRE-HOSPITAL CARE FORM I ! UNIT AUTHORIZATION M-._ �J }.� CHECK OR FILL IN APPROPIIIATE SPACES UZI DATE: `�� PATIENT'S NAME J )lI �" ��. n'�l11 l/ C� /r 1 I,.�._.__-_ � M � F COMPANY q-. 1 ADDRESS __—� . _.... CJ TY __t�ILILLI(t i_._'I.^'13 . STATE-.__. /�._�_ ZIP.-_. _..._ _ DOB. ❑ Sn ❑ M O T O W O Th O F ❑S '1 DRIVER'S LICENSE -. PHONE - '_ NATURE OF DISPATCH S?0Q 9o1.96f' ' 1. TYPE OF TRANSPORT. AMBULANCE ❑ OTHER❑ _ INCIDENT LOCATION / RESPONSE CODE: REOUFSTED BY: TIME- (24 HOUR CLOCK)' 1 C Y r� I Lh TO SCENE - Iq S.O. .--_. CALL RECEIVED 4 :.2 -"3/e�� ❑ P.D __ TIME 10-8 :`qz PATIENT DESTINATION: FROM SCEN�j 11 FIRE. TIME 10-97 _.0`_--_ ❑ PSAP TIME 10-49 6 , '•� c, ---K)r-HR MILEAGE , ❑ OTHERiPVT TIME 10-7 6- t END------u___� 'Q� _ TIME 10-98 DOCTOR _-_Fl-/ _.._ - _. PMD/ER START_ . ��`Ly� _ - TIME 10-22 HOW CHOSEN. TOTAL ..._._____E-_ STANDBY TIME - - ❑ NEAREST ❑ FAMILY ❑ TRANSFER / WAIT TIME YJ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COMPANY- PT.AMBULATORY'T OMPANY•PT.AMBULATORY'T PATIENT TAKEN TO AMBULANCE. v RESPONSE ZONE YES ❑ NO ❑ WW-.l':ED P GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER /��_ EMT-1A TECHNICIAN _...� f�---/ SL- PARAMEDIC 7 �• Hx: _.EAT► F15N � M< _ .I.)'-Lti-�.�1�.� f�M'�.�DISPATCHER: �s/_ I C 11>]14 O D I I, CHIEF COMPLAINT __)�'f'CA^1 .__IJAu C'90_ DRY RUN: ❑ YES V NO REASON FOR DRY RUN f l�"'/✓U_T1)�f)f�' /� C Z"11=_R. .N�y✓J UTHORIZATION FOR DRY RUN(EMS USE ONLY) I�tt/`C 3' ,- ENTTFLK l�yL��rZ�['NTI LfI TIt�� USED SER VICES (SIGNATURE) X. MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: c/,� s.s PRIVATE INS. CO.: _.__-_.__ ---_— _ BASE RATE: /J } KAISER a: ? . _�__' _=�.�-_..�__..� _ MULTIPLE PTS.BASE RATE p!)it rROSS --... --- --- - -— .-..._ TOTAL MILES:- — X .----____-._—_-_- E O B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP,'PPHP#:--.- --.__-.- ._ EMERGENCY RUN: J 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 - ' I��I DRUGS: (PER ADMIN.)_ X ( 'r NAME. LEON_CCT<<'�'/` RELATIONSHIP 5..-Ffin 4 O A (IF NOT REPLACED) ADDRESS: . G� '� /� //l . .S"i --- / a p ORAL AIRWAY: (IF NOT REPLACED) Ir CITY .. ./�(.L' �/vTE� STATE C.4—ZtP:?!#C�_'./ C-COLLAR: (IF NOT REPLACED) PHONE: -.;�3.3 '.�'_f' WORK PHONE _ q3.U-L:C3 DRY RUN: (AUTHORIZED) _, �� � EMPLOYER: N._ . ___ OCCUPATION:_ ._-__ OTH�R: _/ ADDRESS:.--- GfJ . � CITY: —_-. -_.__..__..-.__ STATE:--ZIP:,_— COMMENTS:—__. ..—__.__.__- -.- --------- --- TOTAL PATIENT RECEIVED BY:X ., r.. :•�• r.... �. - 1' r•r:.— ov �4r•., I.:I „ A QIS-T CONTRA COSTA COUNTY AMBULANCE �� ^ �-- PRE-HOSPITAL CARE FORM I `` UNIT rJ AUTHORIZATION N W CHECKOR FILL IN��A��PP��ROPRIATE SPACES DATE: PATIENT'S NAME_L4� ✓ ��itJi�/2 �- « �M ❑ F COMPANY 2 c2 ` ADDRESS � l�/'•r' T T /-�yt.. � AGE _ � CITY r'ni /�� • /J STATE ��L- ZIP D013 -2 7� OS. OAA OT,pO W O Th�F C3 S � DRIVER'S LICENSE a __-___ PHONE =-J�_ NATURE OF DISPATCH/Jy7A TYPE OF TRANSPORT: AMBULANCE OTHER❑ - STATION 1(A) 2(B)_3(C)_4(D)_5(E)_"-- INCIDENT LOCATION: I I. RESPONSE CODE R QUESTED BY: TIME- (24 HOUR CLQCK) 3 TO SCENE- O. CALL RECEIVED �� ,..� ❑ P.D. TIME 1,0-8 6 `. :7 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �� O ��� ❑ PSAP TIME 10-49 w ✓ MILEAGE: O OTHER/PVT TIME 10-7 END---- -gg�--.2 TIME JO-98 DOCTOR S Gd ��j PMiIR START- _ TIME 10-22 HOW CHOSEN: TOTAL -3 STANDBY TIME O NEAREST FAMILY ❑ TRANSFER WAIT TIME - --- O PATIENT ❑ DIRECT ❑ OTHER (,�- CALL BACK N: AMBULANCE CO PANY: f �•� i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES}MNO Cl WAL'<ED UERNEY ❑ OTHER / PATIENT CONDITION: DRIVER ���8 a 6o _ M-7 TECHNICIAN �� PARAMEDIC r% H.: .s���' Z'42 DISPATCHER: Ll( ( IL,4 0 0 `) I� CHIEF COMPLAINT: T/i2L [? DRY RUN: Cl YES AJ NO REASON FOR DRY RUN < ! Oi7/"V-> AUTHORIZATION FOR DRY RUN(EMS USE ONLY)- PATIENT NLY)PATIENT REFUSED SERVICES: (SIGNATURE) X_ _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a Q.,_.. PRIVATE INS. CO.: BASE RATE: //O,C"{ KAISER a: MULTIPLE PTS. BASE RATE ! y BLUE CROSS N: TOTAL MILES: y X A ✓ -' MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: �U G � MEDT-CAL N: CODE 2/3 _ OTHER: OXYGEN: (PER TANK) i P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) I DATE"ILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN,) X DRUGS: IPER ADMIN.) X NAME�'S'!R Z e,)e �l "RELAT10NSHIP: 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: n TOTAL: ��- PATIENT RECEIVED BY:X � �- Dlf-1 Prou{dProviderrotair Vhilr rd �. •,r,L 4r!um Y�'Ir6' ro9M. �� t " when tiii itl� (SIGNATURE) mow aCONTRA COSTA COUNTY 1 AMBULANCE 9 �. ` PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M 3 S-7 CHECK OR ML IN APPAOMAAT-E SPACES DATE: �`✓ PATIENTS NAME � "�` ` t�0( V ® AGM ❑ f COMPANY MADDRESS 1 O IC VS ! CITY JA/V PARC 6 STATE ZIP r Y� ' DOB 2+7 Y ❑ SR ❑ M ❑ T ❑ W ❑ Th F ❑ S I DRIVER'S LICENSE 0 _ __ PHONE __ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION 1(A)_2(B)-3(C)-41D),5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) c TO SCENE -/� ❑ S.O CALL RECEIVED / ' f_f ❑ P.U. TIME 10-8j PATIENT DESTINATION: FROM SCENE Z ❑ FIRE TIME 10-97 77- :-, •'i'' �L /a /� I 4 11 MILEAGE: TIME 10-49 '( 1— C MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 !eDOCTOR PMD/ER STARTTIME 10-22 HOW CHOSEN: TOTAL 4 STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER .i CALL BACK w AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1 DCYES ❑ NO ❑ WALKED IKGUERNEY 17 OTHER (:J l L n PATIENT CONDITION: DRIVER ��/ - ' EMT-tA Q TECHNICIAN S elu/v I G' !.PARAMEDIC HX: / DISPATCHER: `,1 I ��i, C 1 -,4 J CHIEF COMPLAINT: s—/ S— DRY RUN: ❑ YES 'Q NO REASON FOR DRY RUN- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ IMEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: r X j MEDICARE M: -1 G3 4/4-J;�7 /I- E O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �. CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 fY1S5- OTHER: OXYGEN: (PER TANK) a O P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) \,JATES 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' PAIIFNT RECEIVEDV X C 00181 fI�T1U�1 .,-- ' •, X30� r CONTRA COSTA COUNTY AMBULANCE . PRE-HOSPITAL CARE FORM I \ UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: ._ — 1:T PATIENT'S NAME_`L_! +��a �r', O M COMPANY N Q —� ► ADDRESS r c) 4L ll AGE •� I��J—7 CITY- J STATE CI"� ZIP_ I DDOCCB''�S ❑ Sn 0 M O T O 1N ❑ Th 0 3--I DRIVER'S LICENSE N ____� __— _ PHONE a� =�_. 7�_ NATURE OF DISPATCH 61 I(E US AXE Ci•L.A0 TYPE OF TRANSPORT: AMBULANCE THER O _ S`TATIDN 1(A) (8)-3(C)^4(D)_5(E)_L_ . r ' INCIDENT LOCATION: RESPONSE CODE: BY: TIME—(24 HOUR CLACK) tf��(� TO SCENE- O. / CALL RECEIVED — ❑ P.D. TIME 10-8 f ► •..I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49• ✓• L1 �� MILEAGE: ❑ OTHER/PVT TIME 10-7 END _�7z 9 7 TIME 10-98 �-r:ef DOCTOR k I L,T-S r PMD(jp START � S � TIME 10-22 HOW CHOSEN. TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK IN: AMBULANCE CO PANY: _ MBULATORY? PATIENT TAKEN MBULANCE: RESPONSE ZONE w IP S ONO ❑ WAL'<ED LGUE EY ❑ OTHER PATIENT CONDITION: DRIVER im EMT-1A TECHNICIAN L;�6! PARAMEDIC HK: Vqj���—.C�-� DISPATCHER: i CHIEF COMPLAINT: M V � ���' LD'RVY RUN' ❑ YES REASON FOR DRY RUN --' 6-M55 k' THOX(ZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDirAL COVERAGE: INDUSTRIAL ❑ YES NO. OF PATIENTS: e7N� '7 41VATE INS. CO.: BASE RATE: 'I ./ G•y��� KAISER N: MULTIPLE PTS, BASE RATE �� 1 BLUE CROSS N TOTAL MILES: X G •-'rU G�� MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r 5 T A`4 Ir✓C� S N ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: v' MEDI-CAL N: CODE 2/3 OTHER: _ OXYGEN: (PER TANK) ► _�,"„r P.O.E. STICKER ❑ YES NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RE IV E//RE$F NSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X I'I NAME: yr RELATIOSHIP: E.O.A.: (IF NOT REPLACED) ( I ADDRESS: `�? ePr�US �y� ORAL AIRWAY: (IF NOT REPLACED) CITY: _�LT�/ "IJ _.__ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: h -�-Z�) ( WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: --- - •- ADDRESS: CITY: STATE: ZIP:: COMMENTS: �� S !�i i F'�lu t14 1' (3v r_ HAS VQ 11�lOIV_;,� c✓ /-1 � TOTAL: /,1576 y PATIENT RECEIVED BY:X Provider re►a:e Vhite vd Pin, -;rp .5etyr+ YI i!'4' -n;,y EMS uhrn biI ing TORE) 0018r, � I I , CONTRA COSTA COUNTY r AMBULANCE PRE-HOSPITAL CARE FORM I ` < UNIT ' AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME O M ❑ F COMPANY K J } 1 ADDRESS AGE- CITY GE CITY STATE ZIP _- DOB O Sn OM OT O W ❑ Th ❑ F O S DRIVER'S LICENSE N ____—___.___ __..____. ___—_-. PHONE __. __... __... NATURE OF DISPATCH `'11 r; y TYPE OF TRANSPORT AMBULANCE O OTHER❑ __ __._._.__._. .._. STATION 1(A)_2(B)-_3(C)_4(D)_5(E)_ r Ll ��. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE - ❑S.O._ _ CALL RECEIVED �' 1 </c /C� ❑ P.U. - TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE --_ TIME 10-97 J'► -V�� - O PSAP TIME 10-49 T MILEAGE: O OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PMD/ER START_ TIME 1D-22 i c,i1 HOW CHOSEN ITOTAL - STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: l PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: Sc) RESPONSE ZONE ❑ YES ❑ NO O WAL'<ED ❑ GUERNEY ❑ OTHER . . , I PATIENT CONDITION: DRIVERLy« • • "%<< EMT-tA TECHNICIAN <<t - PARAMEDIC Hx: DISPATCHER: �z')1 EC< <� C.L_• CHIEF COMPLAINT: DRY RUN: © YES ❑ NO REASON FOR DRY RUN l�`t `' 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 R: MULTIPLE PTS. BASE RATE r BLUE CROSS TOTAL MILES:_ X - MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ONO NIGHT: (19:00-07:00) i CCHP/PPRP#: EMERGENCY RUN: % MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O 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) �l PHONE: W RK PHONE: DRY RUN: (AUTHORIZED) — EMPLOYER: CCUPATION: OTHER: 1 ADDRESS: CITY: STATE: ZIP: COMMENTS: _— -----------. TOTAL: -------------- Q PATIENT NI:Cf IVCD By X __ _lt ONTRA COSTA COUNT AMBULAN E `Q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#X31 30 ; = t" CHECK OR FILL IN APPROPRIATE SPACES DATE: 3 PATIENTS NAME T �,,/�/Gyl^K.�2- ❑ M F COMPANY k ADORE LQ1. _� d ` AG -1 '2 I CITY STATE ZIP_ DOB__ -_ L ❑ Sn ❑ M ❑ T ❑.W ❑ Th ❑ FS DRIVER'S LICENSE M __ PHONE `��! NATURE OF DISPATCHSQ J'�ufi 0 - TYPE OF TRANSPORT: AMBULANCEit<OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME• (24 HOUR CLOCK) TO SCENE- kS.O. CALL RECEIVED `� 3 CD -? ❑ P.U. TIME 10-8 'PATIENT DESTINATION: T FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 �� :l1✓_ rr END TIME 10-98 -12aa4L -,--DOCTOR , ' / PM01(ER 1 START_J - TIME 10-22 HOW CHOSEN: \J TOTAL STANDBY TIME -y.., ❑ NEAREST-, ❑ FAMILY ❑ TRANSFER WAIT TIME —� 7 PATIENT ❑ DIRECT ❑ OTHER / CALL BACK s AMBULANCEC PANY: PT. AMBU TORY? PATIENT TAK�GUERNEY TO AMBULANCE: RESPONSE ZONET- ❑ YESNO ❑ WALKED ❑ OTHER ' PATIENT CONDITION: �fl R�_ DRIVER _ U EMT-'IA _ �I ( TECHNICIAN _ 0 PARAMEDIC — Hx: DISPATCHER: /vv 6/c, �Q So CHIEF COMPLAINT: DRY RUN: ❑ YES �51(NO REASON FOR DRY RUN `1�b 4 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) D j. .PATIENT REFUSED SERVICES: (SIGNATURE)X_ `?5� s MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S. 'II P VATE INS. CO.: BASE RATE: ��' KA SER#: – MULTIPLE PTS. BASE RATE BL E CROSS N: TOTAL MILES: X ICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) j CCHP/PPRP 0 • 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 y�1 DRUGS: (PER ADMIN.)_ X ° NAME: RELATIONSHIP: E.O A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACEi CITY: STATE_ ZIP: C-COLLAR:. (IF NOT REPLACED),, PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �CJL EMPLOYER: OCCUPATION: OTHER: t ADDRESS: -CITY- STATE: ZIP '--COMMENTS:- //_ - .._. TOTAL: �d 4� G✓ .- -- PATIENT NECFIVFD IIY X .: } r tib'+ +M Ir 7''� i�' CONTRA COSTA COUNTY AMBULANCE �ncr , ,� C►# ' PRE-HOSPITAL CARE FORM I UNIT ® AUTHOR1ZATIO CHECK OR FILL IN APPROPRIATE SPACES DATE- PATIENT'S N E � _ _ �► !9 ❑ F COMPANY#losaw / ADORES AG//E 6 D � J, CITY STATE ZIP DOg�/ ❑ Sn ❑ M O IT,O W 0 Th.10% F 0-g_'1 DRIVER'S LICENSE# _ PHONE _ NATURE OF DISPATCH �.....�J TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ I STATION 1(A)_2(B)-_3(C)_4(D)_5(E)�+r`- INCIDENT LOCATION: RESPONSE CODE E UESTED BY: TIME-(24 HOUR CL CK) TO SCENE- S.O. CALL.RECEIVED ^�.,, f J / ❑ P.U. TIME 10-8 I T_ PATIENT DESTINATION: FROM SCENE-� ❑.FIRE TIME 10-97 t�P".) ❑ PSAP `TIME 10 49' MILEAGE O OTHER/PVT TIME 10-7 ; END ' TIME'10-984 rr DOCTORc PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME' Tom. ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULAN NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE Z NE ❑ YES ❑ NO' ❑ WALKED d GUERNEY ❑ OTHER � PATIENT CONDITION: DRIVER EMT-1! _ i TECHNICIA / / DIC Hx: . DISPATCHER: Lam) L?Z AVy ( ( CHIEF COMPLAINT: DRY RUN: ❑ YES -)d NO REASON FOR DRY RUN / !r� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO,OF PATIENTS: %7 S.S. # ten,., PRIVATE INS. CO.:L' • �J<'i' •� �-� ,,P L ��s BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS TOTAL MILES: X MEDICARE#: �� =' G , / "� E.O.B. ATT. POUND TRIP: O YES 13 NO �1 ❑ YES ❑ NO NIGHT: (19:00=07:00) 1Ut , CCHP/PPRP#: EMERGENCY RUN: `��• - MEDI-CAL#: CODE 2/3 OTHER: OXYGEN:' (PER TANK) t ;T 1. � _s- -•- + C{ ' J P.O } 1 .E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES'PILLED: STANDBY: (OVER 15 MIN.) 0-1 .. EPISODE) _ E K.G• (PER 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: Al TOTAL: L1y '0O BSc PATIENT RECEIVED BY:X 00185 r. ... . I¢IlNATI)gF1 IT CONTRA COSTA COUNTY AMBUL N E X31312 7IN E-HOSPITAL CARE FORM I UNIT AUTHORIZATION K CHECK OR APPROPRIATEE SPACES DATE: ~ ' PATIENTS NAME�)N ) 1 I �" C IY� ` O.M WF COMPANY N �J�� } I ADDRESS 17050�050 / ���7Y- AGE__L_l1� CITY ' 'n�L� STATE ZIP-1.�<<<�. DOB—�^I D -6(0 Sn ❑ M OT OW ❑ Th OF S DRIVER'S LICENSE N _ PHONE __LYL1 5 ATURE OF DISPATCH I'1 TYPE OF TRANSPORT: AMBULANCE OTHER❑ _--.__ STATION 1(A) 2(B)_3(C)_4(D)_ (E)_ `< INCIDENT LOCATION: ,; RESPONSE CODE: RUESTED BY. TIME- (24 HOUR C4OCK) (� TO SCENE- S-0.--__ CALL RECEIVED ` ��� 61dt. V -L�- -�_ O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: Cl OTHER/PVT TIME 10-7 1� END �' TIME 10-98 _ :J' DOCTOR PMD ER START�'y�� TIME 10-22 HOW CHOSEN: TOTAL ' L STANDBY TIME .. NEAREST ❑.FAMILY ❑ TRANSFER ' WAIT TIME ,- PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE.COMPANY: EC] AMB LA DRY? PATIENT TAKEN TO AMBULANCE: �. RESPONSE ZONEYES 10 ❑ WAL'<ED GUERNEY ❑ OTHER PATIENT CONDITION: (-,0-,S_T__t')L4L_4: DRIVER 1-rL6Y411-gl,Y,1 _T_ EMT-1A TECHNICIAN 1tiS ^I PARAMEDIC Hx: �-I�L-- DISPATCHER: I ' CHIEF COMPLA NT: /f OL _ DRY RUN: ❑ YES NO . REASON FOR DRY RUN l' I AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X. r MEDICAL,COVERAGE: I NYUSTRIAL ❑ YES1 NO NO. OF PATIENTS: S.S.« ''7- l�(a r y��� PRIVATE INS.'CO.: BASE RATE: I / KAISER K: MULTIPLE PTS. BASE RATE \. BLUE CROSS M. 2 �`i�/i•/�J:> .� TOTAL MILES: '`� X MED[ ARE C y E.O B' . ATT. ROUND TRIP: ❑ YES ONO ❑ YES ONO NIGHT: (19:00-07:00) �I ( 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/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: At - — ---- - ----- TOTAL: Sy.�d 001.86 PATIENT RE•CEIVFD BY. X - . Provider roto:r. Vhi (SIGNATURE) t e ,.n/ /•:r. ,.,� w I. •,i. . 4 4r .'I'. i y.. IMS I i CONTRA COSTA COUNTY AMBULANCE PRE HOSPITAL CARE FORM I UNIT © AUTHORIZATIO p..3 .' W r•: 17 w CHECK ON FILL IN APekOPRIATE SPACES DATE: �� - I IENTS NAME ❑ M ❑ F COMPANY N ADDRESS- AGE ale ` w i CITY t STATE_ ZIP DOB -❑ Sn ❑ M O T Ow O Th OF OS DRIVER'S LICENSE N PHONE �_,^ NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ — STATION 1(A)._2(B)_3(C)-4(D)_5(E)_ INCIDENT LOCATION:♦ `l S+, RESPONS�"CODE REcAjtoTED BY: TIME—(24 HOUR CLOCK) _3 re TO SCENE- S.O. CALL RECEIVED 5 IC ❑ 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 c DOCTOR`.' ! PMD/ER START TIME 10-22 HOW CHOSEN: - TOTAL STANDBY TIME aTiw❑,NEAREST ,R ❑ FAMILY ❑ TRANSFER , WAIT TIME . 1 13PATIENT O DIRECT 11OTHER CALL BACK N: AMBULANCE COMPANY{-Pq I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S0 RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER'- A PATIENT CONDITION: I DRIVER � EMT-1A r TECHNICIAN �' PARAMEDIC Hx: DISPATCH '�(�(� CHIEF COMPLAINT: ' DRY RUN: > S ❑'NO REASON FOR DRY RUN. —2- / 7 AUTHO ATION FOR DRY,RUN(EMS USE ONLY) / 99 ! .I'r:.;PATIENT REFUSED SERVICES: (SIGNATURE) X / 1 MEDICAL COVER E: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: I �+ S.S. N c 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 .O NO NIGHT:(19:00-07:00) CCHP/PPHF N: r ! 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: w ---- --_ TOTAL: �G: � __ 18'l PATIENT RECEIVED BY. I . II '� CONTRA COSTA COUNTY AMBUUL-,ANNCCE-, PRE-HOSPITAL CARE FORM i UNIT I I��Z I AUTHORIZATION N 1 _7 � CHECK OR FILO INAPPROPRIATE SPACES � DATE: S' ( / PATIENT'S NAMEt11Yl�; p(1 M ❑ COMPANY q L •\ l ADDRESS cu 1"L. HJTlCl�n AGE ��7.5 C• v CITY 12\lC A r__v .j2 STATE` �__ ZIP_ DOB_'"J� �-5 ❑ Sn ❑ M ❑T O W O Th 0 F DRIVER'S LICENSE# ____ — PHONE — NA RE OF DISPATCH— TYPE ISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ — STATION 1(A) 2(B)_3(C)_4(D)_5(E)_I I C� 1 4a'� /��ll t INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLO TO SCENE- S.0. CALL RECEIVED 3 '_�"Q— ❑ P.D.' TIME 10- PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 f77 14 S i^ ❑ PSAP TIME 10-49 MILEAG ❑ OTHERiPVT TIME 10-7 1' END TIME 10-98 DOCTORL. PM /ER START TIME 10-22 j HOW CHOSEN: TOTAL I J STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME t PATIENT ❑ DIRECT . ❑ OTHER r� CALL BACK k: AMBULANf,1WMPANY: PT AMBUL TORY? PATIENT TAqEN'TO AMBULANCE: --� RESPONSE ZONE ' ❑ YES NO ❑ WAL'<ED G UERNEY ❑ OTHER ( PATIENT CONDITION:S- DRIVER c ON EMT-IA ' TECHNICIAN ��� PARAMEDIC Hx: _}".��QXun,.n=el_"_I) 0_Lb�=� DISPATCHER: CHIEF C_O_MPLAIIIN 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. # 1 PRIVATE INS. CO.: BASE RATE: ' KAISER a: MULTIPLE PTS. BASE RATE _ I BLUE CROSS#: TOTAL MILES: X _�) MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �� f CCHP/PPHP a: 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.) I E.K.G.: (PER EPISODE) i : l NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: hl - L 1'� RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE �S DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY.: STATE: ZIP:— COMM ENTS' IP:COMMENTS: l 1 '7/73(t71J TOTAL:—, —r✓�� _._ PATIENT RECEIVED BY:X Pn7uidrr mai. whit, �:. . ., (SIGNATURE) ds I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 83 1314 h t CHECK OR fill IN APPROPRIATE SPACES DATE: I PATIENTS 1NA I t ` OM 'OF COMPANY N ADDRESS;" „' AGEAJ v CITY STATE ZIP DOB—DOB ❑ Sn OM OT ❑ W O Th OF DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:, AMBULANCE OTHER 0 ___ STATION i(A)_2(B)-3(C)_4(D)-51E)_ INCIDENT LOCATIOWI }= RESPONSE CODE! R UESTED BY: TIME-- (24 HOUR CLOCK) �. ek /_i Z C 7+ t l TO SCENE- r O. CALL RECEIVED -7�I— J 1 i I ❑ P.D. TIME 10-8 ,/ Io-- PATIENT DESTINATION: ) FROM SCENE- ❑ FIRE TIME 10-97 � D � ❑ PSAP TIME 10-49 (/ (�'•��Iy-Z"1' �� `��' A1 MILEAGE: ❑ OTHER/PVT TIME 10-7 11 END TIME 10-98 / DOCTOR' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEARESTi ❑ FAMILY ❑ TRANSFER WAIT TIME —� O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AM(B,INCE COMPANY: + PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: r RESPONSE ZONE T �.. YES .❑ NO ❑ WAL KED ❑ GUERNEY ❑ OTHER 'V PATIENT CONDITION. p DRIVER I ' 1A (��1�� EMT-1A R u3�pL TECHNICIAN (,_`(N EN ' PARAMEDIC ��,( Hx: I r7`Z.L DISPATCH R: -hu Co-C, ck>y y CHIEF COMPLAINT: PRY RUN: YES ❑ NO REASON FOR DRY RUN A H I I N F DRY U ( M$USE ONLY) ::.; PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE!. INDUSTRIAL ❑Y-S D NO NO. OF PATIENTS: ✓''� S.S.0 PRIVATE INS.CO.: BASE RATE: KAISER R: I MULTIPLE PTS. BASE RAT r BLUE CROSS 0: TOTAL MILES: X /� MEDICARE M: E.O.B.ATT. ROUND TRIP: YES 13 NO / O YES .❑ NO NIGHT: -07:00) CCHP/PPRP N:' I EM ENCY RUN: MEDI-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) . K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I. (PER ADMIN.) X RU (PER ADMIN.) X NAME: ELATIONSHIP: Eb,A.: ( NOT REPLACED) ADDRESS: ORAL:AIR Y: (IF NOT REPLACED) CITY: STATE ZIP: C-COLLAR: (I NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHpRIZED) EMPLOYER: OCCUPATION: OTHER: \\ ADDRESS: CITY: STATE: ZIP: COMMENTS: - TOTAL: zI .. 011-8 PATIENT RECEIVED BY:X.. k CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE F RNS i UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME orl\6(Dri_Z O M It F COMPANY ADDRESS a,\ 0S\t�nSK�? C�— AGE R q CITYC,�k mz) STATEGa . ZIP D082\ t O Sn OM ❑ T O W 0 Th OF g S DRIVER'S LICENSE N PHONE —_--- NATURE OF DISPATCHMF I>\CQ.\ TYPE OF TRANSPORT AMBULANCER OTHER O _— _—_ __—_ .- STATION 1IA),_2(8)_3(C) 4(D)_5(E)_. INCIDENT LOCATION:; RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)C! T TO SCENE- YY S.O. CALL RECEIVED �_ C �_ O P D TIME 10-8 PATIENT DESTItVA ON: FROM SCENE- O FIRE TIME 10 97 _ I _ � .L 4 / � Cl❑ PSAP TIME 10-49 t •l� lLr1i1L1 / I MILEAGE O OTHER/PVT TIME 10-7 /`/ END— r TIME 10-98 DOCTOR _ PM ER START'�� TIME 10-22 HOW CHOEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME IX PATIENT ❑ DIRECT O OTHER CALLBACK#: AMBULANCE COMPANY: C/ z) PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: , RESPONSE ZONE r ❑ YES 'Z NO ❑ WALKED XGUERNEY O OTHER J t.PATIENT CONDITION: DRIVER Mc,,L I (� TECHNICIAN L� `�C PARAMEDIC Hx: i;hLx� DISPATCHER: )CICN�L• (.C. '� CHIEF COMPLAINT (moi( c`nr1 Y_ >> DRY RUN: DYES %NO REASON FOR DRY RUN 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_S-)rl n\ S PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE r UE CROS _ r)R (�k �_^L `� TOTAL MILES: X r) r) E.O.B. ATT. ROUND TRIP: O YES ❑ NO OYES ONO NIGHT: (19:00-07:00) /. CCHP/PPRP#: EMERGENCY RUN: �. MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) l� P.O.E. STICKER ❑ YES O 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: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP:_ C-COLLAR: (!F NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: - 0 PATIENT RECEIVED BY. X IINATURE) - 1'rvv:!ur stair, 41uco m! !y ,; ,pp ,,:rw .q•• err :..h,r'l t: 00190 [ns-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: ` v PATIENT'S NAME O M ❑ F COMPANY N ADDRESS AGE I CITY STATE.,_ ZIP DOB O Sn OM ❑ T OW O Th ❑ F DRIVER'S LICENSE M ( PHONE NATURE OF DISPATCH . A A TYPE OF TRANSPORT:, AMBULANCE D OTHER O — STATION 1(A)_2(6)_3(CI_4(D)._5(E)_ . INCIDENT LOCATION' t L/ '1+a' RESPONSE CODE' RE UESTED BY: TIME— (24 HOUR C `OCK) �(/ L - 1��Tte ti TO SCENE- O. CALL RECEIVED [� P.D. TIME 10-8 t7 t v PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 { { } ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 lYYYYY��'_ END TIME 10-98 ,-,�-- "DOCTOR! r~ I PMD/ERI START TIME 10 22 :U D HOW CHOSEN: TOTAL STANDBY TIME -Y ❑ NEAREST. : O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT I O DIRECT ❑ OTHER CALL BACK M: AMBULANCCOMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' O YES ONO O WALKED O GUERNEY O OTHER PATIENT CONDITION: - DRIVER EMT-1A I fa �, A, TECHNICIAN r- �> 0 P ARAMEDIC t z Hx: U" ZZ i t LJ`���-1 1J� L v=,r DISPATCHER: _c L-c-- `� CHIEF COMPLAINT: DRY RUN: ES O NO REASON FOR DRY RUN tlq 7 I AUTHORIZ#fibN FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X , MEDICAL COVERAGE: . INDUSTRIAL O YES ❑ NOO. OF PATIENTS: S.S. M I PRIVATE INS. CO.: I BASE RATE:- KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS 0: �' TOTAL MILES: Y MEDICARE M:' E.O.B. ATT. ROUND TRIP:' O YES 13NO 13YES -O N NIGHT: (19:00-07:00) CCHP/PPRP#. I EMERGENCY RUN: ( MEDI-CAL k: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES 1:1NO 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: STATE_�ZI C-COLLAR: ( N TREPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE• ZIP: COMMENTS: TOTAL: ��v 0019 PATIENT RECEIVED BY: X Pn,niil�r' rvtnfv V6lre ,-.I pi .. (SMNAT(InE) . CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATI N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY 0 G1 J /24" ADDRESS 1 AGE �� L) N CITY STATE ZIP�_ DOB ❑ Sn ❑ M OT O WC3 Th 13F VS - DRIVER'S LICENSE N _ PHONE _ NATURE OF DISPATCHAIAA/ %6dc'`inJf TYPE OF TRANSPORT: AMBULANCE 1) OTHER 0 _ -- STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ ~ INCIDENT LOCATION:' 1 ' RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) `L I, �,' TO SCENE- O. CALL RECEIVED W /�l &j 3- O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ��, „ ^ 13PSAP TIME 10-49 tj CiC1-� MILEAGE: ❑ OTHER/PVT TIME 10.7 ` END TIME 10.98 D ' OCTOR t PMD/ER STARTME 1"2 t ?• :_. HOW CHOSEN: TOTAL STANDBY TIME O NEAREST_ O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY,^^ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE ZONE 7�. ❑ YES ❑ NO, ❑ WALKED ❑ GUERNEY ❑ OTHER J PATIENT CONDITION: DRIVER �-L- '"-C-4-1 EMT-IA TECHNICIAN UT L� �'' ~ PARAMEDIC Hz: DISPATCHE�RR: J r ( 4 ) F I CHIEF COMPLAINT: L- Ic DRY RUN: e"YES ❑ NO REASON FOR DRY RUN/y LL �c N koVl'(� j AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ! I PATIENT REFUSED SERVICES: (SIGNATURE) X Lj /-- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: f S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: O YES ❑ NO t O 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) ,^,1 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) � •C�1 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: � e7C0 _. O PATIENT RECEIVFD BY.X . CON I IIA COSTA COLIN I Y AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 O CHECK OR f/l1 IN APPROPRIATE SPACES DATE: 'Ctc7; A(M ❑ F COMPANY It PATIENT'S NAME /LL%1t. ADDRESS(tZ 2 I C /LC 9`2 �? AGc). 7 J t�.....,, CITY STATE ZIP1 D�O7B Sn 13 M 0•T. O W 0 Th_.13 IF DRIVER'S LICENSE a __.__—_ —__ PHONE �`2 e;fNATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEOTHER❑ __ _ STATION 1(A)_2(B)-_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,1f - �� TO SCENE-2 �6-S.O. CALL RECEIVED ❑ P.D. TIME 10-8 Q�-37-:7:�i PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 /L' ❑ PSAP TIME 10-49 l; MILEAGE: 00 THER/PVT TIME 10-7 END TIME 1"8,r DOCTOR C�� « PMD(E) STAR TIME 10-22 .- HOW CHOSEN: TOTAL —L STANDBY TIME ---1 ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0- AMBULANCE COMP/,JJY: i f J . PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 2 -1 ❑ YES t�rNO ❑ WAL',ED WGUERNEY ❑ OTHER - PATIENT CONDITION: DRIVER dw��F� `,/ /� F/M t6� TECHNICIAN ,4"11)4,tw• i f PARAMEDIC e ( / Hx: DISPATCHER: I } CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR RY RUN(EMS USE ONLY) - PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 'S l S.S. 4 PRIVATE INS. CO.: BASE RATE: ..l C` . KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSS It: TOTAL MILES: / X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP K: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) vd- S ,J�^ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'V) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X E/may"' 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 c�L Pr�uider reta:n whit,, rrd �'i..: (SIGN TU ®0-1 s!) ps-I COp� .4Bt Lr+' Ye'2w ^(7,7Y r !KS uAtn timing �J CONTRA COSTA COUNTY AM�NCE� PRE-HOSPITAL CARE FORM I UNiI'I / f AUTHORIZATION N CHECK ON fill IN APPROPRIATE SPACES DATE: `'- �10) _Z1 ij PATIENTS NA ❑ M ❑ F COMPANY N ADDRESS ' = AGE CITY TATE ZIP DOB �'Sn OM ❑ T ❑ W ❑Th ❑ F ❑S DRIVER'S LICENSE N - PHONE �� NATURE OF DISPATCHJ'�eCl I L P94 TYPE OF TRANSPORT: AMBULANCE 121 OTHER❑ _ STATION 1(A)_2(B)_3(C)-4(D)_5(E), INCIDENT LOCATION:l- 4c ! RESPO�JSE CODE: QUESTED BY: TIME— (24 HOUR CL K) / TO SCENE-2 RS.O. CALL RECEIVED :L._.__ ❑ P.D. TIME 10-8 . _. _J-f — PATIENT DESTINATION: .. . 1 FROM SCENE- ❑ FIRE TIME 10-97 , ❑ PSAP TIME 10-49 : � I j •, 1 MIL EA ❑ OTHER/PVT TIME 10-7 - • END TIME 10-98 ':DOGTOR.'` T r ( I PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME �► : .O NEAREST.'; FAMILY O TRANSFER WAIT TIME —_ O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE CC NANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: v RESPONSE ZONE ❑ YES .❑ NO ❑ WALKED Cl GUERNEY ❑ OTHER 2L / ) .•4 r PATIENT CONDITION:, `( DRIVERT! /`' EMT-lA TECHNICIAN PARAMEDIC Hx: DISPATCHER: /Nyvv CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORI TION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: - BASE RAPE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X t 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: 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: - STATEN ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X !ti- !i� r.•, pl. .• (SIGNAYURE) - Y'7 CONTRA COSTA COUNTY AMBULANCE � PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: -7, 7 A?j ._ PATIENTS NAME� �t/�-L' L�M ❑ COMPANY N �ADDRE I- - - -'� _. .. r_ ' /- AGE CIT U X% STATE_ ZIP_ DOB _� Sn ❑ M O T O W O Th: ❑ F O s_ DRIVER'S LICENSE p __ —_ PHONE _� NATURE OF DISPATCH '�� - TYPE OF TRANSPORT: AMBULANCE OTHER O STATION 11A1_2I81_3(C)_4(D)_5(E)_�--- INCIDENT LO ATION: � RESPONSE CODE: REE UESTED BY: TIME— (24 HOUR CLOCK) 6 � j TO SCENE- S.O. CALL RECEIVED 56 b J _ O P.D. TIME 10`8 �� t PATIENT DESTINAT N: FROM SCENE OFIRE TIME 10-97 / ❑ PSAP TIME 10-49,- .. MILEAGE: ❑ OTHER/PVT TIME 10`7 : /A P)117 �� END 1. 2- TIME 10-98 �: DOCTOR 1L PMDyER/ START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 1 13y v NEAREST l7 FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER ) CALL BACK M: AMBULANCE COMPA �/J LJf4�•- _I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES X NO ❑ WAL",ED IR(GUERNEY Cl OTHER _ PATIENT CONDITION: DRIVER jf d V �-50 EMT-1A ) 71 I j� TECHNICIAN () PARAMEDIC ' Hx: _ ^ - �r 'c'�t-G� .Lf yl'?' it/ DISPATCHER: 91-7 ' I ) (' I CHI COMPLAINT: %'!� DRY RUN: O YES NO REASON FOR DRY RUN !y 22 lit ��-' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MED151L COVE A-G ` INDUS IALC YES I`NO NO. OF PATIENTS: S.S.�_ V 6 a �'y ` '� ���•/ i ( PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE / BLUE CROSS M: TOTAL MILES: X s2_.1_ Z✓?� MEDICARE p: E.O.B. ATT. ROUND TRIP: OYES 0 NOil I ❑ YES ❑ NO NIGHT: (19:00-07:00) fI CCHP/PPRP a: EMERGENCY RUN: -�U•4J�� MEDT-CAL�'� CODE 2/3 tT OXYGEN: (PER TANK) P.O.E. STICKER O YES 41NO 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 IONS I E.O.A.: (IF NOT REPLACED) ADORES ORAL AIRWAY: (IF NOT REPLACED) CITY: l STAT ZIP: C COLLAR: (IF NOT REPLACED) - PHONE: .2�/ 7 3 b WORK PHONE: DAY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: % ADDRESS: -' �� "�' / CITY: STATE:-ZIP, - -... ._.. . COMM TS:- } " I/i-!'r.;�,[�-Ci►` I TOTAL: . ,S gul. PATIENT RECEIVED BY: I Provider rets-n White vd Pia: vr� ON' when bii'i (SIGNATURE) Dis-1 CONTRA COSTA COUNTY AMBU NCE 00 PRE-�HOSPITAL CARE FORM I UNIT " AUTHORIZATION AJ. - �. • CHECK OR FILL IN APPROPRIATE SPACES DATE- PATIENTS NAM L ❑ M O F COMPANY N ADDRESS AGE ' CITY 7STATE kA ZI DOB / Sn ❑ M ❑ T ❑ W O ThgP F ❑S DRIVER'S LICENSE N I PHONE NATURE OF DISPATCH ��� �`'c `"h( A TYPE OF TRANSPORT:. AMBULANC OTHER❑ _ STATION 1(A�2(8)_3(C)_4(D)_5(E)_ CIDENT LOCAT O :r i RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ` C 1/ '? _ TO SCENE- S.O. CALL RECEIVED /-I : 14 t -AAAr• r O P,D. TIME 10-8 /:-2 :LL-2 PATIENT ESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 lb i , ef��,',, _� A I� ❑ PSAP TIME 10-49 ► 'o ►'. ' /�� IBJ MILEAGE: ❑ OTHER/PVT TIME 10-7 r END TIME 10-98 DOCTOR"'` ! PMD/ER START TIME 10-22 HOW CHOSEN: _ _ . TOTAL STANDBY TIME `�•: ❑ NEAREST 'Ly• ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRE ❑ OTHER CALL BACK N: AMBULANCE CO A Y, (u-. ) PT. AMBULATORY? PATIENT AKEN TO AMBULANCE: J RESPONSE ZONE 13YES 1:1NO ❑ WALK ❑ GUERNEY ❑ OTHER" PATIENT CONDITION; DRIVER 1 1)/EMT-tA TECHNICIA / rn PARAMEDIC Hz: DISPATCHER: 3 0 CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUT IZATION FOR DRY RUN(EMS USE ONLY) PATIENT FUSED SERVICES: (SIGNATURE) X ' r MEDICAL COV RAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N 5/ t PRIVATE S.CO.: BASE RATE: KAISER N. MULTIPLE PTS. BASE RATE ; BLUE CROS ' " TOTAL MILES: MEDICARE N:: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#:a EMERGENCY RUN: MEDT-CAL N: i CODE 2/3 OTHER: OXYGEN% (PER TANK) P.O.E. STICKER ❑ YES ❑ N l NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MI E.K.G.: (PER EPISO ) NEAREST RELATIVE/RESPON IBLE 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: IP:-COMMENTS: TOTAL: PATIFNT RFCEIVED BY X_ on L.�.� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N X3 CHECK ON/ILL IN APMOPRIATE SPACES DATE: PATIENT'S NAME / 13M . O F COMPANY 8 CA ADDRESS / AGE _ CITY STATE ZIP DOB �Sn OM OT ❑ W O Th O F O S DRIVER'S LICENSE 0 PHONE _ NATURE OF DISPATCH �=L) TYPE OF TRANSPORT:.AMBULANCE OTH _ STATION 1(A)_-2(8)_3(C)_4(D)._5(E)-_ INCIDENT LOCATION:. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 'p Q ,, TO SCENE- m-.O. CALL RECEIVED Y �i�/;�M /O P.D. TIME 14.8 _L.Z–: PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 /� r� •,"/�%�1�' MILEAGE: C3OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR '_L' I PMD/ER START HOW CHOSEN: TOTAL STANDBY TIME 71 O NEAREST' O FAMILY O TRANSFER WAIT TIME _— ❑ PATIENT . ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: n� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c_} RESPONSE ZONE ,..�.T O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER�� C-C 7 L\ EMT-IA , [[[ TECHNICIAN �G u 1 PARAMEDIC � �— Hx: DISPATCHER: V1r i L l L' CHIEF COMPLAINT. DRY RUN: YES ONO REASON FOR DRY RUN 10-1-1 G U A AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X tci✓,, I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 Lf( PRIVATE INS.CO.: BASE RATE: t KAISER C MULTIPLE PTS.BASE RATE ` BLUE CROSS N: TOTAL MILES: X MEDICARE C _ E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C, EMERGENCY RUN: MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (.OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) 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: /y 1 STATE: ZIP: t COMMENTS:C,4,& CI f_�-� C,,to 14 TOTALt--<7' '-' PATIENT RECEIVED BY: X.- Pv•nl,lar r+[.i/� Vln f• i. l /•int •q•� kil— Y.. ,,. ....Lr 1 /7r• ,,:6on 141 in,/ (SIGNATURE) CRS-1 \ CONTRA COSTA COUNTY AMBULANCE _ /RE-HOSPITAL CARE FORM I UNIT (-'7 AUTHORIZATI N 113 x3CHECK OR i1Ll IN APPROPRIATE SPACES IBJ( DATE: 7 . PATIENT'S NAME'.j OM ❑ F COMPANY N 12 ADDRESS A AG ._,___- C E` CITY S ATEZIP DOB Sn OM OT ❑W O Th ❑ F OS DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH.j_Q ' l - TYPEOFTRANSPORT:; AMBULANCEK OTHER 0 — STATION 11A1_2(B)_3(C) 41D1_5(E)_ . � (NCIDENT;tOCATIONir~ I RESPONSE CODE: RE ESTED BY: TIME- (24 HOUR CLOCK) 7 O - ` TO SCENE- 0. CALL RECEIVED142- —'`Z/ y•� rp.D. TIME 10-8 LZ PATIENT DESTINATION: -• FROM SCENE- ❑ FIRE TIME 10-97 - 1 ❑ PSAP . TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 .I END T TIME 10-98 R DOCTOR .' Y' _ PMDlER START TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME O NEARESTr ❑ FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPA _., PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 50 RESPONSE ZONE ❑ YES ,❑ NO 1 ❑ WALKED O GUERNEY ❑ OTHER PATIENT CONDITION:— � DRIVER � l �L) EMT-1A l� .. .11 : _' " TECHNICIAN ( V PARAMEDIC CHIEF COMPLAINT: -'k DRY RUN: 1 'YES NO REASON FOR DRY RUNI-Q' 0 1Q --AUT.H4AIZATION FOR DRY RUN(EMS USE ONLY)— ',I NLY)5!•1.l ;i :PATIENT REFUSED SERVICES: (SIGNATURE) X T� MEDICAL COVERAGE:.. _ INDUSTRIAL ❑ YES ❑ NO NO!OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: - KAISER U: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROPND TRIP: ❑ YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/FSPHP N() ' 1 EMERGENCY RUN: MEDT-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: ` "" ' - " 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: "COMMENTS: 'L TOTAL- - OTAL ((�� QQ - - _. PATIENT RECEIVED BY: X ._ -.----0010.� � For+ Air Iyt..I• Nei , ,•I P,'-' o... .. IRInNAi upF) i . i PATIENT'S NAME: Crockett Fire Department i ADDRESS: 746 Loring Aye- . f Crockett., Ca i • DATE OF SERVICE: AUTHORIZATION NUMBER:p.3 13919 ;y AMOUNT DUE: 540.00 INCIDENT LOCATION: 20 Command Post ( Standby ) PATIENT DESTINATION: Stand By ( No pick up I i I I I•4 ''�, CONTRA COSTA COUNTY AMBULANCE 83_ 6 PRE-HOSPITAL CARE FORM I UNIT n AUTHORIZATION N hr CH ?Lzy CHECK OR FILL IN APPROPRIATE SPACES f DATE: , LC PATIENTS NAME +�(��u` 16��ff ,, � ❑ M ❑ F COMPANY N ' ADDRESS. AGE " CITY " STATE ZIP DOB _ ❑ Sn ❑ M ❑ T ,<W ❑ Th D F ❑ S DRIVER'S LICENSE N 1 PHONE _�—_— NATURE OF DISPATCH vow TYPE OF TRANSPORT: AMBULANCE D OTHER❑ INCIDENT LOCATION:"' j RESPONSE CODE: REQUESTED BY: TIME— (24 HOURUCK, �'.D(Yp� ��}_ .Z TO SCENE- S.O. CALL RECEIVEDc8C T)�"' � + � D p.U. TIME 10-8wl V PATIENT DESTINATION: FROG 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 :2 L HOW CHOSEN: ( TOTAL STANDBY TIME D NEAREST' :❑`FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT D DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANx: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE__J OYES D NO ❑ WALKED ❑ GUERNEY D OTHER J PATIENT CONDITION: DRIVER �Z '} '160 EMT-1A TECHNICIAN - 5"10 PARAMEDIC x Hx: R-- DISPATCHE �-�- �-� '^ ' OD CHIEF COMPLAINT: 1�Z-Z _�—N DRY RU . YES NO REASON FOR DRY RUN I AUTHOR. FOR DRY RUN(EMS USE ONLY) KFW PATIENT REFUSED SERVICES:(SIGNATURE) X 75v1 MEDICA OVERAGE:1 I INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE 1 BLUE CROSS N: TOTAL MILES: MEDICARE N: ' E.O.B. ATT, ROUND TRIP: ❑ YES ❑ NO �: ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP it: 1- EMERGENCY RU - MEDT-CAL N: COD /3 OTHER: Y (PER TANK) P.O.E. STICKER O YES D NO EO L: (INCUBATOR) I DATES BILLED: STANDBY: R 15 MIN.) E.K.G.: (PER EPIS NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: ELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY- STATE_-ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: OMMENTS: �-�j TOTAL'.`:..3�C��./_- - -- 00201 ( ' PATIFNT RECEIVFD RY X -- CONTRA COSTA COUNTY C AMBULANCE PRE-HOSPITAL CARE FORM I ` UNIT AUTHORIZATION N CHECK OR Flll IN APPAOPAIATE SPACES DATE.ooe ��'Z( 33• PATIENTS NAME �+�� I SU r� �I r�. _ )i�M ❑ F COMPANY N /� / 9z ADDRESS 2_I 2L+� -S I 'it- '�} AGE 7I A l� 113 CITY QA I~L Ani STATE ZIP DOB ��)�5_�� ❑ Sn ❑ M ❑ T JR W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ _ PHONE 5 3 3 Z- NATURE OF DISPATCH_IA n IG(),_u�Le nl TYPE OF TRANSPORT AMBULANCE El OTHER❑ .._ _—__._____._.._....: STATION I(A)_2(B)_3(C),A:�4(D)_5(E)_ - INCIDENT LOCATION RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE - S.0. CALL RECEIVED L- L�`T— ❑ P.U.— TIME 10-8 y PATIENT DESTINATION: - FROM SCENE - 1 ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 L / (y) .. t'f J -2 MILEAGE: ❑ OTHER/PVT TIME 10-7 END .22. 7 TIME 10-98 DOCTOR Htd n �L'/ PMD�RJ START- TIME 10-22 HOW CHOSEN: �/ TOTALS STANDBY TIME ❑ NEAREST FAMILY ❑ TRANSFER WAIT TIME -- IZ PATIENT ❑ DIRECT ❑ OTHER r CALL BACK N: AMBULANCE COMPANY:Cas PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE -� YES jjNO ❑ WALKED I GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER L_t C A F _ EMT-1A ✓ (\� TECHNICIAN PARAMEDIC Hz: T, Torts DISPATCHER: I f 1 CHIEF COMPLAINT: n- ��� DRY RUN: ❑ YES NO REASON FOR DRY RUN Q AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: &S. N 2`6,vg IVA NT£1JS�0.;� BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N:_ TOTAL MILES: X MEDICARE N: �� '•�_R 7.G= l 1 - E.O.B. ATT. ROUND TRIP: ❑ YES X NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: I MEDI-CAL N: CODE 2/3 1(" OTHER: OXYGEN: (PER TANK) -✓ ��' P.O.E. STICKER ❑ YES I 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: IAJ 11:0 E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: l%-i , it CITY: STATE: P: COMMENTS: 0111 t I fa 11 -!V O TT,i'%Th _ VA _ U TOTAL ' ! f E� -�Z� •, :Lx <�^ � - ------ 'I 5.. 5 ��.i' H�L_ t�t1tll l Ccs �. PATIENT RECEIVED BY: X l`^^Q_.'._ ($IGNATUBI) F'rvuider rota-,, whit. .nJ Pi.;: ,,q,b h,:tern Y:"•.,, „i,, I r.*r. uh,a f i! �� I� !.n•. 1 00202 CONTRA COSTA COUNTY AMBULANCE (L PRE-HOSPITAL CARE FORM i UNIT ® AUTHORIZATION# i CHECK OR FILL IN APPROPRIATE SPACES DATE: A L� Q L� PATIENTS NAME Q OM ❑ F COMPANY# /� ADDRESS AGE CITY STATE ZIP— DOB_____ ❑ Sn ❑ M OT W ❑ Th ❑ F. O S DRIVER'S LICENSE# _ PHONE __—__ NATURE OF DISPATCH I�r� lZv� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ INCIDENT OCATION: I RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR(y OCK) �'i'/\J TO SCENE- O. CALL RECEIVED `� S `7 O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 .\\QQ w �D�f �01 ►��' ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ENDTIME 10-98 DOCTOR PMD/ER START TIME 10-22 ��Z HOW CHOSEN: TOTAL STANDBY TIME 13 NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER �+ /0 EMT-1A TECHNICIAN �������� PARAMEDIC J 3 Hx: DISPATCHER: -�� O`Z2 CHIEF.COMPLAINT: RY RUN: ❑ YES O REASON FOR DRY RUN Y N Q �� AUTHORIZATIOOR DRY RUN (EMS USE ONLY) J PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: I INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �� C S.S. # _ PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE E CROSS#: TOTAL MILES: X MEDICA E.O.B. ATT. ROUND TRIP: O Y ❑ NO ❑ YES ❑ NO NIGHT: (19: 7:00) CCHP/PPRP#: EMER CY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) ,. P.O.E. STICKER ❑ YES ❑ NO ONATAL: (INCUBATOR) .DATES BILLED. STAN (OVER 15 MIN.) E.K.G.: (PER DE) NEAREST RELATIVE/RESPONSIBLE PA 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: —.____. —v — ------ n.\7VF-�ITnrrrl ri nV V . 00203` CONTRA COSTA COUNTY AMBULANCE 1) / l " PRE-HOSPITAL CARE FORM I UNIT (�-� AUTHORIZA ION k` •-- 1 CHECK Oq FILL IN APPgOPgIATE SPACES /� DATE: PATIENT'S NAME �^ 1 1cY C/" /D l� /yl J [ M O F COMPANY M I •� "- �l ADDRESS 3 ( / S GAGE LO ".. ....( CITY R I C I-•( 11"M Al) UTATE ZIP DOB �.W❑ Sri O M ❑T WO F 13S "-1 O Th DRIVER'S LICENSE q ____ _._� _ PHONE U 'V V7 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-124 HOUR Cr�OCK} I TO SCENE- ❑ S.O. CALL RECEIVED `'/ ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 HO PSAP TIME 10-49 ' MILEAGE: THER/PVT TIME 10-7 RD I END __ 447 TIME 10-98 DOCTOR PMD/ER START-14-5 _ Ik1Y►e SQA TIME 10-22 -- HOW CHOSEN: TOTAL ^2 _Iz F� STANDBY TIME . W� EAREST ❑ FAMILY ❑ TRANSFER i�) WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �� CALL @AC N' AMBULANCE COMPANY: PT. AMBULATORY? P TIENT TAKEN TO AMBULANCE: 1�) RESPONSE ZONE_ T� ES Cl NO JAU<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J EMT-tA TECHNICIAN EDIC Hx: _ ) _ DISPATCHER: _ ' CHIEF COMPLAINT Z21 P- t DRY RUN: ❑ YES .0 NO REASON FOR DRY RUN r _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) y� PATIENT REFUSED SERVICES: (SIGNATURE) X_ -' 1,AL CO ERAGE:^ry INDUSTRIAL 0 YES ❑ NO NO. OF PATIENTS: a� PRIVATE INS.CO.: BASE RATE: 'f/0`." KAISER#: MULTIPLE PTS. BASE RATE 2 /9;�D BL ROSS p: TOTAL MILES: X MEDICA S E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) in !, 1 CCHP/PPHP N: EMERGENCY�UN: I MEDI-CAL N: COO 2/3 OTHER: OXYGEN:'jPER 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 - (_14. � J� DRUGS: (PER ADMIN.) X - NAME: ��) �`S ZCN� �ELATIONSHIP:'0 E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIONS OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: .- TOTAL: L 9. 00 PATIENT RECEIVED BY:X -00204.. . (SIGNATURE) Provider reta' White crd Pie rop} Aetur" YI'1aen -u v••. r nt, hF, ina roc 9"s-I c . r. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT 1_ci AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: - ` - S PATIENT'S NAME l '�^ ❑ F COMPANY N c— ADDRESS Z 4. .7 AGE _ Ao L . CITY ��„ )� 4���. STATE C-S- ZIP q T:6 DOBS2=fig ❑ Sn OM O TW 13 Th O F 0 S 2,1DRIVER'S LICENSE It ___^_ — PHONE . y5�_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A) 2(8)_3(CI_4(D)_5(E)_,- INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CL, CKL� // TO SCENE-3 Y� S.O. CALL RECEIVED Uc-, f ��{ _J ❑ 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 DOCTOR C- 5 PMD/ R, START `��`y TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER } WAIT TIME PATIENT ❑ DIRECT ❑ OTHER I CALL BACK N: AMBULANCE COMPANY: L/A PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: r� (� RESPONSE ZONE JslYES ❑ NO A WAL'<ED ❑ GUERNEY ❑ OTHER r PATIENT CONDITION: DRIVER 1.41:1e_ �P EMT-1A I TECHNICIAN 1 C( �C c� { r c1 -� PARAMEDIC X / Hx: _G1( r C`'L Lig DISPATCHER: r - I I_'o i i l I CHIEF COMPLAINT: `l ei k r­-16 v A, tpr­ DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X._ MEDICAL COVERAGE: INDUSTRIAL ❑ YES Jk NO NO. OF PATIENTS: S.S. a _ (�i -�,yy PRIVATE INS. CO.: BASE RATE: Lti:LSrC� KAISER a: 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/PPHP N: EMERGENCY RUN: \ MEDI-CAL N: CODE 2 13 1 - I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 j1 ( E.K.G.: (PER EPISODE) r_ NEAREST RELATIVURESPONSIBLE PARTY: I.V.: (PER ADMIN.) X lDRUGS: (PER ADMIN.) X NAME: ,jC 1'� RELATIONSHIP, <_ E.O.A.: (IF NOT REPLACED) ADDRESS: /♦ 1' 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: ff ZIP: CR TENTS: �' ��'< .�r C((. )1i�C� cc_J n Y( (' A C TOTAL PATIENT RECEIVED BY:X ®®2 05 e5 n•'•+�r� rt - Lt:. , r:,., (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE q� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATIO N Y �Q CHECK OF FILL INAVPgOPR/tAiE SPACES ( PATE: Q ' PATIENT'S NAME- _�O L !v_ VI ❑ F COMPANY ` r ADOREssL._il ST_Ln1r _� AGE _ A o t3 �� CITY �' P_S STATE C ZIP DOH-1 II o ❑ Sn O M ❑ T W O Th OF OS DRIVER'S LICENSE a __ _. _ PHONE 0O.�VATURE OF DISPATCH 6 1 i TYPE OF TRANSPORT: AMBULANCEOTHER Cl INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CT- TO K SCENE- O._ CALL RECEIVED 5 �� _ j 1L yJ/ O P.D. TIME 10-8 �— y PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Z ❑ PSAP TIME 10-49 ;clOZMILEAGE ❑ OTHER/PVT TIME 10-7DOCTOR _ END TIME 10-98 O PMD/ER START I TIME 10-22 _ } HOW CHOSEN: TOTAL — - STANDBY TIME NEAREST ❑ FAMILY d TRANSFER WAIT TIME - PATIENT ❑ DIRECT ❑ OTHER <`{ CALL BACK A: AMBULANCE COMPANY: i PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONSE, YES ❑ NO WAL'CED ❑ GUERNEY Cl OTHER PATIENT CONDITION: .ti TECHNICIAN _G•41L. t ? �� IC Hx: _-V_iv.1L .mC�rIC1 - --- -- --- DISPATCHER: / CHIEF COMPLAINT: .__ ] lE�Q l I _ DRY RUN: ❑ YES TrT 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: C/^�d-�r S.S PRIVATE INS. CO.:-_ __ _ BASE RATE: f� KAISER a: __. MULTIPLE PTS. BASE RATE BLUE CROSS q: —___ TOTAL MILES: 4- X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES O NO " ❑ YES ❑ NO NIGHT: (19:00-07:00) �'�'�� C l CCHP/PPRP N: _ EMERGENCY RUN: f MEDT-CAL i+:— CODE'2 13 _ ,/ I• OTHER: —. OXYGEN. (PER TANK) I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I •;' I� DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:JV '."._-�-...�f���S RELATIONSHIP:-100— E.O.A.: (IF NOT REPLACED) ADDRESS: ___.__ ..__.._ _ . ORAL AIRWAY: (IF NOT REPLACED) CITY. .___.-__-__. .. _-_ _ _._ STATE--__—ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: �2.-U ._- u/_D7 WORK PHONE —. -_ DRY RUN: (AUTHORIZED) EMPLOYER ___...__.___-._-_.._. OCCUPATION:—_ __ OTHER: ADDRESS:--.---- CITY: DDRESS: ---_-CITY: _ STATE ZIP: �CO NTS ._���___S/`I"..`�s•__N�_w�_�.L.�g�r - lv� iNSuKrs — - TOTAL:)Li"D - -- ---- - - ----- 00206" `. -__ PATIENT RECEIVED BY:X p•hrr, f!i"ink TORE) DIS-1 ` �E�+ -•A CAfgs FC*W Ay AUTHORIZATION N_ )t� :1. ..rte nr .+ . .. •t I l: i'71�./ DATE:I-� ( ' I �� C' :i.._ .�5 `.A�.�_ ....� � ._t._I-L -)-- -- --------- -- kv O, M ❑ F COMPANYN J-' ' a,^arcs !tl (L\ ( l AGES / 11 -- __ _ ._ ; CITY$ L_ ' L(. -.._.- STATE -_----.-----((ZIP------ DOBI1 Z. --k(/ ❑ Sn ❑ M ❑ T f�W] A❑ Th ❑ F OS nRIVER'S LICENSE a �: CLI LL�5PHO :._.- �- NATURE OF DISPATCH - ` V TYPE OF TRANSPORT AMBULANQE7 OTHER❑ _ ____._..__.__— ... INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) I ' ] f 1 TO SCENE- IrS.O. CALL RECEIVED � ]_L]-Ll����- J`T�- ���4 - � ! - --- ❑ P.U. TIME 10-8 %IC- PATIENT DESTINATION: FROM SCENE- ❑ FIRE �_ TIME 10-97 l � /l /�(� 1 \l ❑ PSAP TIME 10-49`�� �I1LJ Il_�.11.,!.1�,�--1�.t�.- �. MILEAGAE: ❑ OTHER/PVT TIME 10 7 j l p END TIME 10-98 V DOCTOR _� :5 ._ - PMD/GR STARTZ TIME 10-22 HOW CHOSEN: TOTAL - __ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME __ t PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: i - I PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: C, RESPONSE ZONE YES El ❑ �VAL',ED GUERNEY ❑ OTHER PATIENT CONDITION. DRIVERSR �. l I-f TECHNICIAN_- / �� 2LD PARAMEDIC Hx: _ LI_iLt��_. �I DISPATCHER: ll , �'•0 EUHIEC4O\M_P),AINhT: I(]rr/�_�.L�1��I �C.�_�� RY RUN: ❑ YES NO REASON FOR DRY RUN I _ {�_ '�.1.,!__��( L_! l_ ._I-__-__.____�_ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Ll PATIENT REFUSED SERVICES: (SIGNATURE) X._-_____._-__.__.________ MEDICAL COVER E: INDUSTRIAL 11 YES 19 NO NO. OF PATIENTS: c 4 S.S. a 1-70 -1 PRIVATE INS. CO.: _- __.._ BASE RATE: KAISER a: ___- ___ ___. MULTIPLE PTS. BASE RATE i BLUE CROSS a _-- —_ TOTAL MILES: X � MEDICARE a: ____ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) v CCHP;PPRP It: — _---- �•�_- EMERGENCY RUN: �O. TvtEDI-CALti+: CODE 2/3 OTHER ____ _ OXYGEN: (PER TANK) :l P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: � - STANDBY: (OVER 15 MIN.) l' E.K.G.: (PER EPISODE) 1 ' ) NEAREST'RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 1 r ,� DRUGS: (PER ADMIN.) X NAME:�,..1 1 �. ._L._�.� .Ik' cELATIONSHIPILOL•Q E O.A.: (IF NOT REPLACED) ADDRES _._,�11 .L�''___. _..__-_ ______ ORAL AIRWAY: (IF NOT REPLACED) CITY. __--_-- STATE_—ZIP:__ C-COLLAR: (IF NOT REPLACED) - PHONE _—_ WORK PHONE DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: Af ADDRESS: --- --— -- /.� J CITY: - - STATE:__ZIP:_ /Zl /„'9 r .COMMENTS: TOTAL: " Ll —__-- PATIENT RECEIVED BY:X fYwi'rr -i ,•"gyp r�•:.•.•• yr•1 -c�•. t f�•.' c•hva Fi]"in� (S NATURE) _ Em-1 00207 i CONTNA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATF.SPACES DATE: T-2 PATIENT'S NAME J ' `'W n�'-,! j- ._._v - LC F COMPANY N _..— V✓lac_}«, ❑ ADDRESS _.. 7- � _ AGE V CITY. STATE``�� ZIP--..--)) �`/l DOB)Z - -/5❑ Sn ❑ M ❑ WrnO Th ❑lFF D❑S DRIVER'S LICENSE a .. _ _._ _-._ PHONE- ,f.v�I_ __9 J�> NATURE OF DISPATCH 5 ISO � �`r rZ 1 TYPE OF TRANSPORT AMRUI.ANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK TO SCENE - ❑ S.O. CALL RECEIVED ❑ P.U.----- TIME 10-8 PATIENT DESTINATION FROM SCENE - ❑ FIRE �— TIME 10-97 (' r 1� Uj A N• L 0 ---- ❑ P TIME 10-49 MILEAGE: / /9 D THER/PVT TIME 10-7 END_ (�_. TIME 10-98 DOCTOR _-V_U_�__^____-, PMD STAR �11 �, TIME 10 22 HOW CHOSEN: fZ A Vi TOTAL —� _ STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER r1 WAIT TIME ❑ PATIENT ❑ DIRECT OTHER ` CALL BACK a: AMBULANCE COMPANY: PT AMBUU ORY7 PATIENT T KE O AMBULAN �f I RESPONSE ZONE— ❑ YE$/�`f!O ❑ Wtil':E GUER EY THER PATIENT CONDITION. DRIVER_ » � � EMT- TECHNICIAN z PARAMEDIC Hx: _ . _ I���1'___.._-'____ DISPATCHER: CHIEF CO\MPLAlN L �1..s��.V_w_r_________-- DRY RUN: ❑ YES -4� NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 J'rn, PATIENT REFUSED SERVICES: (SIGNATURE) X—_ _ AL VERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 7 PRIVATE INS. CO.:_ _— -- BASE RATE: KAISER a: _—_ _-_ MULTIPLE PTS.BASE RATE BLUE CROSS#'_ _ _ __ TOTAL MILES: r X MEDICARE a: ____ E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO Q.cPJ r� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP>t: _____ — EMERGENCY,FUN: s � IMEDT-CAL a:_._._____--- CODE 2/3 1 OTHER —_.__._ OXYGEN: (PER TANK) P.O E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: _—._ -- 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) ADDnESS: ..__-_. - .._ _____......._-. - ORAL AIRWAY: (IF NOT REPLACED) CITY. STATE .._.._ZIP:__-.-- C-COLLAR: (IF NOT REPLACED) PHONE: __-_-_.._.._-.-__. WORK PHONE:-- _. DRY RUN: (AUTHORIZED) EMPLOYER: -._.-__- OCCUPATION:-- OTHER- ADDRESS:--------- CITY THER-ADDRESS:CITY __- STATE.___ZIP:-___ COMMENTS:- - - -- — - — -- - ._- TOTAL PATIENT RECEIVED BY: X :,r.. :.•F: 1 '1'rl��t•Lw.C..EIS-i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M I CHECK OR FILL IN APPROPRIATE SPACES DATE:- PATIENTrs NAME _ OM ❑ F COMPANY N � � 7:� 4ADD9ESS �� J'2 I�0 / � s AGE.` U)ply CITY STATE ZIP DOB— ❑ Sn ❑ M ❑ T O W ❑ F ❑ S DRIVER'S LICENSE M _ _ PHONE _ — – NATURE OF DISPATCH �� . TYPE OF TRANSPORT: AMBULANCE NOTHERO t INCIDENT LOCATION: j RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) . ✓� /��L. ����y'. C I/' �� TO SCENE-? ❑ S.D. TIME 0-8 RECEIVED t (� •/ tom. `/ a. PATIENT DESTINATION: I ,n FROM SCENE- ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR; I PMD/ER START TIME 10-22 ) HOW CHOSEN: 1 TOTAL STANDBY TIME �3. ❑ NEAREST, ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT -MOTHER CALL BACK p: AMBUL CEOMPANY: gC /// ,5, . - PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �7 RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED13GUERNEY`�OTHER ��1 I gI.:PATIENT CONDITION: DRIVER �V TECHNICIAN PARAMEDIC Hz: DISPATCHER: CHIEF COMPLAINT: 4�,j�,9 uS DRY RUN: ffig'fES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �o �� :�.�PA346UTT-REFUSED SERVICES:. X LM((�� MEDICALCOVERAGE: INDUSTRIAL .YES NO NO. OF PATIENTS: 9�zS.S. - T ❑ D PRIVATE INS. CO.: BASE RATE: KAISER C 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) C� CCHP/PPRP 0: j I EMERGENCY RUN: MEDT-CAL U: 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) W EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP; _ COMMENTS: AA21/es 7.-v /�c{ccJpl TOTAL�V-CIC-1-- 0C . �. — PATIENT RECEIVED BY: X ISIGNA:LIRE) 133 I CONTRA COSTA COUNTY AMBULANCE (U S PRE-HOSPITAL CARE FORM 1 [ UNIT ® AUTHORIZATION N CHECK OR Flll INAPPROPRIATE SPACES DATE: , JJ i I PATIENTS NAMEli M O F COMPANY N ADDRESS,° AGES CITY STATE ZIP DOB ' O Sn OM OT OW 13Th O F OS DRIVER'S LICtNSE N - -� , PHONE _ NATURE OF DISPATCH Lo>_�S c TYPE OF TRANSPORT: AMBULANCE OTHER _ STATION 1(A)`218)_3(C 4(D)_5(E)_ / INCIDENTLOCATION� � / � �= ' RESPONSE CODE: RE UESTED BY: TIME– (24 HOUR CLOCK) ( t TO SCENE- S 0. CALL RECEIVED •"�` L I ! O P.D. TIME 10-8 3,[ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Q O PSAP TIME 10-49 �'~1.a., '{• ! !Z MILEAGE: ❑ OTHER/PVT TIME 10.7 I i END TIME 1048 PMD/ER START J TIME 10-22 :—Z- HOW CHOSEN: TOTAL V=2 STANDBY TIME O NEAREST-; O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: CA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: r 1 RESPONSE ZONE ; ❑ YES O NO I O WALKED ❑ GUERNEY ❑ OTHER �J (� PATIENT CONDITION: J DRIVER t -1A TECHNICIAN PARAMEDIC Hx: �'N DISPATCHER: //__ CHIEF COMPLAINT: '— DRY RUN: T�/YES 11 NO REASON FOR DRY RU S 950 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Vq fi PATIENT REFUSED SERVI ES: (SIGNATURE)'x 7 5� MEDICAL COVERAGE: INDUSTRIAL OYES 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:. O YES NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: MEDT-CAL N: 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 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 OG210`� .......;,... .. ISirNA-11AF) / CON111A CO:,1A COIJNTY AMnULANCE PRE-HOSPITAL CARE FORM I UNIT Z Z AUTHORIZATION a - G , CNFCK OR FrLL W APPAOPRurr SPACES DATE: 1'A_7_ � PATIENT'S NAME_�Gcv:'_l._C� �11�1ES "V ❑ M ❑ F COMPANY �- 1 ADDRESS /G'.1'� FYI/I A AGE A )U Z2 CITY STATE ZIP OOBLSI+—S-0 0 Sn O M O T O W-.19 Th O F DRIVER'S LICENSE a _____..____ ..__.. —____. PHONENATURE OF.DISPATCH f �O � TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ — STATION i(A)`2(8)_3(C)_4(D)_5(E)_- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) \ TO SCENE- 8 S.O. CALL RECEIVED 7�. ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- r> O FIRE TIME 10-97 �Z �� 0 PSAP TIME 1449';.•-• I D MILEAGE: O OTHER/PVT TIME 147 i'�G S _ END TIME 1498. DOCTOR _�� ,� 4,PM ER START`, . TIME 1422 HOW CHOSEN: TOTAL STANDBY TIME ' 0 NEAREST ❑ FAMILY O TRANSFER_ ] WAIT TIME ❑ PATIENT ❑ DIRECT 'B OTHERCALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: f' RESPONSE ZONE_�� M YES ❑ NO B WAL"ED ❑ GUERNEY 0 OTHER � ) PATIENT CONDITION. DRIVER +�L / 2 `� EMT-1A 1 TECHNICIAN� 5� PA MEDIC Hx: ��� i1SF ' DISPATCHER: ` p r r- :I CHIEF COMPLAINT: �� �1<'1��GL]�11 nFLY F3}1N: 0 YES O NO REASON FOR DRY RUN _ T Az-,L) Liz LZ�Ly�'[�/.�r7— ro'4;Tj� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X— a MEDICAL COVERAGE., INDUSTRIAL 0 YES 9 NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE:/ Po- KAISER KAISER a: MULTIPLE PTS. BASE RATE • ` Q BLUE CROSS a'_ � � TOTAL MILES: --• X •�U �.�.� MEDICARE a: f I E.O.B. ATT. ROUND TRIP: 0 YES O NO ❑ YES 0 NO NIGHT: (19:00-07:00) CCHP/PPHP a: I EMERGENCY,RUN: {� �_. . .:" CODE:2/3 , • MEDI-CAL a: - �_�! �/�' l7S��,g /SS OTHER: _ OXYGEN: (P1tR TANK) 1 IL P.O.E. STICKER ❑ YES 0 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 AOM(N.) X NAME. RELATIONSHIP: , .O.A.: (IF NOT REPLACED) ADDRE ��L.�_/_�!1 �J ORAL AIRWAY: (IF NOT REPLACED) CITY:_lrif l�J/�7.�iLl,C�___—_ STATE2-,4--,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE-/�?3��5�1� WORK PHONE: DRY RUN: (AUTHORIZED) EMR-4/iccOCCUPATION 40/ �UW 'OTHER: -^^� ADDRESS: _ CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL: V PATIENT RECEIVED BY. Y X n.._... -a. r. •rr. c,. . ... r.• ..� (SIGNATURE) • .. OP21nn nn •has-1 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK OR Flll IN APPROPR!00,q SPACES DATE: PATIENTS NA ❑ M ❑ F COMPANY ,ADDRESS AGE'S_ CITY STATE ZIP DOB—_– ❑ Sn ❑ M ❑ T ❑W ❑ Th ❑ F O S DRIVER'S LICENSE N _ _ PHONE ___— __ NATURE OF DISPATCH / / oll TYPE OF TRANSPORT: AMBULANCE lk4 OTHER❑ INCIDENT LOCATION: ' RESPONSE COO RE�UESTED BY: TIME— (24 HOUR CLOCK) q TO SCENE- `lf 5.0. _ CALL RECEIVED 1Z IV P.D. TIME 10-8 :. Lz PATIENT DESTINATION: L FROM SCEN ❑ FIRE TIME 10-97 'r°C ::Ii`..: ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 '1 DOCTOR PMD/ER START TIME 10-22 17 1 HOW CHOSEN: TOTAL STANDBY TIME ��3•-• ❑ NEAREST7 ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULAN E MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: \ RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' I JYi I „PATIENT CONDITION: DRIVER Q /EMT-1A TECHNICIAN FtL' Hx: DISPATCHE CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FO DRY UN12 �DAlJTHOR17 I N FOR DRY RUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X— �q9 ry�� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 77 i S.S. N PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS(t: TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:I EMERGENCY RUN: MEDI-CAL M: 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: �ry —_ TOTAL: PATIENT RECEIVED BY X (SIG002 — 11• r(.1, .. . . :�.:�— — If. ,.. -- --- NATURE) CNS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ONIT ® AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: - n r `/. l PATIENT'S NAME-- 4.Ca +���/G_h /r lTM COMPANY# e7 41e ADDRE Z-�G �r(~.�_-'.. 1._....� � AGE_ CITY STATE_.. ZIP___ —__ DOB Q Sn ❑ M O T O W & OF PS -— -- DRIVER'S LICENSE a _.- ..-- _. ... PHONE �_�.� NATURE OF DISPATCH -- ,n/ c -- TYPE OF TRANSPORT: AMBULAN THER❑ I IDENT LOCATION: {� RESPONSE CODE: E STED BY: TIME— (24 HOUR CLOCK) It cq �?7,� �e,� / TO SCENE- � S.O. CALL RECEIVED 19— : _i ❑ P.U. TIME 10-8 / PATIENT DESTINATION: "'C� FROM SCENE ❑ FIRE TIME 10-97 : J —`—/� ( / -- „ 1.�_C �-'' — -- Z -- ❑ PSAP TIME 10-49 � S Z. ' MILEAGE� `c7 11OTHER/PVT TIME 10-7 END (_ TIME 10-98 . 1 DOCTOR ---� T — PM ER STARTTIME TIME 10 22 HOW CHOSEN: O AL —r-� STANDBY TIME ❑ NEAREST Cl FAMILY Cl TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT Cl OTHER CALL BACK#: AMBULANCE COMPAf�Yr- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �. RESPONSE ZONE c 'YES O NO ❑ WAL',ED ti--60ERNEY ❑ OTHER t 1 PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN S PARAMEDIC Hx .__iC�rL%'!mak"`^_ q�IIJ(' DISPATCHER: le t Q E 7`--- --- CHIEF COMPLAINT _ _ .r_ ° .. DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLYJ /I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE IND STR L YES 11 NO NO. OF PATIENTS: S S # - PRIVATE INS. CO.:----. BASE RATE: KAISER #: MULTIPLE PTS. BASE RATE BLUE CROSS# TOTAL MILES: r X MEDICARE#`. — E.O.B. ATT. ROUND TRIP: ❑ YES O NO ,�r r ❑ YES ❑ NO NIGHT: (19:00-07:00) C- C P a:_-77 EMERGENCY RUN: MED- AL a: _��� -C. 1 ?(r.( ^ t` 1 CODE 2/3 VV OXYGEN (PER TANK) J O P.O.E. STICKER Cl YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: — STANDBY: (OVER 15 MIN.) E.K G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V. (PER ADMIN.) X q �1 DRUGS: (PER ADMIN.) X NAME�r-�f7�� , l'��' i_�IA RELATIONSHIPr�/�`�' E.O.A.: (IF NOT REPLACED) ORAL AIRWAY: (IF NOT REPLACED) CITU . ______-._. .._ STATE.-____ZIP:- C-COLLAR: (IF NOT REPLACED) PHONE: __ .. WORK PHONE:— — DRY RUN: (AUTHORIZED) EMPLOYER: .—. _—._____ -_ _ __ OCCUPATION: OTHER: _ ADDRESS:-- --. CITY: — STATE:—_ZIP: C0M►,AFNTS -- ------ - -- - PATIENT RECEIVED BY: X • F1••�rr.{rr prl: ih,i+•\ r i•' (SIGNATURE) 00213 :r. °r/r.r+. 1'r'. .. ��.,. .:II�n I:�-f•IJ tlls-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION K S 3-l6 S y Z ` 1`,r �J L , P Il l� 1 CHECK OR FILL INAPPROPRIATE SPACES DATE: L A PATIENTS NAME,Cl Q Cera 1 Ph //.'F�1 ��M OF COMPANY M ADDRESS 'SsSrn G �+�G►�� Ale,e, �AGE AD AN CITY � D.�- - IWATEe-14 — ZIP DOB-1-7-171�Cb Sn O M ❑ T O W 4Th ❑ F O S DRIVER'S LICENSE 0�_ ` PHONE_��G L NATURE OF DISPATCH_ C' C4 I TYPE OF TRANSPORT: AM13ULANC OTHER❑ INCIDENT�OCATION: i RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) t TO SCENE- 3 S.O. CALL RECEIVED S S ❑ P.D. TIME 10-8 :PATIENT DESTINATIONI : - FROM SCENE- O FIRE TIME 10-97 2 13 PSAP TIME 10-49 �` :�� ;? < IQ MILEAGE: 11OTHER/PVT TIME 10-7 2— END yG-6 TIME 10-98 2 p•DOCTORPMO START TIME 10-22 HOW CHOSEN: TOTAL Z ' 3 STANDBY TIME -ER"JEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY: t_f9 j PT. AMBULATORY? - PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ 'm.- O YES 'NO 13 � WALKED CUERNEY O OTHER PATIENT CONDITION: DRIVER�,:n vim,__ EMT'-1A TECHNICIAN Lf PARAMEDIC ylp HxDISPATCHER: �Q CHIEF COMPLAINT: k-DRY RUN: O YES>�NO REASON FOR DRY RUN (i Ie>Le-"'�{ .•, AUTHORIZATION FOR DAY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE')X t MEDICAL COVERAGE: INDUSTRIAL O YES NO NO. OF PATIENTS: 1 .. s PRIVATE INS.CO.: � ` BASE RATE: � KAISER N: �- 1 MULTIPLE PTS. BASE RATE BLUE CROSS p:r 1 1 TOTAL MILES: X ,J5,? MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO �- BAG r, YES ❑ NO NIGHT; (19:00-07:00) 1U. n-5 O CCHP/PPRP N;D `.3 'D,2 yL X195`�S -D EMERGENCY R N:. r MEDT-CAL M: CODE 2/SN 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 b G s n DRUGS: (PER ADMIN.) X NAME: / RELATIONSHIP E.O.A.: (IF NOT REPLACED) ORAL AIRWAY: (IF NOT REPLACED) 4imck 4 $%jsTI TY: Y ' ST •2 C-COLLAR: (IF NOT REPLACED) Ii�NE ;{ WORK PHONE:— DRY DRY RUN: (AUTHORIZED) E l� f' • !• I OTHER: 9�'P AD CITY:. STATE:_ 7k COMMENTS: _ a TOTAL: 2(— Q, PATIENT RECEIVED BY:X-.----- _ • Pr'v!for �rla!• N:i t. •ml r' a: .•,ni. �chn . (SIGNATURE) O 0 ^IMI CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I !(I LINITFM AUTHORIZATION M ' CHECK OR FILL IN APPROPRIATE SPACES DATE: lZq �� PATIENTS NAME OM ❑ F COMPANY N ,/ ADDRESS. AGE I +' ry CITY STATE ZIP DOB O Sn ❑ M ❑ T ❑W ❑ Th .F OS w DRIVER'S LICENSE If _•- PHONE NATURE OF DISPATCH 'f TYPE OF TRANSPORT: AMBULANCE 0 OTHER — STATION 1(A)_2(8)_3(C)_ (D)_5(E)_ INCIDENT LOCATION'. j , RESPONSE CODES R QUESTED BY: TIME— (24 HOUR CQC�) TO SCENE- S.O. CALL RECEIVED v � • v O P.D. TIME 10-8 -�' PATIENT.DEStINATION: FROM SCENE ❑ FIRE TIME 10-97 r- - ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVTTIME 10-7 :. : END TIME 10-98. :DOCTOR'' '''•' ( PMD/ER START TIME 10-22 HOW CHOSEN: _ TOTAL STANDBY TIME . 71y.D NEAREST O FAMILY ❑ TRANSFER WAIT TIME D PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBUL/,DJG�MPANY: LZN PT,AMBULATORY? PATIENT TAKEN TO AMBULANCE: •��;) RESPON7 ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: { DRIVER % b SLI EMT-1A r'I TECHNICIAN PAR EDIC Hx: I DISPATC R: rS✓ CHIEF C N DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHO ZATION FOR DRY RUN(EMS USE ONLY) +� PATIENT RE ED SERVICES: (SIGNATURE) X MEDICAL COVERAGE' INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M 1 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 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0. I EMERGENCY RUN: , MEDI-CALM: ` CODE 2/3 ' l OTHER: OXYGEN:. (PER TANK) 1 1 P.O.E. STICKER ❑ YES O 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----.:- C-COLLAR: (IF NOT REPLACED) — A i PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) AZA w%01 EMPLOYER; OCCUPATION: OTHER: ADDRESS: f CITY: STATE: ZIP: COMMENTS: TOTAL: J� PATIENT RECEIVED BY:X Provider retain, White csld Pink copy Return Ye'Iuu ropy ti , DO When bil'ina (SIGNATURE) 0 0 21�,S-1 rlr,)•'r 7 !s Y FnUH SAS V JIi PAIN ;r CONTRA COSTA COUNTY AMBULANCE ". PRE-HOSPITAL CARE FORM 1. UihT ® AUTHORIZATI N M CHECK OR FILL/N APPROPRIATE SPACES DATE: PATIENTS NAME GAt.vez�,_ /r/L!0. ❑ M COMPANY M I Z 9 3 ADDRESS L'71 1 9_h-P_�_ pp AGE_ O 5?— ` CITY � STATE ZIP yOt7/ DOB____ 1 6 ❑ Sn ❑ M ❑ T• ❑ W:.❑ Thk-r $ QT., DRIVER'S LICENSE# _____._ _.._.. PHONE S � � NATURE OF DISPATCH IZO CAR. TYPE OF TRANSPORT: AMBULANCE 01 OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR COLO •Z Sfi LtnA t, TO SCENE- �.0. CALL RECEIVED �J, �L ;:p:P.D. . -I Z ' J PATIENT DESTINA)ON: FROM SCENE ❑ FIRE TIME 10-97 z ❑ PSAP TIME 10-49'A.,I MILEAGE: ❑ OTHER/PVT TIME 10-7 �� END 66' TIME 10-98' DOCTOR . PM /4 E� STAR TIME 10 22 ����...JJJ HOW CHOSEN: ((�/ TOTAL STANDBY TIME ❑ NEAREST ❑ F /Ly ❑ TRANSFER WAIT TIME •�,,,J ❑ PATIENT ❑ DIRECT ❑ OTHER l CALL BACK#: AMBO CE GOMS;PANY4 r I est PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: (` RESPONSE ZONE ❑ YES SSNO ❑ WAL! ED kGUERNEY ❑ OTHER J ~ PATIENT CONDITION: DRIVER ' C - TECHNICIAN PARAMEDIC Hx: a DISPATCHER: 1 T: CHIEF OMPLAINT: �' DRY RUN: ❑ YES 0 REASON FOR DRY RUN AUTHORIZATION OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES.- (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. # PRIVAi­&_I,NS.CO.: BASE RATE: �� + AIS�R MULTIPLE PTS. BASE RATE BLE L�ODp L D 4jL 7 TOTAL MILES: , X J�_� ICARE\. + E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO OYES ❑ NO NIGHT:(19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: scriac-OD MEDI-CAL#: CODE,2/3 ' OTHER: OXYGEN: (P TANK) I U 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) - 1 111 DATES BILLED: STANDBY: (OVER 15 MIN.) /�' �•�Q� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X _ NAME: _ctfCL RELATIONSHIP 'J O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 77STATE_C-t._ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: `7WORK PHONE:_Z1 RY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: _ ADDRESS: h_ '. "�� IO•Gb l CITY: STATE: ZIP: = !"_ !� . _ - ! S.Uj>�• COMMENTS: TOTAL­'9_?'t5Q ZP 3 ew ` PATIENT RECEIVED BY: � O N L,-.. frvrNATt1RF) CONTRA COSTA COUNTY y AMBULAN E 2, PRE-HOSPITAL CARE FORM I UNITF777 AUTHORIZATION+'1 CHECK OR FILL_X,0,A PROPRIATE SPACES / DATE: •I. PATIENTS NAMv Vto 1c)-_k t _-_ O M'�F COMPANY M ADDRESS ' ��-- AGE CITY C ' STATE ZIP 0� /� _L ❑ Sn ❑ M ❑ T ❑ W ❑ Thi F ❑ S DRIVER'S LICENSE a __ PHONE ��/ -^�� NATURE OF DISPATCH_ . / TYPE OF TRANSPORT: AMBU OTHER❑ �- ✓� . . l�f as IDENT OC NRESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE - O. __.._.._._._ CALL RECEIVED ❑ P.0 ----- TIME 10-8 PATIENT STINATION: -� FROM SCENE • ❑ FIRE ____— TIME 10-97 ❑ PSAP TIME 10-49 - 1� _ MILEAGE ❑ OTHER-PVT TIME 10-7 END— ci TIME 10-98 DOCTOR START— __ — _--- TIME 10-22 HOW CHOSEN: TOTAL —_ _ -- STANDBY TIME ❑ NEAREST --ffqAMILY ❑ TRANSFER _— WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER ) CALL BACK a AMBULANCE CO9 PT AMBULATORY? PATIENT TA N TO AMBULANCE: RESPONSE ZONE ❑ YE5--C& ❑ WAL!,FJ G 1ERNEY ❑ OTHER PATIENT C NpIT ON: DRIVER 1 _._ ._.[L�c,L ! _ EMT-tA_ TECHNICIA i��1 - PARAMEDIC -1� Hx: _ Js__— _ - . DISPATCHER:fff�_L I A 1 CHIEF COMPLAINT: _ � DRY RUN: ❑ YESI_�O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) �vy PATIENT REFUSED SERVICES. (SIGNATURE) MEDICAL COVEW INDUSTgI ❑ YES 10 NO. OF PATIENTS: --— S.S. R &I � �l � � — --- PRIVATE INS. CO.: BASE RATE: ��� KAISER#: MULTIPLE PTS. BASE RATE � BLUE CROSS 4: TOTAL MILES: AZ X (�eS� •dd (CARE � O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00- 07.00) CCHP/PPRP a: EMERGENCY RUN CAL P: a CODE 2/3 4 HER: __ OXYGEN: (PER TANK) v� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ' \\l DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIV RESPONS B E PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAVE RELATIONSHIPS O.O.A.: (IF NOT REPLACED) ADDRESS— ORAL AIRWAY: (IF NOT REPLACED) CITY: e _ _ STATE. -- _ ZIP:._.__..._ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:—__-__---._— DRY RUN: .(AUTHORIZED) EMPLOYER: OCCUPATION._.___-- OTHER: ADDRESS: CITY: STATE:---. ZIP:— COMMENTS: IP:COMMENTS: TOTAL PATILPJT.FiLCLIVIDBY X SIC:NA' ( 11N RM0021'�J� : E1 1 f'r•.u:,!.'r ri(ai.. Wi,i t. r,.! ,';..: 1� .I;,,, . ., � � !, .I �U C �- CONTRA COSTA COUNTY AMBULANCE d /6 � ` 1 1 J PRE-POSPITAL CARE FORM I UNIT AUTHORIZATION © M IV/ �3 () C CHECK OR FILL INAPPROPRIATE SPACES DATE: PA.;IENT'S NAME P ; '"' ! M ❑ F COMPANY M L �1 c/ ADDRESS V �LL�, N AGE CITY- STATE v N ZIP DOB"e_2-,_ Sn ❑ M O T O W O ThJ�F ❑ S DRIVER'S LICENSE N — PHO NF t 9NATURE OF DISPATCHS �A 1n S TYPE OF TRANSPORT: AMBULANCE❑ OTH ---- STATION 1(A)-2(8)-3(C)-4(D)-5(E)— INCIDENT LQCATION: RESPONSE CODE: llESjED BY: TIME- (24 HOUR CLOCK) n V-� �•� LC) TO SCENE- ❑ — CALL RECEIVED ' 7 x TIME 10-6 PATIENT DESTINATION: FROM SCENE- 11FIRE TIME 10-97 C I _ ❑ PSAP TIME 10-49 r - �+ MILEAGE: ❑ OTHER/PVT TIME 10-7 r�- ( (�` END I TIME 10-96 : L DOCTOR �l- - PM /ER START �? TIME 10-22 ` :HOW C OSEN: TOTAL STANDBY TIME EAREST . ❑ FAMILY 13TRANSFER WAIT TIME _— //❑ PATIENT ❑ DIRECT ❑ OTHER 7 ) CALL BACK M: AMBULANCE COMPANY PT. BULATORY? PAT ENT TAKEN TO AMBULANCE: ` RESPONSE ZONEy'r_1_ S ■ NO ALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN - ' PARAMEDIC i�. Hx: `-' "V v`' DISPATCHER: -�°'� �, ` ( / '�-► ,N CHIEF COMPLAI� .(}1�hPl DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN Q �'�1 ` , ` t)L �L14, _ -_ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X t M L COVERAGE: INDUSTRIAL ❑ YE O NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: f f Q_0o KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X }n / �'� MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) C HP� A P KEN 1 1 EMERGENCY RUN: ��•�� DI-CAL N p�1T O.THER: _ 7 f.z 0 3 19 06 8 80 31 CODE 2/3 OXYGEN: (PER TANK) P. ^S71CKE,� 09 Ttb u4N0( NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) Its E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: N I.V.: (PER ADMIN.) X _ 9-V [BRUGS: (PER ADMIN.)_- X NAME:�.IC+l0C- L- RELATIONSHIP. LLJ)t '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 --- i7 —.---.—_--- -.__..—_---- .---,--.. - PAIIENI RECEIVLU 13Y X _ 00218 . . :SI/;JiI ti iHf 1 t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M X316 6cj 3 CHECK OR FILL IN APPROPRIATE SPACES DATE: � ( PATIENTS NAME OM OF COMPANY# Lf ADDRESS AGE 'y CITY STATE ZIP DOB ❑ Sn OM OT ❑ W ❑ Th k F. ❑ S DRIVER'S LICENSE N _ PHONE —_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: D RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) �7 2 l� –/ / y le �� llh TO SCENE-� O P.O. TIME10-8 RECEIVED _L�i (,i (` -7� PATIENT DESTINATiO FROM SCENE- ❑ FIRE TIME 10.97 ►(� _ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 1D-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN; TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE OMPANY: PT. AMBULATORY? PATI TO AMBULANCE: U RESPONSE,ZO ❑ YES ❑ ❑ WALKED 13GUERN ❑ OTHER J _ PATIENT CONDITION: DRIVER 5 G b EMT-1A TECHNICIAN i 5 PARAMEDIC I Hx: DISPATCHER: �W"(2 CHIEF COMPLAINT: DRY RUN: (%/�S NO SON FOR DRY RUN L(I/I J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �1 '7 7 PATIENT REFUSED S VICES: (SIGNATURE) X 5.1 MEDICAL COVERAGE: / INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. III PRIVATE INS.CO.: BASE RATE: KAISER 11: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES:_ X MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: 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 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) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) _ EMPLOYE OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 7*A TOTAL: - __... 00219 PATIENT RECEIVED BY: X n.. r ; :T:, ..r •... (SIGNA R1RE) rI CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1UNIT AUTHORIZATION N cq G n CHECK OR FILL IN APPROPRIATE SPACES DATE: 9 Ca PATIENTS NAME ulLLznl c M l L l A O M VZ F COMPANY N 1 ADDRESS Sot 11� N r .S ct V ✓C AGE - L_ 1' I -v 7 CITY „< NKO V� STATE L— _ ZIP DOB - ? ,O Sn O M ❑ T ❑ W ❑ Th ❑ F ❑S DRIVER'S LICENSE N _ _ PHONE L.7. 1''U NATURE OF DISPATCH JL TYPE OF TRANSPORT: AMBULANCE OTHER O STATION 1(A)_218)_3(C)_4fD)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE O S.O.. CALL RECEIVED IC ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-7 O FIRE TIME 10-97 O PSAP TIME 10-49r MILEAGE. fil�DTHER/PVT TIME 10-7 ' 7'77 s END 5 - �? TIME 10-98 DOCTORC,UC('Z/ / "v A PMD/ER START Z �� �1-'1{ �Gy��• TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY 'fit-TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER 1 � CALL BACK C AMBULANCE COMPANY: r PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I 'I -( RESPONSE ZONE Q YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER rTECHNICIAN J _ PARAMEDIC ' r DISPATCHER: Hx: f4 r _ RE( CHIEF COMPLAINT: LSE( 4 /S r! E� � DRY RUN: OYES O REASON FOR DRY RUN t AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ;6NO NO. OF PATIENTS: 1 S.S. N PRIVATE INS, CO.: BASE RATE: KAISER N• MULTIPLE PTS. BASE RATE BLUE CPOSS N: TOTAL MILES: X EOICARJF(t: ,5 D - `f 7 7 Z'9 E.O.B. ATT. ROUND TRIP: OYES ONO (7z _ ❑ YES O NO NIGHT: (19:00-07:00) LEDI-CAL )f('PHP N: ~ t r EMERGENCY RUN: �C) 7 1 b - 9 550 y 7 70 (L> CODE 2/3 R: i OXYGEN: ?PER TANK) .--S`TICKER O YES -�prNO NEONATAL: (INCUBATOR) 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: 1 ADDRESS: r cc/ s�_�?lC-�i /Q,Al CITY: STATE: ZIP: COMMENTS: TOTAL:.r., jff / 00220 PATIENT HLCEIVLn BY X //I J L i(�('• /� v (SIGNAT141[I PT„vila� ryfair, Y11ito �fr) 1'n:% .•,q•� Satrrr i. r . r.r :.•1„q l:l ,:.r 1h' 1 CONTRA COSTA COUNTY AMBULANCE /� PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N ..� (l�t•(/� .,• s ACHECK ON FILL IN APPROPRIATE 3PACE3 DATE: '•} }PATIENT'S NAME e M O F COMPANY N "' C ADORES S AGE I CITY STATE ZIP WftQ�_ DOB�J n ❑ M O T O W O Th -.�,F�❑S .. DRIVER'S LICENSE N PHONE jeNATURE OF DISPATCH�.C7r�� C TYPE OF TRANSPORT: AMBULANGZA OTHER❑ -- STATION 11A►._2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION:Lr -x?, RESPONSE CODE! REOUESTED BY: TIME–(24 HOUR CLOCK) TO SCENE- O. CALL RECEIVED O P.D. TIME 10-8 . s PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _L7: PSAP TIME 10-49 N o''+ ` ' I MI EA ❑ OTHER/PVT TIME 10-7 T s -( 1 ENO TIME 10-98, V l 5.� aDOCTOR PkIpon START TIME 10-22 HOWgHOSEN: TOTAL. STANDBY TIME NEAREST;'_` 13. ❑ FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPAN PT. AMB TORY? PATIENT TA EN TO AMBULANCE: I s- RESPONSE ZONE O YES NO O WALKED OTH l. ?: S ..yc Z PATIENT CONDITION: { DRIVE EMT-1A I ' L TECH IA ARAMEDIC Hx: /T/,`�/ �G� `�`'� s: S DISPATCHER: v ' r CHIEF COMPLAINT: DRY RUN: ❑ YES NO 4A$6N FOR DRY RUN j i.A�� V MC� ► AUTHORIZATION OR DRY,RUN(EMS USE ONLY) �;�-r tt;,JAAJ L J:PATIENT REFUSED SERVICE : (SIG NA E) X s lSI 3 MEDICAL C ERAGE: ) NOUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: �..4. a ".r RIVATE INS.CO.: BASE RATE " ' IS 0i MULTIPLE PTS"BASE RATE BLU SS M: TOTAL MILES: X 5U �1 MEDICARE N: I E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO �i. r' O YES ❑ NO NIGHT: (19:00-07:00) R; CCHP/PPRP k:C' ' EMERGENCY Rt^ MEDI-CAL N: t CODE 2 f3 • . OTHER: OXYGEN- (PER TANK) 1. P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.' (PER ADMIN.) " X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED)' CITY: STATE ZIP' C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: "CITY: STATE' ZIP: "COMMENTS: - - • 41 5 TOTAL: 00221 PATIENT RECEIVED BY:X Prmi.�ir rvr�:. l•6i.� rl r•r.: �r• •- . (SIGNATURE) • 1 I CONTRA COSTA COUNTY AMBULANCE PRE-,HOSPITAL CARE FORM I UNIT © AUTHORIZATION N 1 � I : I CHECK ON FILL/H OPK Tf ACES DATE: 1 PATIENTSNAME M 13F COMPANY N ADDRESS,f,'' AGE .-._1 U� CITY STATE . ZIP` i - DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ', : 1 _ DRIVER'S LICENN _ I PHONE NATURE OF DISPATCH � 14 - se TYPE OF TRANSPOFKIZtMBULANCE THER 0 — STATION 11A) 2( )-3(C)_4(D)_5(E), INCIDENT LOCATION: h '- RESPONSE COD , REQUESTED BY: TIME— (24 HOUR CLgCK) TO SCENE- S.O. CALL RECEIVED (/ lam• 1 6_ 1<5Ait 11V fL CL TIME 108 c �� PATIENT DESTINATION: FROM SCE ❑ FIRE TIME 10-97 ?? ❑ PSAP TIME 10.49 4. MILEAGE: ❑ OTHER/PVT TIME 10-7 �. END. TIME 10-98 is DOCTOR'' PMD/ER' START XL TIME 10-22 HOW CHOSEN: _ TOTAL �-- STANDBY TIME ❑ NEAREST--, D FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j� RESPONSE ZONE 11YES ❑ NO ,. ❑ WALKED 13GUERNEY ❑ OTHER Li ► 'C// �h� PATIENT CONDITION: , DRIVER MT-1A .. _ ! TECHNICIAN 3 PARA EDIC Hx: 1 17 DISPATC ER: /!(�t� CHIEF COMPLAINT: ' DRY RUN: ES EASON FOR DRY RUN AUT RI TION F RUN MS SE NLY) �r WifoSAL 1 l • - PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: ...- INDUSTRIAL ❑ YES NO NO. OF PATIENTS: Q�� �— S.S.k ) PRIVATE INS. CO.: BASE RATE: KAISER 0: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X I MEDICARE N: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO __. ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:` r : EMERGENCY RUN: . .._ :.1 : ./: .... MEDT-CAL N: I CODE 21 3 OTHER: `'1 # _� 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: ()F 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:- IP:COMMENTS:.. — TOTAL: C h ---- 00222 —_ PATIENT RECEIVED BY: X —. • • . (SIGNt TUFF) I�. VCNTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 3 CNECK OR FILL IN APPROPRIATE SPACES DATE: y -7-f ` X•'� _. )�A71ENTS NAME �C h Ll L T�1t-��.Z.p� OM ❑ F COMPANY N 1 ADDRESS'-ZbC� ! 1 Inc (C L4 LiC2• ' lDl `l AGE f2lf CITY 1'n }"t• STATE ZIP DOB ❑ Sn ❑ M OT Ow ❑Th ❑ F ❑ S DRIVER'S LICENSE# L ' PHONE 7 7-$061:1 NATURE OF DISPATCH Ut TYPE OF TRANSPORT:, AMBULANCE 0 OTHER ` STATION 11A)_2(B)_3(C)_4(D)_5(E)_ I' INCIDENT LOCATION-, RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR C,L�O�K) J 1„ TO SCENE- O. CALL RECEIVED `t f O 3 r.D. TIME 10-8 PATIENT DESTlNATlON: FROM SCENE- .�� ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END - TIME 10-98 h DOCTOR PMD/ER STATIME 10-22 , y HOW CHOSEN: _.. _ TOTAL STANDBY TIME NEAREST, ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE COMPANY: c la 0 Ic I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ��J\ RESPONSE ZONE Z_ ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER •% v PATIENT CONDITION: "-+ DRIVE9EMT-1A LI :);Ir'kj ` ..._.) TECHNICIAN 0 RAMEDIC 1 Hx: ?-� DISPATCHER: lo -1_ /" / CHIEF COMPLAINT: '�s�}n 1 N-JOCK' DRY RUN: RYES -❑ NO REASON FOR DRY' LIN IC) -Z Z- 10 AT ti� ZATION FO RUN(EMS USE OILY) ,��-�� }�_I}i Er C4 1 PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE:_...... INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS#: 1 TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHO/PPRP#r` 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/RESPONSIBL PARTY:-' - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: ELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: . STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE DRY RUN: (AUTHORIZED) ! EMPLOYER: - OCCUPATION- OTHER: ADDRESS: CITY: STATE:-ZIP: COMMENTS:- b41 TOTAL: 17 PATIENT RECEIVED BY: X_- 002 q.n•i.lar r•ir: - Ln.;.,. .. i (SIGNATURE) "'� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 3 ` 63 {j2 t 2 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME `- �� t) OI M O F COMPANY N ADDRESS AGE A CITY STATE ZIP DOB ❑ Sn O M O T O W O Th O F O DRIVER'S LICENSE M " PHONE _— NATURE OF DISPATCH TYPE OF TRANSPORT:I AMBULANCE OTHER 0 _ �- STATION 1(A)_2(8)_3(C)_4(D)-_5(E_ INCIDENT LOCATION: %I RES0ONSE CODE: RE PUESTED FAY: TIME—(24 HOUR CLOAK) F TO SCENE- S.O. ( CALL RECEIVED �� 'O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 11FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ' END TIME 10-98 _ i DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ;,• NEAREST O /F MILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i1 RESPONSE ZONE �� O YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER lJJ PATIENT CONDITION: DRIVER -iA v TECHNICIAN F A� EDIC j Hx: DISPATCHE 'i r3 / CHIEF COMPLAINT: DRY RUN: YES 13NO REA ON FOR DRY RUN .� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES;❑ NO NO.OF PATIENTS: �' 7T_S S.S. N / PRIVATE INS. CO.: BASE RATE: ' KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) _:.09 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: ''COMMENTS: TOTAL: ----- - 00224 PATIENT RECEIVED BY. X . �_.. rel,j- 0-1, .I .. (SICNA fURE) , CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �--�-L� AUTHORIZAT ON M��/4' �?,5 CHECK OR FILL IN APPROPRIATE SPACES DATE: ` PATIENTS NAME .{�L�I`t N M O F COMPANY 0 ADDRESS / Z. C R�� I AGE_A0 o/q 5-' I CITY C .rTJZ12H STATE�A _— ZIP%�5e: DOR*� O Sn OM OT O W O'Th' ❑ F OS DRIVER'S LICENSE 0 _ P PNE rte' — NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEOTHER O _ -- STATION 1(A)_2(B)_3(C)_4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL4'(fK) S� J�j TO SCENE- ( '�.0. CALL RECEIVED I ,"6 ❑ P.D. TIME 10-8 �L7 1_ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 \' 2 O PSAP TIME 10-49 I fi� MILEAGE: ❑ OTHER/PVT TIME 10-7 END �'� TIME 10-98 DOCTOP /ER START TIME 10-22 HOW CH EN: TOTAL I �� -� STANDBY TIME ❑ NEARES ILY 13TRANSFER ✓ WAIT TIME XPATIENT 13 DIRECT 13 OTHER I CALL BACK R AMBULANCE COMPANY:nA� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: -�L j RESPONSE ZONE I l c :{ YES ONO ❑ WAL`CED GUERNEY O OTHER PATIENT CONDITION. DRIVER ��H EMT-1A TECHNICIAN '� ) PARAMEDI � fr6 Hx: DISPATCHER; t �' J i)/'D CHIEF COMPLAINT: DRY RUN: OYES ❑ NO REASON FOR DRY RUN it AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: S. S. BASE RATE: �� KAIS MULTIPLE PTS. BASE RATE BLUE C S N: TOTAL MILES: �� X CARE 4: E.O.B.ATT. ROUND TRIP: ❑ YES O NO O YES .O NO NIGHT: (19:00-07:00) CCHP/PPHP R: EMERGENCY RUN: I ' / o MEDI-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER Cl YES ONO NEONATAL: (INCUBATOR) G y DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X NDRUGS: (PER ADMIN.) X NAME: REL TIONSHIP: _ E.O.A.: (IF NOT REPLACED) } � ADDRES j ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_CA ZIP.q� C-COLLAR: (IF NOT REPLACED) i PHONE:(08o 114L,5WORK PHONE: DRY RUN: (AUTHORIZED) -`EMPLOYER:&A 6£f C OCCUPATION: OTHER: 1 ADDRESS: II CITY: '� N aT ?g�4, STATE:L��L ,,I4 ZIP: COMMENTS: 7 �. - ..t._ TOTAL " '- _ PATIENT RECEIVED BY X.-- .. 2 2 5 'J(,NAiI. f . I It � I• `.). . ONTAA COSTA COUNTY AMBULANCE 3I T� RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N _� CHECK OR FILL IN APPROPRIATE SPACES DATE: •, �, ; 4'PATIENTS NAME ( 1 OM OF COMPANY 0 ADDRESS-'.Y' '''' Iv AGE V 1 CITY -- TATER__,,_ ZIP DOBE_ O Sn O M O T O W O Th O F O S _ �:, ; Y,:-1 . . : , . DRIVER'S L16EN§E N L. - ) PHONE NATURE OF DISPATCH t'c TYPE OF TRANSPORT: AMBULANCE OTHER _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:? = RESPONSE R�E�ESTEO BY: TIME— (24 HOUR C}9CK) _ TO SCEN - 3 B�S.O. CALL RECEIVED / (/� r 429 X t iii A U/S W) >t w/C 11 I r /� O P.D. TIME 10-8 �'_ \_ PATIENT DESTINATION: - ) FROM SCENE-/ ❑ FIRE TIME 10-97 n i ",'� -t-�� ❑ PSAP TIME 10-49 . I' 1,h,j•�7.[,• u� MILEAGE: ❑ OTHER/PVT TIME 10-7 ( END TIME 10--98.. 006TOR- t"• j PMD/ER START TIME 10-22 HOW CHOSEN: ._.._ TOTAL STANDBY TIME O NEAREST;'? O FAMA ❑ TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK R: AMBULANCE COMPANY: 1O PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO , ❑ WALKED O GUERNEY ❑ OTHER (-J PATIENT CONDITION: DRIVER I?Lv ✓,'J I I U EMT-tA _. TECHNICIAN �' ARAMEDIC Hx: DISPATCHER: 111 y CHIEF COMPLAINT: I DRY RUN: / YES 13NO REASON FOR DRY RUN z- O u C� AUTHORIZ TION FOR DRY RUN(EMS USE ONLY) i L)w PATIENT REFUSED SERVICES: (SIGNATURE) X C1 3�t i •': - MEDICAL COVERAGE;. . INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: J S.S.tt 1 PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE GLUE CROSS M: TOTAL MILES: X ! MEDICARE R: E.O.B. ATT. ROUND TRIP: O YES O NO O YES 0 NO NIGHT: (19:00-07:00) CCHP/PPRP K:'' EMERGENCY RUN: MEDI-CAL tt: CODE 2/3 OTHER: OXYGEN:; (PER TANK) P.O.E.STICKER O S O 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) `C!/•�v EMPLOYER: OCCUPATION: OTHER: ADDRESS: STATE' ZIP: I COMMENTS:- '- TOTAL: ��' 022.9-• PATIENT RECEIVED BY:X P•mi 4r •..! '. ,n.{., ,., n.,, i (SIGNATURE) CONTRA COSTA C N AMBULANCE p PRE-HOSPITAL CAA FORM I UNIT ' 3 AUTHORIZATION N -3 7 ` CHECK OR FILL IN APPROPRIATE SPACES DATE:. ^� V PATIENTS NAME*- 17 M O F COMPANY N ADDRESS J AGE'S t U t ' '• CITY - STATE P ter, .DOB O Sn OM ❑ T Ow O Th ❑ F ❑3 DRIVER'-,' ICENSl: PHONE 1 , NATURE OF DISPATCH ' S'�I N - -_t TYPE OF TRA S�PO�R,T:I AMBULANCE OTHER _ STATION 1(A)_-2(B)_3(C)_4(D)_.6(E)_. INCIDEN LOCANT O-. 1 or) RtSPONSE CODE: RE ESTED Bx: TIME- (24 HOUR CLOCK) ~-- Irl TO SCENE- S.O. L CC CALL RECEIVED Li0; ❑ D. TIME 10-8 PANT DESTINATION:•- FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE' ❑ OTHER/PVT TIME 10-7 J r •• -1 END TIME 10-98 DOCTOR PMD/ER STAR TIME 10 22 HOW CHOSEN: TOTAL STANDBY TIME Ca jO ,:;NEAREST O FAMILY O TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP Y:^^cc PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO 11 WALKED 13GUERNEY 11OTHER PATIENT CONDITION: DRIVER _ A TECHNICIAN S 1-� P AMEDIC 5 J Hx: DISPATCHER: Lill) . CHIEF COMPLAINT: DRY RUN:JWYES 13N NO R S FOR DRY RUN - / t AUTHORIZATION FOR DRY RUN(EMS USE ONLY) QNNy r A. .::: PATIENT REFUSEDSE ICES:(SIGNATURE) X 5Z MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: Jo S.S.N PRIVATE INS.CO.: BASE RATE: KAISER tl: 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/PPHP N:' I EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER:-"-' OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) - NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X --.NAME:' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) r 'CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) EMPLOYER:' OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: ry --- PATIENT RECEIVED BY:X (� C Pnwi.ier rpt i!. hit, I :•: (SIGNA LURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION a CHECK OR fILL N APPROPglA7E SP ces �DATE: PATIENT'S NAM�,_L�_S ❑ M SCJ F COMPANY a ADDRESS LL<�l �1�- AGE 6 CITY. _. STATE ZIP __ DOB- j Sn ❑ M ❑ T ❑ W ❑ ❑ F � DRIVER'S LICENSE a PHONE3�__.__. NATURE OF DISPATCH 1 rt-S. TYPE OF TRANSPORT_ AMBULANCE OTHER❑ IL., INCIDENT LOCATION: RESPONSE CODE: RE9,UESTED B TIME- (24 HOUR CL K) Z ' / TO SCENE- ws.O._CC-� CALL RECEIVED ❑ P.U._ TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 J_2S ❑ PSAP TIME 10.49 : s� MILEAG ❑ OTHER/PVT TIME 10-7 END--�J TIME 10-98 ----- DOCTOR / DOCTOR ���_ pMD ER START ,�_ TIME 10-22 HOW CHOSEN: TOTAL --�7/ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑PATIENT ❑ DIRECT ❑ OTHER L� CALL BACKa: AMBULANCE COMPANY: _5 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE -0 YES ❑ NO ❑ WAL: CONTRA COSTA COUNTY AMBU ANCE PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: 7 .,P/(TIENT �IAMEi � I� I� �NNFTTI (yt OF COMPANY# < < G1 1— ! l DR SS _LI I� V 1�ALd.. ;' � l j N �--'j� 7� AGE-Li I > J _ ITY Z lit. STATE ZIP `I �� G DOB-&-- 7:E+`1 ❑ Sn ❑ M O T O W O Th OF XS` 4"RIVER'S LICENSE# _ _ PHONE NATURE OF DISPATCHS I w TYPE OF TRANSPORT: AMBULANCE OTHER❑ _. STATION 1(A)_..(_2(8)_31C1_4(D)_51E1_ 4L. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME - 124 HOUR CLOCK) TO SCENE- gCS,O. _ CALL RECEIVED �� '❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 T Z � -I 7 �" O PSAP TIME 10-49 _1 - �T 1 1 { Ll Ln L.7�I MILEAGE- ❑ OTHER/PVT TIME 10-7 �JEND ��1[' / TIME 10.98 DOCTOR PMD/ER START--CO TIME 10.22 HOW CHOSEN: TOTAL S STANDBY TIME 13-_t S _) ❑ FAMILY O TRANSFER WAIT TIME _- .s PATI T ❑ DIRECT O OTHER CALL BACK#: AMBULANCE COMP Y*, { P�ULATORY? PATEN KEN TO AMBULANCE: RESPONSE ZONE ll� YE5.)O NO �) WAl'<E O GUERNEY O OTHER 1 '7 PATIENT CONDITION. DRIVER r - - EMT-lA TECHNICIAN r � PARAMEDIC Hx: ►'�til TRL c-D61 _n• DISPATCHER: �- (_I -> C, CHIEF COMPLAINT: r2 1 5�-LC I DRY RUN: ❑ YES NO REASON FOR DRY RUN lt-'RAn TL'1 Trask AUTHORIZATION PSR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- I �r M COVERAGE: INDUSTRIAL O YES NO NO. OF PATIENTS: s.s 9-z 4 T- 66 PRIVATE INS. CO.: BASE RATE KAISER#:- MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: ` X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO toEOl- _ O YES O NO NIGHT: (19:00-07:00)POeiss [POT AP K E h1OJ- C � EMERGENCY RUN:07630319088803 CODE2/3 09 9 3 P 64 Fl 4 OXYGEN: (PER TANK) 11KER O YES "_0 NEONATAL: (INCUBATOR) /I777V 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 -I r- < RELATIONSHIP: A 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're,( IC-TO �) -- 1. o 1 ` - - --- - -- ._ . . ----- PATIENT RECFIVUD BY x t �� I �1�'.� ��l' •� • '; ��1 fCONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME-(L&,, �,A ti;�- - O M XF COMPANY N ( �� ADORE ( S ��' '� i q/ AGE n U - CITY `''1 i l.I�\ '^:"'T\l l STATE v ZIP Ctl 1U DOB [ -�- Sn 0 ❑ T ❑ ❑ W Th S DRIVER'S LICENSE t+ _____ _�___. PHONEA�TURE OF DISPATCH- TYPE ISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O — — STATION 1(AIAeZl I -3(C)_.4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: RESTED BY: TIME— (24 HOUR CL )S G 1 TO SCENE- S.O..,SCALL RECEIVED _ O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-' ❑ FIRE TIME 10-97 �• _�,5.1 'T O PSAP TIME 10-49 : G MILEAGE (� C� ❑ OTHER/PVT TIME 10 7 `�" END L',� TIME 10-98 7� DOCTOR --�-_ PMD/ER START �� J TIME 10-22 H W CHOSEN:'--____ TOTAL ~ STANDBY TIME - J CGy NEAREST O FAMILY ❑ TRANSFER WAIT TIME O'PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMP Y: PjT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE _ L` YES ❑ NO ';R WAL KEDAGUERNEY ❑ OTHER � 7 PATIENT CONDITION: DRIVER , EMT-tA TECHNICIAN ` PA AMEDIC Hz:,, �_�/�i� DISPATCHER: ' CHIEF OMPLAINT: - Ilk 11 DRY RUN: ❑ YES O bEA N FOR DRY RUN l .r ) AUTHORIZATION F PR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: � rDQSJRJAL ❑ YESANO NO. OF PATIENTS: S "' , S.S. 4A ' ,' +� PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: l X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP k; I 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 t DRUGS: (PER ADMIN.) X NAME,` `'�'`il)% `�"{-1 1 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL::— -y PATIENT RECEIVED BY:X (SIGNATURE) (�' Provider retain White -,d Pink ropy Aeturn yearn ;•npy t, Vc9 when bii"ing 002 1 �� CONTRA COSTA COUNTY AMBULANCE Q� P E-HOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION M t ' L CHECK OR FILL INAPfA4PRIATE SPACES ' DATE: PATIENT'S NAME .L t L ❑ M O F COMPANY M / - 3 ADDRESS AGE q CITY " STATE ZIP DOB _ ❑ Sn ❑ M ❑ T[❑ W ❑ Th O F DRIVER'S LICENSE# PHONE ____ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: : RESPONSE CODE:' RESTED BY: TIME- (24 HOUR CLOCK) / TO SCENE- S.O. CALL RECEIVED : 2 3 ❑ P.D. TIME 10-8 PATIENT DE �^ FROM SCENE - ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49 �S 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 j I END TIME 10-98 DOCTOR ` PMD/ER START TIME 10-22 r HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST''. [:)'FAMILY ....i❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULAy�C04 �� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZO� c ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER ,PATIENT CONDITION: I DRIVERne(sz>d,7 EMT-1A TECHNICIAN(Zt PARAMEDIC 4 Hz: DISPATCHER: �q CHIEF COMPLAINT: DRY RUN: YES ❑ REASON FOR DRY RUN I/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I( '/ PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: !INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: /C I S.S. # j PRIVATE INS. CO.: BASE RATE: . KAISER C _ _ MULTIPLE PTS. BASE RATE I ' i BLUE CROSS N: TOTAL MILES: X MEDICARE 8: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) ) CCHP/PPRP M: EMERGENCY RUN: I ' 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/R SPONSIBLE 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) j PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: i TOTAL: ED r nATu'I1T nrrrwrr nv r 00231 CONTRA COSTA COUNTY AMBULANCE ��/� PRE-HOSPITAL CAPE F9RM I UNIT i AUTHORIZATION N CHECK OR FILL/N APPROPRIATE SPACES DATE: �^ PATIENT'S NAME.' \/ �/ O M ❑ F COMPANY N I �� ADDRESS AGE- CITY GE CITY i - STATE - ZIP DOB ❑ Sn OM OT O W ❑ Th O F DRIVER'S LICENSE u __— ___. _ PHONE _� NATURE OF DISPATCH � _r TYPE OF TRANSPORT: AMBULANCE O OTHER❑ -- STATION 1(A)_2(B)-3(C)_4(D)_5(E)_ -- INCIDENT LOCATION: ? RESPONSE CO E REQUESTED BY: TIME— (24 HOUR CLOQK)�,/ J TO SCENE 9P.D. TIME 0-8 RECEIVED PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Z 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 M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: j\ RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LAA, 6EMT-1A _ 1 TECHNICIAN I&I[ )� Hx. _ ') DISPAT HER: CHIEF COMPLAINT: ��_C DRY RUN: �S ❑ NO S N FOR DRY RUN - Rt`✓jl4 L- • AUTHORI TIO FOR DRY R�U�N(EMS (JSf ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__ !" 1/)n L C / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: - KAISER a: 1 MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X MEDICARE 4: / E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO / ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: MEDI-CAL k: CODE 2/3 -" � ,►1(%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) 5 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL �!�•Gf \ PATIENT RECEIVED BY:X .., �"�,• -Sf Pmoidrr rnrn'• (SIGNATURE) V1 i rr. r� Sr•r. . y -�, Mo L•A•v Fi I'ino 00237 1 1 I , • CONTRA COSTA COUNTY AMBULANCE P E-HOSPITAL CARE FORM I NIT AUTHORIZATION MQ-0� •, CMfCK OR fllL IM p TE SPACES DATE: ' ' `.PATIENTS NAME 1 �Om O.F COMPANY N, f , ADDRESS AGE CITY STATE ZIP DOB ❑ Sn OM OT OW O Th ❑ F?4; S DRIVER'S LICENSE N i PHONE - NATURE OF DISPAT� c TYPE OF TRANSPORT: AMBULANCE OTHER -- . STATION 1(A)V2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: xOp. UESTED BY: TIME-(24 HOUR 9CK) TO SCENE .O. CALL RECEIVED .'^ D. TIME 10-8 �•, .bi1 . PATIENT DESTINATION: _ ` i FROM SC - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE. ❑ OTHER/PVT TIME 10-7 ENDTIM£ 10-98 DOCTOR I t PMD/ER- START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 13AMI NEAREST FLY 13 TRANSFER WAIT TIME �— ` O PATIENT ' O DIRECT ❑ OTHER CALL BACK C AMBULANCE COMP Y: - �i�S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1.� RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER PATIENT CONDITION: .. . .) DRIVER 3 EMT-tA �; �I ;�1 • 'i �,� ! TECHNICIAN PARAMEDIC Hx: DISPATC CHIEF COMPLAINT: DRY RUN YES ❑ NO R ASON FOR DRY RUN77 `ICCj AUTHO IZAT N FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SE ICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: c CD S.S. N PRIVATE INS.CO.: 1' ' BASE RATE: KAISER M: rl-�- MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ONO / ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 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/ ESPONSIBLE 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) Wfu EMPLOYER: �� OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL ?V 00233. PATIENT RECEIVED BY:X (SIGNATURE) rl�J CONTRA COSTA COUNTY AMBULANCE q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME O M O F COMPANY ADDRESS. 1 AGE�� c 0 je CITY _ STATE ZIP_____--^�.* DOB O Sn O M O T O W O ThO F O S •_` s DRIVER'S LICENSE N _-- ' PHONE NATURE OF DISPATCH - 1 TYPE OFTRANSPORT:i AMBULANCE 0 OTHER 0STATION 1(A)_2(8)_31C1_.4(D)_51E►_ INC IDENT.LOCATION:r - i RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) , ,/ 1 TO SCENE- ZI-S.O. CALL RECEIVED I�� �`��� / ) y �' ' ..,r •� . ; ❑ P.D. TIME 10-8 r �- PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 ❑ PSAP TIME 10-49 •'/ y/ `I i ~� MILEAGE: O OTHER/PVT TIME 10-7 .� END TIME 10-98 Z. \ ; DOCTOR T� ^1 PMD/EA START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME + �. 13,NEARESIL T-" O FAMILY O TRANSFER WAIT TIME _ O PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE I, ❑ YES O NO O WALKED O GUERNEY O OTHER. 1 PATIENT CONDITION: DRIVER Jn-S L L / IS-> EMT-1A ' TECHNICIAN PARAMEDIC qqqHx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN � � ! q`l l AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL OYES ONO NO..OF PATIENTS: yrs S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: + MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X 1 MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES O NO _. O YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: ' EMERGENCY RUN: ME I-CAL N: CODE 2/3 PTH R: I I ' OXYGEN: (PER TANK) P.O.E. TICKER OYES ONO NEONATAL: (INCUBATOR) DATES LLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "NEAREST R -ATIVE/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 '-*COMMENTS:: TOTAL: 'oe _ PATIENT RECEIVED BY; X 00234 (SIGNXTIME) [MS-1 CONTRA COSTA COUNTY AMBULANCE ��� �3 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N _ - &3 CHECK OR FILL INA PPAOPRIA/E SPACES DATE:_ PATIENT'S NAME_ __l��_r,� .".� _C, ❑ M XF COMPANY ADDRESS ..� jL3-._.�_C,r_�.L._f'C->�_�1-,.�h -- PGE �.Sn CITYSTATE'5 ZIP__ — DOB-__- Sn ❑ M ❑ T ❑ W ❑ Th ❑ IF11 S � DRIVER'S LICENSE N _. . . ..,._ _ PHONE_.__ .- NATURE OF DISPATCH140o, I Arr '-'fi}�.r TYPE OF TRANSPORT: AMBULANCE❑ CTHER❑ INCIDENT LOCATION: RESPONSE CODE: UESTED BY: TIME- (24 HOUR C K) r � TO SCENE- S.O. CALL RECEIVED o , L 6 r3. . RE __Cc,�LC_G ��Q�_.'j_�1.0 n -___.� _ ❑ P D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.79 OTHER/PVT t � MILEAGE: ❑ OTHER/PVT TIME 10-7 ( � END _ TIME 10-98 - DOCTOR - �✓ _ PMD/ER START_ TIME 10-22 :G� HOW CHOSEN: % TOTAL - - STANDBY TIME ❑ NEAREST /❑ FAMILY ❑ TRANSFER f WAIT TIME ❑ PATIENT Cl DIRECT ❑ OTHER / CALL BACK N: AMBULANCE COMP - - PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONSE ZO Rmftm 9l ES ❑ NO ElWAL"ED ElGUERNEY ❑ OTHER C Q�E- �:� PATIENT CONDITION. DRIVERQI_SSo��__ pcr EMT-1A - • TECHNICIAN _ _ (�jn �� S PARAMEDIC O Y1� Hx --.... -.----------------- --. .. ----- ---- DISPATCHER: CHIEF COMPLAINT: R,+-pt'cr_ L�(�Cn_>>`_��` 1__ DRY RUN: kYES ❑ NO RES ON FOR DRY RUN �r✓�'�-C r4�er�___F Ch-� �_ �C�iN AUTHORIZATION FCR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X _i __ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIE;.BASE : [� :(O S.S. PRIVATE INS. CO.: ___ _ BASE RATE: = KAISER:': .__ ---_ _ MULTIPLE PT RATE -X �I BLUE CROSS N: -� / TOTAL MILES:' X AMEDICARE u. jj -E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO j ❑ YES ❑ NO NIGHT (19:00-07:00) i- CCHP;PPHP It: EMERGENCY RUN: v '� 10 MEDI-CAL a: - , -, 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 TATE: .ZIP:COMMENTSP- --- ------ ._---`�_._ TOTAL: n �Q -------------•------ —_-.....-- -_—_-.--__-__ . . PATIENT RECEIVED BY: X_ `- _.. - �\ n ...,;: . .,•r: :.., / (SIGNATURE) L•11G-) I • CONTRA COSTA COUNTY AMBULANCE � PRE-HOSPITAL CARE FORM I UNIT ® AUTHOR12 ON 0 .46 35 r CHECK OR RLL/N APPROPRIATE SPACES DATE: `PATIENT'S'NAME _�df\ t7_ 2t(i ❑V/V .I.i- U ` COMPANY ADDRESS ;T (� f i AGE CITYr ] 1 STATE_ ZIP _, DOS '"Q Sn ❑ M 0 T ❑ W ❑Thi,(3 F 13S DRIVER'S LICENSE N PHONE ___,._ NATURE OF DISPATCI -f y TYPE OF.TRANSPORT:!AMBULANCE 0 OTHER❑ - l STATION I IA),_2(B)_3(CI_4(D)_5(E)_ ' INCIDENT J_OCAT10N:r %'• RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) I TO SCENE- ? I ffi S.O. CALL RECEIVED , �� ✓� ( Nlr� i)e( ,.. ,• J I ❑ P.D. TIME 10-8 r I + 1 PATIENT DESTINATIO :- FROM SCENE- ❑ FIRE TIME 10-97 / }1 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-71 t END I TIME 10-98 S?DOCTOA s T" PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL; STANDBY TIME ❑ NEA IL ❑ TRANSFER WAIT TIME 13P TIENT ❑ Din 0 OTHER CALL-BACK C AMBULANCE COMPANY: PT. AMBULATORY? I PATTEN TAKEN TO AMBULANCE: I S U RESPONSE ZONE C3 YES ❑,NOS,; ❑ WA" ED 13GUERNEY 0 OTHER: '" ' ` + PATIENT CONDITION-.—. �; DRIVER. EMT-1A I `V' TECHNICIAN�_{L Nnx ��LT-D 0 PARAMEDIC i Hx: DISPATCHER: ✓" � / CHIEF COMPLAINT: DRY RUN: •YES 0 NO REASON FOR DRY RUN �Z QQq I AUTHORISATION FOR DRY RUN(EMS USE ONLY). / I 'PATIENT REFUS RVICES:(SIGNATURE) X h 95� MEDICAL COVERAGE: , INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: .� 1 `t I i ! • PRIVATE INS.CO.: P BASE RATE: -" KAISER 4 MULTIPLE PTS..BASE RATE i BLUE CROSS K: TOTAL MILES: ) X MEDICARE M; E.O.B. ATT. ROUND TRIP: '0 YES 0 NO ! ❑ YES ❑ NO NIGHT: (19:00 07:00) r CCHp/PPRP N`.^ ( EMERGENCY i UN: --y 1 MEDT-CAL M; ( ` � CODE 2 V 3 ! cOTHER: C ' OXYGEN:, (PEP TANK) P.O.E. STICKER ❑ YE ❑ NO y NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "NEAREST RELATIVE/R SPONSIBLE PARTY: - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "NAME: - -RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (1F NOT REPLACED) ..STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHON V I WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE* ZIP: '-'COMMENTS: TOTAL: PATIENT RECEIVED BY:X 00236 n....:..... .. .. ... (SIGNATIIRF) ! �{ T i CONTRA COSTA COUNTYAMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 93 16 7VV !•tel CNECK OR fltl INAPPROPRIATE SPACES DATE: - 7 PATIENT'ls NAME ( O'M. O F COMPANY N r ADDRESS AGE ` +� CITY STATE ZIP DOB- -O Sn OM OT O W O Th OF O S DRIVER'S LICENSE N f I ' PHONE NATURE OF DISPATCH TYPE OF.TRANSPORT: AMBULANCE 0 OTHER -- STATION 1(A)._2(81_3(C)_4(D)_5(E)_ t IN (DENT LOCATION:"` �" •v' r'. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) i �1 S.O. CALL RECEIVED 1Z : a TO SCENE- .� 7' .• G�i[t G GQ�CQ.O"'c t! ❑ P.D. TIME 10.8 P TENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 �.-- ❑ PSAP TIME 10-49 :t �,Jol ,^_ I MILEAGE: ❑ OTHER/PVT TIME 110-7 \�— / _ END TIME 10.98 rDOCTOR l' PMD/ER START TIME 10.22 i.. HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST., ❑ FAMILY O TRANSFER WAIT TIME 13..O PATIENT""2 ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: S [RESPONSE ZONE O YES ❑ NO O WALKED O GUERNEY ❑ OTHER; PATIENT CONDITION: .... _. DRIVER �i�ij�,(j�1'}« -}/ EMT-1A TECHNICIAN UG/^�L % PARAMEDIC yIHx: DISPATCHER: 'Wee 143 � 16-Cl , CHIEF COMPLAINT: r DRY RUN: E1 YES O NO REASON FOR DRY RUN .N R9AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ; `j '.:. -.PATIENT REFUSED SERVICES: (SIGNATURE) X !✓� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N r { PRIVATE INS.CO.: / BASE RATE: _ KAISER C. MULTIPLE PTS. BASE RATE - BLUE CROSS N: + '• TOTAL MILES: X l MEDICARE 0: E.O.B. ATT. ROUND TRIP: O YES ONO t_ OYES ❑ NO NIGHT: (19:00-07.00) CCHP/PPRP A: ' EMERGENCY RUN: MEDT-CAL N: "-` ' 'CODE 2/3 i OTHER: OXYGEN:.(PER TANK) J 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) :1'.•y PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER�_ OCCUPATION: OTHER: ADDRESS: • CITY: STATE: ZIP: �.COMMENTS: TOTAL: Cr,0•dz) • (�IIrrk� r�� �i3 0l� 7 a PATIENT RECEIVED BY: X.... __, -_ - Pr•avidar retain Yhiti rrd Pin: rupp M�ta.rn v,••; .L ••err r • �r.. ,.� lir ;•�,r 11.1I(SIGNATI RE) l �• •+ ' CONTRA COSTA COUNTY , AMBULANCE V 2 1 '? �� PREHOSPITAL CARE FORM { UNIT AUTHORIZATION M O J CHECK OR MLL M APPROPRIATE SPACES DATE: , 9 = 2 --E . •PATIENTS NAME �J. 2 O'M* O F COMPANY N ADDRESS AGE CITY STATE ZIP DOQ�1 xsl- OM OT. O W OTh OF O S j r . i I : �. I , DRIVER'S LICENSE 0 - PHONE NATURE OF DISPATCH QK� TYPE OF TRANSPORT:I AMBULANCE 0 OTHER = STATION 1(A)_2(B)_3(C)_4(D)_5(EI_ NCIDENT LOCATION;' - �t6`Sf10NSE CODE! UESTED BY: TIME— (24 HOUR CLOCK) (� j C TO SCEN Z 'N S.O. CALL RECEIVED ❑ P.D. TIME 1D-8 t PATIENT DESTINATION: FROM SIE E- 13 FIRE TIME 10-97 1� U-ZZi ❑ PSAP TIME 1049 ��- • j L/ MILEAGE: ❑ OTHER/PVT TIME 10-7 N T ` END TIME 10-98 rLDOCTOR•' ' PMD/ER l START TIME 10-22 HOW CHOSEN: _ TOTAL�� STANDBY TIME • O NEAREST ❑ FAMILY O TRANSFER I WAIT TIME —_ O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPArIY;, /• PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C L) RESPONSE ZONE O YES .❑ NQ ., I 13WALKED 11GUERNEY 13 OTHER. PATIENT CONDITION,—- DRIVER �✓� �� �' EMT-1A i TECHNICIANS PARAMEDIC Hx: DISPATCHER: r r CHIEF COMPLAINT: I DRY RUN: ES ONO REASON FOR DRY RUN 1 C) -(7 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 I r it/'•,:I i.: PATIENT REFUSED SERVICES: (SIGNATURE) X 7 MEDICAL COVERAGE: INDUSTRIAL O YES ONO NO, OF PATIENTS: S.S. K i PRIVATE INS. CO.: BASE RATE:- KAISER W. MULTIPLE PTS.BASE RATE BLUE CROSS N: • `' "'t I TOTAL MILES: X - I MEDICARE C a E.O.B.ATT. ROUND TRIP:• O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 4: f I EMERGENCY•RUN: MEDI-CAL 8: " ( , 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:• !ham TOTAL:L -- N`� O0238•.., ._... _.. .. n1T,rp,T r•r^rt%,rn n-, v I CONTRA COSTA COUNTY ` AMBULANCE -39 / / -7 S- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M V CHECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENT'S NAME ❑ M -❑ F COMPANY f ADDRESS AGE CITY - &TATE ZIPS- DOB- - �.Sn ❑ M ❑ T OW ❑ TA ❑ F ❑S" -' DRIVER'S LICENSE M _-----j PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCED OTHER❑ ' STATION 1(A)_2(8)_3(C)_4(D)_5(E).._ 1 INCIDENT L•QCATION:r� -I RdSPONSE CODE: REQUESTED BY: TIME— (24 HOUR 01 n K) I� � /i t^_ D, ,Q••„ TO SC€{IE- S.O. CALL RECEIVED _• G y�/. 40�141 �/ / ►'1 �Jl3C. L_ ❑ P.O. TIME 10-8 T OESTINATION:•-- FROM SCEN - ❑ FIRE -- TIME 10-97 / ❑ PSAP TIME 10-49 1 ?3V:!n '��ISl:a -- MILEAGE^ ❑ OTHER/PVT TIME 10-7 Y' �� END TIME 10-98 , At5bcTOA 1 sr` •�"'' f ~—� PMDfER START TIME 10-22 . : ZL HOW CHOSEN: ,-. ._ _, TOTAL STANDBY TIME r M:-"❑.NEAREST(rP_ O FAMILY ❑ TRANSFER " WAIT TIME 1 O PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE CO �O I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �. RESPONSE ZONE ❑,.YES, t❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER i J� .' ,L C� 1 PATIENT CONDITION: - DRIVER � _ EMT-1A I TECHNICIAN ✓ _' "— ARAMEOIC n Hx: DISPATCHER: J I ! � yv j u CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN .AUTHORI N FOR DRY RUN(EMS USE ONLY) '] ( }7,Z,•1.!':, PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE;-- INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: L I S.S.M PRIVATE INS. CO.: BASE RATE: f KAISER 0 ; MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X 1 E,O.B.ATT. ROUND TRIP: ❑ YES ❑ NO MEDICARE M: ' _ I ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP•:'' ► (� ( EMERGENCY RUN: MEDI-CAL R: , " 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) .r PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) �•�J EMPLOYER: OCCUPATION% OTHER: ADDRESS: "'-CITY: - STATE: - ZIP: —COMMENTS: - TOTAL: • ��.__ PATIENT RECF..IVFD BY X .. . .. CONTRA COSTA COUNTY t AMBULANCE �3 /G 7–TY PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N I G i 55 CNECK OR FILL IN APPROPRIATE SPACES - DATE: / PATIENTS NAME S�O lir_ -�L c� n� S �J M ❑ F COMPANY N -� Cj �'? C' -J . 1 : ADDRESS 7�� f n ice- 1 c__ AGE CITY /L • c- t, STATE c ZIP DOB L"7L 3L 17 Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N -- PHONENATURE OF DISPATCH tr• TYPE OF TRANSPORT: AMBULANCE Ll OTHER — —_.._ STATION 1(AJz-2(B)_3(C)-4(D)_51E1— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLgCK) L tI TO SCENE 3 0 P U. TIME a8 RECEIVED � i: Y �� -709 pGHnSYI✓ .. .'t— PATIENT DESTINATION. FROM SCENE- a ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE. / ❑ OTHER/PVT TIME 10-7 END _ TIME 10-98 DOCTOR / PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST d FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: c /1 x PT. AMBULA Y? PATIENT TAKEN TO BULANCE: J RESPONSE ZONE ❑ YES 9440 ❑ WALKED ❑ GkItRNEY ❑ OTHER PATIENT CONDITION: DRIVER A r 1 I EMT-1A- TECHNICIAN S' 1_ -_ r i��., L b�• pARAMEDIC � Hx: fivo"ar=X4.3,% DISPAT HER/� � �;1 _'1-C ( L J . l 'I CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN a(7� Y AUTHORIZATION FOR DRY RUN(EMS USE O LY)- PATIENT REFUSED SERVICES: (SIGNATURE) ,�� T. T�Z -, MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: ' KAISER N: MULTIPLE PTS. BASE RATE — I BLUE CROSS N r, A TOTAL MILES: X MEDICARE N: E. .B. ATT. ROUND TRIP: ❑ YES ❑ NO YES ❑ NO NIGHT: (19:00-07:00) 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 NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORA4 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 3�:.o0 ... ---- -- —.. _.-.-----.--- --.-----------.-....-----.... I'A11ENI RECEIVI0BY X ,. t:u:�intl.nt 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 11 8 3- !676 I{ CNECK OR.FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME --lb r—' OM ❑ F COMPANY 0 1 2 9 GOS ADDRESS '' AGE CITY -STATE .ZIP DOB Sn X 11 T O W O Th O F .O S DRIVER'S LICENSE N t PHONE NATURE OF DISPATCH 4d m kso+" TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 1(A_2(8)-_3(C)_4(D)_5(E)_ 1 A INCIDENT•LOCATION:j _ } RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) yt� TO SCENE- S.O. CALL RECEIVED \ ZI Ll Ll S ;t r . " 3 O P.D. TIME 10-8 S'7 \ PATIENT DESTINATION: - ( FROM SCENE- d. ❑ FIRE TIME 10-97 �(S ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT .TIME 10-7 :9 END TIME 10.98 Si DOCTOR T}''`r PMD/ER- START TIME 10-22 HOW CHOSEN: _ TOTAL ' STANDBY TIME t' 1... ❑ NEAREST' O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: c PT. AMBU RY7 PATIENT TAKEN TO LANCE: S U RESPONSE ZONE f r ❑ YE NO ! ❑ WALKED ❑ RNEY ❑ OTHER i PATIENT CONDITION: DRIVER /Tr_ EMT-tA TECHNICIAN SA e-r PARAMEDIC Hz: } DISPATCHER: o ( � CHIEF COMPLAINT: DRY RUNXYES 13 NO REASON FOR DRY RUN-Jipn� IL AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REF SED SERVICES: (SIGNATURE) X �1 I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: I S.S. 0 PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE E.O.B.ATT. ROUND TRIP:/ANK ❑ NO— YES O _ O YES O NO NIGHT: (19:00 ' CCHP/PPHP.#`U ' EMERGENCY MEDI-CAL N: CODE 2 OTHER: OXYGEN: (PE ) P.O.E.STICKER ❑ YES ❑ NO NEONATAL: ( TO DATES BILLED: STANDBY: (OMi .)E.K.G.: (PER NEAREST RELATIVEIRESPONSIBLE PARTY: LV.: IPER ADX DRUGS: (PER :) X NAM£:"" RELATIONSHIP: E.O.A.: (IF NOACED) 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: D 0024 _ PATIFNT RFr'FIvFn nY k a' CONTRA COSTA COUNTY AMBULANCE l PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION k S3_A, CHECK ON FILL IN APPAOPNIATE SPACES DATE: J PATIENTS NAME r-j V S S $1200 k Z�?,-g w K X+ O F COMPANY M ADDRESS iZ 3 6 /y ' YN l� (�/ �- AGE 7 � .) CITY C STATE «' ZIP I7 S.�Fe DOB"-�1 �� ❑ Sn t9 M 0 T Ow O Th ❑ F Os DRIVER'S LICENSE N ___ PHONEL sI l NATURE OF DISPATCH M POie A C TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ __-___ STATION 1(A);2(B)_3(C) D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOC�) TO SCENE- S.O. CALL RECEIVED O 3 �) A)• ✓rA Al V rJ % ?Z- z ❑ P.D. TIME 10-8 0 : ! PATIENT DESTINATION: FROM SCENE ❑ FIRE -_ TIME 10.97 cL, O PSAP TIME 10-49 1 U ._lli.2 �J 1 �) MILEAGE: /1 O OTHER/PVT TIME 10.7 _101^ :I� / (�� END� TIME 10-98 I :�� I �rDOCTOR ��` �� PMDf(�j%) START TIME 10-22 HOW CHOSEN: �� TOTAL U STANDBY TIME L>11. O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT DIRECT O OTHER ` CALL BACK C AMBULANCE COMPANY: e,RESPONSE s• PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j RESPONSE ZONE S VYES O NO fit-WALKED O GUERNEY O OTHER PATIENT CONDITION- DRIVER_,AdJAyll• T- h fF L I I TECHNICIAN � I �" PARAMEDIC � Hx: Q DISPATCHER: CHIEF COMPLAINT: ecADRY RUN: ❑ YES O REASON FOR DRY RUN . AUTHORIZATIO OR RY RUN(EMS USE ONLY) 1 PATIENT R FUSED ERVICES: (SIGNATURE) X- 1 �r AL COVERAGE: INDUSTRIAL ❑ YESO NO.OF PATIENTS: SCI PRIVATE INS.CO.: BASE RATE: eKAIS . MULTIPLE PTS. BASE RATE TOTAL MILES: Xn E.O.B. ATT. ROUND TRIP: O YES O NO ❑ YES .O NO NIGHT: (19:00-07:00) EMERGENCY RUN:CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) �" • p��.. 1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (JF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) - EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: j COMMENTS: - -- --- TOTAL• ^�d •©�- - -- - -- -- --- PATIENTREC,E(VroEKY: X ..� !a • 00242 ItiinrrA n inF l - CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I (J UNIT AUTHORIZATION _ �CHECK ON FILL IN APPROPRIATE SPACES DATE: ME PATIENT'S NAlI M 11F COMPANY N ADL) ESS AGE CITY 1 STATE 1 ZIP ( , 1D EI - ❑ Sn M 1 T O W O Th O F Ip S—) DRIVER'S LICENSE u __ _, PHONE —!l l NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEP OTHER O — . STATION 1(A) 2(8)_3(C)_4(D)_5(E) -- INCIDENT LOCATION: RESPONSE CODE: R OUESTED BY: TIME— (24 HOUR CLQ (1 I r TO SCENE- S.O. CALL RECEIVED Q rill P.D. TIME 10 8 U ,`` PATIENT DESTINATION: FROM SCENE-� O FIRE TIME 10-97 �I 'I l ❑ PSAP - TIME 10-49 _Q 1 \of ` Ur+ h MILEAGE: 6 13OTHER/PVT TIME 10-7 o9 1 END TIME 10-98; DOCTOR / -�- PMD(E TIME 10-22 START HOW CHOSEN: TOTAL '7 STANDBY TIME _�: ""•'3 T�1 NEAREST D FAMILY O TRANSFER WAIT TIME �a PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: � — PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: • S RESPONSE ZONE YES ❑ NO ❑ WALKED X GUERNEY D OTHER pr PATIENT CONDITION: DRIVER r im 1 EMT-1A; TECHNICIA Z- PARAMEDIC Fir•_ A DISPATCHER: I' t H I E F, OMPLAINT: DRY RUN: 13 ..�.. YES NO REASON FOR DRY RUN ` _I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - PA TENT R USED SERVICES: ( IGNATURE) X— _._ ..) MEDICAL COVERAGE: INDUSTRIAL. ❑ YES )a.NO NO. OF PATIENTS: S.S. q / t----� PRIVATE INS. CO.: BASE RATE: L -- KAISER q: MULTIPLE PTS. BASE RATE -- 1 BLUE CROSS N: TOTAL MILES: X is - MEDICARE M: 4c ATT, ROUND TRIP: ❑ YES ❑ NO�,'U( �J ., I � YES ONO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: 1. 0 MEDT-CAL N: CODE 2/3 -- . OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' 1V I n c,tt. _ DRUGS: (PER ADMIN.) X 11 NAME:himnlc l RELATIONSHIP:KIr E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ _ STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: )L- () { 1 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: TOTAL: PATIENT RECEIVED BY:X Pronidcr meta-*. Whitc ,ri r,K .•DPL .4eLYrn Ye',,,v ropy t• !NF uhe-i Dil-ina (SIGNATURE) Ott-1 00243 CONTRA COSTA COUNTY AMBULANCE PRE/-HOSPITAL CARE FORM I � �I UNIT ED AUTHORIZATION MZAP '. C)CHECK OR FILL IN APPROPRIATE SPACES DATE: •-•..���^ PATIENT'S NAME G. _J�v. �� ❑ M ❑ F COMPANY N G9 `�'2� 'ADORES �-) 1 1�� ] y AGE _ G CITY STATE ZIP DO _:)Z❑ Sn O M ❑ T OW ❑ Th OF DS DRIVER'S LICENSE++ __� _ PHONE - _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE THER❑ _ -- STATION 1(A)_20._30_40-51E)._ ff I � +�L INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) _ 1 TO SCENE- R'-S.0. CALL RECEIVED / � I 11_ O.P.D. TIME 108 oaf PATIENT DESTINATION. FROM SCENE-• 13 FIRE TIME 10-97 n ❑ PSAP TIME 10-49 ( l�� .4)E : z Ir`C MILEAGE:L/� q ❑ OTHER/PVT TIME 10-7 �_{ : 1 END/�UU ,, TIME 10-98 DOCTOR 3 J'-;:�l.'5611 PMO® START S TIME 10-22 - HOW CHOSEN: TOTAL J STANDBY TIME ❑�1 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME N _ t PATIENT ❑ DIRECT ❑ OTHER .3 CALL BACK N: AMBULANCE COMPANY;/ -• PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �, RESPONSE ZONE—f YES ❑ NO WAL'tED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER or� ' S (i U EMT-IA l TECHNICIAN ��LZ ��'��PARAMEDIC Hx: I�(w'E- DISPATCHER: 4 L� CHIEF COMPLAINT: ���<.I�S DRY RUN: ❑ YES /L`X O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X. MEDICAL COV AGE: INDUSTR L ❑ YES ❑ NO NO.OF PATIENTS: C. 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 - 1'�' YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUIN: J•U�� ( " MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 , t DATES BILLED: STANDBY: (OVER 15 MIN.) 1 ( E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: IIF NOT REPLACED} ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN:. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: r S,J TOTAL:/?,'? -" PATIENT RECEIVED BY:X Provider reLt:.. Whit, ,.r.d Pi.: �, 6etum hv'1 •v r;•, t �Tt uhrn hi I"ino (SIGNATURE) o -1 CONTRA COSTA CO NTY AMBULANCE �(� PRE-HOSPITAL CARE DORM I UNIT ) AUTHORIZATION#(9 i CNECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME✓ �.__..__) 1 I O #�_O F COMPANY N ADDRESS'* 't:'--5-----�- AGE �f t'r CITY -$TATE ZIP DOB O Sn OM OT OW O Th OF O .w DRIVER IIC�N�EI N ( ----.j PHONE NATURE OF DISPATCH t f TYPE•OFTRANSPORT:,AMBUUNCEr OTHER 0 STATION 1(A)_2(8)_3(C)_4(D)_5(E), L-. INCIDENT" OOATION., `Y ) RESPONSE CODE: REOI.IESTED BY: TIME—(24 HOUR CLOCK) I j TO SCENE- O S.O. CALL RECEIVED O P.D. TIME • ._. 10.8 LETDESTINATION: -1 FROM SCENEoFIRE TIME 10-97. 1 O PSAP TIME 10.49" tT MILEAGE: ❑ OTHER/PVT TIME 10.7 r - --• rq END 0. TIME 198 PMD/ER START TIME 10 22 l/ Vy i `- HOW CHOSEN: r�� -- TOTAL7> STANDBY TIME Y ,j�w❑ NEAREST,'2 O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O"DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: v RESPONSE ZONE t j ❑ YES 10 NO/,.. 1 ❑ WALKED O GUERNEY ❑ OTHER ' PATIENT CONDITION: DRIVER f'/C7r ��C..0 EMT-IA ; TECHNIC=IAN u f�D:4 191 PARAMEDIC Hx: DISPATCHER: S�'�,r e l 1 y 0 r f CHIEF COMPLAINT: DRY RUN: O YES ❑ NO REASON FOR DRY RUN 1 QH AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X 7 5�. MEDICAL COVERAGE:- _. _i INDUSTRIAL ❑ YES ONO NQ. OF PATIENTS: Ll S.S.M ` PRIVATE INS. CO.: BASE RATE: I ± KAISER N: t. MULTIPLE PTS. BASE RATE 1 ` BLUE CROSS A: t 7 1 TOTAL MILES: X MEDICARE :' ) I E.O.B.ATT, ROUND TRIP: OYES NO ';'�,•. / O YES '•O NO NIGHT:(19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAI N: r CODE 2!3 OTHER: ' r OXYGEN: (PER TANK) r,:Y P.O.E. STICKER O YE3 ❑ N 5 NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G-: (PER EPISODE) NEAREST RELA VE/RESPONSIB6 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) :t PHIONI WOR PHONE. DRY RUN: (AUTHORIZED) . *:j "EMPLOYER:'- OC UPATION: OTHER: ADDRESS: CITY " . . - _.._ TATE ZIP: COMMENTSr -- TOTAL:_ 45 CONTRA COSTA COUNTY AMBULANCE I l� PRE-HOSPITAL CARE FORM 1 UNIT MI AUTHORIZATION# —� r CV CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME /PT7 Y^�{� � 1��I\',- C M ❑ F COMPANYY# ADDRESS 1 ( 1 ' tAGE* . -�). �` h D CITY LCL STATE .ZIP— DOB ��LLLS,S ❑ Sn ❑ M O T O W 0/K? Th O /F 0 S _ - DRIVER'S LICENSE M _ PHONE _—_�—_ NATURE OF DISPATCH_ - TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ --- STATION i(A)-_2(B)_3(C)_4(D)_5(E)_ va INCIDENT LOCATION: ( c-, Or"LPS> RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) J .� � TO SCENE- S.O. CALL RECEIVED CIL'> L[^�c�c,�t� l/-�V J)�.cic wi -j ! ❑ P.D. TIME 10-8 PATIENT DESTINATION FROM SCENE- ❑ FIRE TIME 10-97 C C' -^ ❑ PSAP TIME 10-49 L ` MILEAGE: ` 7 ❑ OTHER/PVT TIME 10-7 ' END TIME 10-98 DOCTOR Q- � PM !ER ; START C TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �— O PATIENT O DIRECTOTHER ) CALL BACK a: AMBULANCE OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONEYES ONO ❑ WALKED'bERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT'1,q TECHNICIAN ��t - - PAR 1C Hx: DISPATCHER: CHIEF CAINT: �� ^ DRY RUN: ❑ YESEfO REASON FOR DRY RUN AUTHORIZATION F0 DRY RUN(EMS USE ONLY) L PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. 0 PRIVATE INS. CO.: BASE RATE: KAISER c LA -1 !� Gt MULTIPLE PTS. BASE RATE W� BLUE CROSS K: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) i CCHP/PPRP C EMERGENCY RUN: f MEDI-CAL 0: CODE 2/3 OTHER: OXYGEN: OPER 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: ' G CITY: STATE: ZIP: COMMENTS: _ TOTAL' -- —.--- PATIENT RECEIVFD BY XSIFN i(n ...-0-tT 4-6 ( , ,..... 1.•. ,.. _ CONTRA COSTA COUNTY AMBULANCE ��// � �. PRE-HOSPITAL CARE FORM I ( "I UNIT �' AUTHORIZATION M D J CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 PATIENTS NAME I '' ❑ M OF COMPANY M ADDRESS AGE— CITY GE CITY STATE ZIP DOB— ❑ Sn ❑ M ❑ T OW ❑ Th OF OS- DRIVER'S SDRIVER'S LICENSE N PHONE __ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ — T_—_ STATION I(A)_2(8)_3(C)_4(D)_5(E).._ \INCIDENT LOCATION: RESPONSE CODE' REQUESTED BY: TIME— (24 HOUR CLOCK) ��, �- j �., TO SCENE- _ D'S.O. CALL RECEIVED �y "2 �•`�—if :�l/l� !' ❑ P-D, TIME 10-8 E PATIENT DESTINATION: FROM SCENE- 17 FIRE TIME 10-97 PSAP TIME 10-49 —7— MILEAGE: ❑ OTHER/PVT TIME 10-7 yy I END TIME TIME 10-98 I DOCTOR PMD/ER START �� TIME 10-22 j HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ONO O WALI(ED ❑ GUERNEY O OTHER ` PATIENT CONDITION: DRIVER i EMT-1A TECHNICIAN i PARAMEDIC Hx: DISPATCHER: c i t• I ( 'I ilk/ CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DAY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r PATIENT REFUSED SERVICES: (SIGNATURE) X— 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. Of PATIENTS: I S.S. M I ) PRIVATE INS.'44CO.: BASE RATE: tt KAISER M: I MULTIPLE PTS. BASE RATE ` BLUE CROSS M: TOTAL MILES: X _ MEDICARE a►: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO , i ❑ YES NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: I 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 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: _ COMMENTS: _ - -- TOTAL ---- -- - --- - — q r� -- - -- - - - - - r n11rNT cIs rrlvr n by x L1 e � t ` �1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 53 �`•��`( CHECK OR FILL IN APPROPRIATE SPACES - DATE: - •� PATIENT'S NAME ❑ M O F COMPAN N ADDRESS L AGE f �) (� ??,o/ CITY STATE ZIP_ DOB____ ❑ Sn @ 1��O T OW O Th OF ❑ S DRIVER'S LICENSE N _ _ PHONE NATURE OF DISPATCH RASt kill k V5 (eltC F TYPE OF TRANSPORT:AgULANCE 0 IDTHER❑ NATION 1(A A)(B)-3(C)_4(D)._.-5(E)_- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME – (24 HOUR CLOCK) S cl t TO SCENE ki) S.O.<<-"- CALL RECEIVED w-t5sJOLL) O P.U. TIME 10-8I G i PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10 97 ((�� \) ❑ PSAP TIME 10-49 D� 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 COMPANY: CnS UYPMYULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE S" NO O WALKED ❑ GUERNEY ❑ OTHER 130A)4 PATIENT CONDITION: DRIVER /1 l DC��`� I �_SMT-1A X TECHNIGIAW. YkI T _ t ' PARAMEDIC Hx: AISPATC ER: CHIEF COMPL T: hi < < !( ' bRY RUN: YES NO REASON FOR DRY RUN a�1� 1p�rL 1�� Me-�`i �,) f"c U R1ZAT10 OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ') MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO }NO. OF PATIENTS: S.S. If .- 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 0 NO jO YES ONO 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _- - -- TOTAL- --- "- -- --- - -- --- - -- --- ---__ - - ---------- -- - .24 � F CONTRA COSTA COUNTY ) AMBULANCE PRE-HOSPITAL CARE FORM I y�, UNIT AUTHORIZATI N w U W 1 (' CHECK OR FILL INAPPROPRIATE SPACES - DATE: C `+ PATIENT'S NAME_—_ L_(� "�� `� I+ i J �� ❑ Nt O f COMPANY N 1 �G ADDRESS ; 4" AGE_3� 000 CITY J�j e,,� r i) STATE A .ZIP Q(-1 006 9-19 fl❑ n T ❑W ❑ ❑ F ❑S- DRIVER'S LICENSE# __-_._ .l._� �:�..____ PHONE_ _. �j �. NATURE 0 IS TCH .52 - TYPE OF TRANSPORT: AMBULANCE D OTHER❑ �__._ STATION 1(A)_2(8)_3(C)_4(D)!5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K} TO SCENE- Q S:O. CALL RECEIVED ❑ P.D. TIME 1a8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 1 `• _ MILEAGE: ❑ OTHER/PVT TIME 10-7 — END TIME 10-98 DOCTOR PMD/ER START ' TIME 10-22 HOW CHOSEN. j TOTAL-:J=. STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY:/1)� PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �-• RESPONSE ZONE (1, ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER /r EMT-tA - TECHNICIAN ' /-4"" PARAMEDIC 1 Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUNES ❑ NO RE SON FOR THORIZATION FOR DRY RUN(EMS USE ONLY) ATIENT REFUSE,2 S RUICES�(SIdNATURE) X / C MOICAL COVERAGE: .,�IINDUSTRIAL ❑ 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) II 1 CCHP/PPRP C / 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 - `I � DRUGS: (PER ADMIN.) X w 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: TA; `�' �j L/ PATIENT RECEIVED BY:X 0024 Pr"i.der r•ctai.. White rrd Pira "lr` Reh r+ Y: <y t• nf.- when F1'iaa (SIGNATURE) EN r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I l')� UNIT AUTHORIZATIONS CHECK OR FILL INAPPgQPRIATE SPACES i DATE; IL7� PATIENTS NAME �/��� OM OF COMPANY It ADDRESS Ir AGE r h I I, Irl CITY STATE ZIP DOB _ ❑ Sn OM OT .O W O Th OF ❑ S DRIVER'S LICENSE M _ PHONE —_ —_ NATURE OF DISPATCH.,nj-� , 5 TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ STATION 1(A)_2(B)_31C)_4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: RkOUESTED BY: TIME— (24 HOUR CL CK) TO SCENE- S.O. CALL RECEIVED ): LT ��•� �� � L ` v`� ---� ❑ P.D. TIME 10-8 PATIENT DESTINATION: _ FROM SCENE}- ❑ FIRE _ TIME 10-97 ❑ PSAP TIME 10-49 ;r 1� 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 ' END TIME 10-98 DOCTOR / PMO/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —, ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: � -v S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER / EMT,IA TECHNICIAN -PARAMEDIC r Hx: DISPATCHER: _ CHIEF COMPLAINT: DRY RUN: ❑ Y S?NO) REASON FOR DRY RUN 11.4 AUTHORIZATI FOR RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M i PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS 0: MILES: X MEDICARE 4: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: / EMERGENCY RUN: MEDT-CAL M: / CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ Y S ❑ 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_ 0 2 5.0 SI NATURE Pmuidar rvralc Whi br.l !'r.: Ip i,•tr,r+ 1' " r. nr, r..hra F i 1 i.:,, ( G ) CMS-I PATIENT'S NAME: Rakpr.judy ADDRESS: 1219 Warner ft. I afayettp,ca. DATE OF SERVICE: 09-26-83 AUTHORIZATION NUMBER: 83-16819 AMOUNT DUE: 75.00 INCIDENT LOCATION: 3502 Mt.Diablo.LUCky 5 PATIENT DESTINATION: John Muir Memorial Hospital 00251 i ' O() M ABLANCE ENROUTE 10 8 PF. FIVF0 AMBULANCE DISPATCHED _ U- _ ry I CALLED BY-- I PATIENT INFORMATION a T W i AC A NCr __..__ CUSTOMER a(PT. 1): _. DOB D Z ll DEPT'FLOORlROOM n. NAME: "- / ' n -...--- ---------------- m 1 a CALLBACK ++ _ ____..__ ..___._.._ —____ _ INS. TYPE: PVT MCAR .MCAT KHP PHP VA IND CHAMPUS --i F-+ c. w INCIDENT LOC �? _L '� 4J� �!� �TI \� POLICY;MCAL p: n c - - �- --- -'— — - MCAR a: m -- 1 CROSS STREET ____._-____ VERBAL PRIOR: 1 , JURIS: -- - - -- -- -- _.City �-_� DOCTOR: i -- --- DESTINATION - PT. #2 NAME: DOB: a f NATURE: - 1 CUST, u m ^, �J ----- - PT. $13 NAME: DOB: o a c-� TYPE OF ALL I ,TRANS TIh1�UMT rr CUST. a ' m o J _�_— n Y�i�,' m W CREW: -�_ __ �-_yG�_ _� t.J ( WAIT TIME: vE5 NO REASON: m f A N C UNIT TYPE: ALS lits WC RESPONSE CODE: 0 1 2 3 4 REASON FOR IO-22: O _ � c i INCREASE: CRE O T3 10-49 CODE: 0 1 3 4 CANCELLED BY: m u LIN BY: 1.11�I�..���_'�_j-1�-CEND MILEAGE: _ COMMENTS: O K TIME L__7I_ BEG MILEAGE: j JISPATCtER: TOTAL MILES: ' o XL OL N0I1V1S 3DNVmgv4'v 61-01 ONIN8ni38 3JNv1f18`A'v. 86'Ol 318vlIVAV 3DNvingwv L-Ol 1V11dSOH 1V 3:)NVU18Wv �r Fir !1 F++ ---Y. ^vM, 7�v4•�.•.. yryw moi.' ..+f�• +4- +At.1�g'! •4-[y�/�s•.. f �•. � � !>~ +. y v x !ti T .+n•t40. -.r*=..•: - .; -as1a� '�:e� �•.ter'-'+?T-'.:..RS.:w :r.�'.�iy': ":+',f'..:.if'Vd yh� -vF...�.:� � •!•Il+.i � _ yw,�„ .:- �•,, �.%+rw>• \ .�rw: ..hw1�s:�c�.aw�n• w►� �ry JL to IN kv ti. ti' .l;» .._:•- R.. - 'J 'rs..*��'�....�.: #'�Y��' �. • ri;f�p,+•�..j' .`� .Z,Y` � ,a.•a, '��''(%► '��,•:� ' .-t R �f.1�..J tY.'.i i'' �+,{� '° � �r'1' •� ,w1 .1'� -.� 'y'. . , - CONTRA COSTA COUNTY I AMBULANCE 7_761 PRE-HOSPITAL CARE FORM I I .`.I UNIT AUTHORIZATION MCHECK OR FILL IN APPROPRIA?E SPACES DATE: 912&/6>3 PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE CITY STATE — ZIP DOB____—_ O Sn 1bM Cl T ❑Wry❑ Th ❑ F 13S DRIVER'S LICENSE N _ --_ PHONE—_—._..—..�—__ NATURE OF DISPATCH �� / TYPE OF TRANSPORT: AMBULANCE D OTHER❑ — _ _—__.. STATION 1(A)_2(B)L!3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- D S.O. -- CALL RECEIVED �//�1, �� v _-C� ❑ P.0 _ TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: j ❑ OTHER/PVT TIME 10-7 _T 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 C MPANY: PT. AMBULATORY? PATIEN AKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WAC' E ❑ GUERNEY ❑ OTHER c PATIENT CONDITION: DRIVER ��L"''L r - EMT-1A TECHNICIAN PARAMEDIC +2� Hx: DISPATCHER: / CHIEF COMPLAINT: DRY RUN: KYES ❑ NO REASON FOR DRY RUN AJOLW_ r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1(l`-I PATIENT REFUSED SE ICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO 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: ❑ 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 ❑ YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RSPONSIBLE 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:—_ - -- ------- ---- 0025, PATIENT RECEIVED BY: X ,,. (SIGNATURE) LMS-1 N4 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N a/6,R37- r' CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NSA - I7 M /ME 1 , F COMPANYN ADDRESS n y��7 ONTO ��/E AGE_ y5' A42 I'V 6 CITY RI µ STATER ZIP y� DOB ❑ sn O M ��t O W p Tp.17 F. F1'$:.. DRIVER'S LICENSE M.- PHONE 2-%`2 2&2-.'NATURE OF DISPATCH �t�us �'�`' Imo_ TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ STATION 11 2(121)__�310_.41D)-,"61E INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOURbL TO SCENE- S.O. CALL RECEIVED v �-- 4,E 1�►LE� 3. � P.D. TIME 10-8 i T, PATIENT DESTINATION: - FROM SCENE- ❑ FIRE TIME 10-97 [3 O S 1�I 1 PSAP ..TIME ' -41' AD MILEAGE: 0 OTHER/PVT TIME 10-7 END- Z - TIME 10-98IAg I DOCTOR c^� PMD(a START �3 TIME 10.22 HOW CHOSEN: TOTALSTANDBY TIME - NEAREST ❑ FAMILY 13TRANSFE I WAIT TIME � ( `F•' , PATIENT 13 DIRECT 13 OTHER CALL,BACK 4t: AMBULANCE COMPANY: CD PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: r---- �',(� , RESPONSE ZONF _ or ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER t 1 PATIENT CONDITION: DRIVER PAIIcy EMT-1A �y�� ,!� TECHNICIAN PARAMEDI Hz: '�7 A IDL45 E DISPATCHER: 1' � �B' � :, _ 1 CHIEF COMPLAINT: SC/2u-e- DRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY)• { PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: ( S.S. K ( _ A..°1.3 j PRIVATE INS. CO.: BASE RATE:' i KAISER R: , MULTIPLE PTS.BASE RATE 3Fy -;T- BLUE OR T-BL SS N: TOTAL MILES- xx 1acr�= it MEDICAR `�ys` `� E.O.B.ATT. ROUND TRIP:- O YES 1] NO a I ZAG r 73 ❑ YES •❑ NO NIGHT:(19:00-07:00) CCHP/PPHP M: EMERGENCY I,Y�N: 0 com 2 3l e7Vi Z.IaViAFi�R�' OTHER: OXYGEN: (PEA TANK) THS I RW 3V 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 - Q_ r_ DRUGS: (PER ADMIN.) X NAME:—� �I RELATIONSHIP:Uj:f 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) I EMPLOYER: OCCUPATION: OTHER: ADDRESS: - _ - CITY: STATE* ZIP, s .S se COMMENTS: - - TOTAL: Al _ •0... PATIENT RECEIVED BY:X ISIONA URE) 4 . 0 j CONTRA COSTA COUNTY 7 AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION k CHECK OR FILL IM APPROPRIATE SPACti DATE: 9 - .) PATIENTS NAME L4 "� O M ArF COMPANY k V ✓ / ADDRESS ` e ' AGE�S CITY 72 `1 Cy� STATE ZIP DOB ❑ Sn ❑ M ;VT0 W O Th OF O S DRIVER'S LICENSE k = PHONE NATURE OF DISPATCH `/'fhca- b&it TYPE OF TRANSPORT:, AMBULANCE OTHERO — -_ STATION 1(A) 2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION; RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) Z (},9 TO SCENE- 4 S.O. CALL RECEIVED D ( ❑ P.D. TIME 10-8 PATIENT.DEINATIO : FROM SCENE ❑ FIRE TIME 10-97 l� 5 195' /� I ❑ PSAP TIME 1D-49 i y ) j MILEAGE: ❑ OTHER/PVT TIME 10-7 L END �' TIME 10-98 3 bOCTOR •11 C g I PMDo START _ TIME 10-22 HOW CHOSEN: _ TOTAL J ' '3 STANDBY TIME O NEAREST O FAMILY O TRANSFER L WAIT TIME XPATIENT ❑ DIRECT ❑ OTHER C ' J CALL BACK k: AMBULANCE COM At�Y: Ek BULATORY? EATIENT TAKEN T AMBULANCE: RESPONSE ZONE '❑ NO KED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LA 3Q ` J`'� ' EMT-1A f- J`51� TECHNICIAN C - Lr pL _7)PARAMEDIC Hx: DISPATCHER: I ( I L� 5 7 CHIEF FOMPLAINT: 'IIP S C 540,(0 b 1 hL5 DRY RUN: ❑ YES F10 REASON FOR DRY RUN ' vl C LAPS AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I a q PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COV EGE: — CQINDUnS/TRIAL ❑ YES NO NO. OF PATIENTS: J. S.S. k �� ) PRIVATE INS. CO.: BASE RATE: l/�� ! KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X �� 1 MEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHPk:, EMERGENCYRQN: 1 MEDT-CAL k: CODE 2/3 J O E OXYGEN: (PEA'TANK) �7� :, 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: ,/ STAJT�'E:: ZIP: COMMENTS: Ua �, J�/,may I,IA Jv TOTAL: Flcf&-O 00255. _ PATIENT RECFIVI n BY x ..... At uI ONTRA COSTA COUNTY AMBULANCE CNEC;OR FILL IN APPROPRIATE SPACES DATE_ Z PATIENT'S NAME -0 M COMPANY If ADDRESS DRIVER'S LICENSE# ...... PHONE NATURE OF DISPATCH __ZZ_f_9___ TYPE OF TRANSPORT: AM.BULANCE?_'_10THER IN91DENT LOC#TION: RESPONSE CODE: EOUESTED BY. TIME - (24 HOUR CLOCK) 2, ) TO SCENE- S3.0. CALL RECEIVED z- ATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 1G-97 0 PSAP TIME 113-49 MILEAGE: 0 OTHERiPVT TIME IG-7 END TIME 10-98 ^ -22 DOCTOR ' P /E4,ART ILI TIME 10 � � HOW CHOSEN: -TOTAL STANDBY TIME C3 NEAREST Cl FAMILY 0 TRANSFER WAIT TIME PATIENT DIRECT 11 OTHER CALL BACK# AMBULANCE COMPANY: PT AMBULATOR7PATIENT TA E TO AMBULANCE: RESPONSE ZONE 2- � PATIENT CONDITION: on/vsn / ""� DISPATCHER:�sn�- ' u DRY RUN: OYES--~\N'"' REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN/smsUSE ONLY) / ~ ' PATIENT REFUSED SERVICES: (o/sm^runs) x_-_-__-__--____--___�____________' �o- Cl YES bruo NO. oppAr/swra � _--�__-_-______- -��mATs /wa. co.: BASE RATE: nmasnMULTIPLE PTS. BASE RATE BLUE CROSS w: TOTAL MILES: x �� MEDICARE#: E.O.B. ATT ROUND TRIP: 11 YES 0N O veo O NO NIGHT: (19:00 n/uo) oC*p/ppHpw: EMERGENCY n�w wsoI'cALw: CODE x / o � mT*sn: -_-_____ oxvosw: (PER TANK) _--�--- --_-__. p.osSr/cnsn \z vso O NO wsowArAL (/wouaATon) ---__-- --__-_� DATES BILLED: arAwoev (OVER 1ow/w.) sxm.: (PER EPISODE) ^\ v� v�� /psn ^om/w) x onuaa. (psn �om/m> x -_-�-_ wAmsnsLAnowa*`p�-_�- ' so.A: (IF NOT REPLACED) _---__- ---___ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY- '` ^ - arArs-_--'.Z/p:___-_ C'coLLAn: (IF NOT REPLACED) p*ows: WORK pHows. DRY RUN: (AurHon/zso) smpLoYsn: __-_'_--_____' oCoupAr/owmrHsn: Aoonsso: o/ry STATE:-_-_-Z/P:__-__ - Commemro: ----- ----- - - - ^m� �� --- — --------------' rorxL���*��_~~ ������� � D� �� ------------------'- - | PATIENT nsCpwcna»� x --Npr `w CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM i UNIT AUTHORIZATIONN# .<iL CHECK OR FILL IN APPROPRIATE SPACES �•- DATE. _._J ` 7 ^ 23 PATIENTS NAME N h 1� , t GVt1 1 t/1� �j/ C U �'Y O M r COMPANY ft ADDRESS S tic-Y��.?_! 1 i AGE�L CITY ..► V L 1 f e, STATE ZIP ` _ DOB��- _ 2 ❑ Sn 11M�T ❑ W ❑ Th ❑F\❑S DRIVER'S LICENSE M _ PHONE_ _-.it_— NATURE OF DISPATCH— TYPE ISPATCHCTYPE OF TRANSPORT: AMBULANCE WOTHERO — STATION I(A)_2(B)_3f 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE l,6'9-0. CALL RECEIVED y TIME 10 t , p PATIENT DESTINATION: FROM SCENE - D FIRE TIME 10-97 ; (4 � 13PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 , H END � TIME 14-22 .DOCTOR fU PMD R START_-_ TIME 10 22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME r� �ATIENT ❑ DIRECT ❑ OTHER LD CALL BACK N: AMBULA CE CffA�Yt PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j, RESPONSE ZON:1, ( _'fes ES 11 NO ❑ WALKED,�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER, _ ))� .FMT-1A TECHNICIAN << '- til!itARAMEDIC q� Hx: DISPATCHER: CHIEF COMPLAINT: Z'r DRY RUN: ❑ YES REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: J ; S.S. 0 �J PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE � Q�� �I�• BLUE CROSS N: TOTAL MILES: X MEDICARE#: ( -05; 'nQ 1 0 E.O.S. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) / 1� CCHP/PPRP M: EMERGENCY RUN: MEDI-CAL 0: CODE 21,3 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 rr R �� � , DRUGS: (PER ADMIN.) X NAME:(LfeHTI t1 Q '"rC[t4(C'� RELATIONSHIP.4V E.O.A.: (IF NOT REPLACED) ADDRESS: ) 5t<C_ o T C RCI ORAL AIRWAY: (IF NOT REPLACED) CITY:D:I y'k tI P STATECt, Z)P: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER:_ � ��%k�C"�� .w•� ' ADDRESS: CITY: STATE: ZIP: COMMENTS:' szqist_o r_y,rO 1 G ` add► �x �r ;���de�T ;��;, - — /^/��/� (j j-r 0'NG-\� S gyp„ (d hL' S�t� �� -- TOTAL #.. _ �I .._ . -..._.A.(Ill - - r 00257 I PATIENT RECEIVED BY X Prvuid,r /vW:c whit, oml Pr.;; .­pp hJCYrn Yr'i.w i ISIGNATURF) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z+ AUTHORIZATION 6 CHECK OR FILL IN APPROPRIATE SPACES DATE: 2_1- 09 _1_ 1.� PATIENTS NAME I . f2t ❑ M '[IF COMPANY 0 ADDRESS-`"2 + AGE;_. — K ' CITY .-» STATE.___.___ZIP DOB - '❑ Sn ❑ M if T..❑ W ❑Th ❑ F ❑ S r DRIVER'S LICtNSE 0 --� PHONE NATURE OF DISPATCH 1�`w TYPE OF TRANSPORT? AMBULANCE OTHER❑ ' STATION 1(A)_2(8)_3(C)_!(_4(D)_51E1^ ' t } INCIDENT LOCATION:1 �T� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) j J' / �.-- TO SCENE- 3 S.O. CALL RECEIVED s• � 27 t Dk(A1 t/ � f^t_ r ❑ P.D. TIME 10-8 r72� 1-� � ' PATIENT DESTINATION:--.-_, FROM SCENE- ❑ FIRE TIME 10-97 ;' '- ❑ PSAP TIME 10-49 �-._�,— MILEAGE: ❑ OTHER/PVT TIME 10-7 ) END- 1 TIME 10-98 s F-bbCTOR -' �� PMD/ER START TIME 10-22 HOW CHOSEN: _ _ .7 TOTAL STANDBY TIME arj l_•:❑ NEAREST,•]; ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALLBACK N: AMBULANCE COMPANY: t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: , S, o RESPONSE ZONE S 0.YES ..13.NO, ❑ WALKED ❑ GUERNEY ❑ OTHER + ~ PATIENT_CONDITION:— DRIVER L I c/AT'h EMT-1A 0;1Ifi10 TECHNICIAN f�QJ d-r PARAMEDIC ) <lt, Hx: DISPATCHER: o6 CHIEF COMPLAINT: !- ' DRY RUN: YES NO REASON FOR DRY RUN �- t.a-'r Scene-' 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 Kj MULTIPLE PTS.BASE RATE t .' BLUE CROSS k: TOTAL MILES: X MEDICARE C( E.O.B.ATT. ROUND TRIP: ❑ YES NO { _ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M:n - I EMERGENCY R _1 MEDT-CAL M: CODE 2/ OTHER: 12 '''""' OXYGEN:. (PER TANK) P.O.E. STICKER ❑ YES ❑ `' NEONATAL: (INCUBATOR)141 �— 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST REtAT1VE717 SIBLE PARTY: - - LV.: IPER 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) _4 v-CV ""'-EMPLOYER:• OCCUPATION: OTHER: ADDRESS: 1, " CITY: STATE' ZIP: ""COMM TS: TOTAL:�,J Q02 ^- PATIENT RECEIVED BY: X / p,.•. 1.. .-,,;.. �1:. ..I ,.. . I (RIrfJATtlPFI l CONTRA COSTA COUNTY AMBULANCE RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 V jS I CHECK OR FILL IN APPROPRIATE SPACES DATE: 5'pATIENTS NAME I J�-l/ {�il� '." A,'i 1 1 r ❑ AA• O F COMPANY M ADDRESS,;;' 4 1 I .1 t AGE' ; co f 1 CITY- STATE �.ZIP DOB ❑ Sn O M 4,T O W O Th ❑ F Q S DRIVER'S LICtNSE 0 �-- PHONE NATURE OF DISPATCH �k To � I TYPE OF TRANSPORT:I AMBULANCE OTHER -• STATION 1(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT-LOCATION- A3 RESPONSE CODEOVESTEO BY: TIME- (24 HOUR CLOCK) R ENE r 1= .3 /� TO SC - 5.0. CALL RECEIVED 3 �_ C as0 R( (}� ❑ P D TIME 10-8 TIENT DESTINATION: FROM SCENE- ❑ FIRE _ TIME 10-97 ' ---'•-� .. - ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 ' yl rt END TIME 10-98, . 1 nOCTOR(' PMD/ER START SZ ( TIME 10-22 ' HOW CHOSEN: _.__, TOTAL - STANDBY TIME 2;"�;1❑_NEAREST, ❑ FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPI}tJ 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I S ,(�) RESPONSE ZONE C3 YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER'• I 1 j 2C`_� _ - ,��t Tr,PATIENT CONDITION: ' " �- � DRIVER EMT-1A'' 1�zv:I TECHNICIAN i C�t 2 10, -PARAMEDIC Hx: DISPATCHER: q3o CHIEF COMPLAINT: DRY RUN: WYES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES: (SIGNATURE)X J MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO N0.OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES :O NO NIGHT:(19:00-07:00) CCHPJPPHP M: � � I EMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: 1 OXYGEN: (PER TANK) P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) EAREST 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) t '�f "'EMPLOYER: - OCCUPATION: OTHER: ADDRESS: --,CITY.-,-- - STATE: • ZIP: —COMMENTS: - TOTAL— �OPJ 00259.-, • - PATIENT RECEIVED BY: X_.__._._,------- CONTRA COSTA COUNTY AMBULANCE ` PRE-HOSPITAL CARE FORM I UNIT = AUTHORIZATION M I! 1J I: `,. 36,, V CHECK OR FILL IN APPROPRIATE SPACES DATE: C( ` Z r- :� 3 PATIENT'S NAME I'( t�M ❑ F COMPANY#1 ADDRESS � AGES 3 ' CITY1,/02 ite n STATE-/q- ZIP DOB.ILpJ ❑ Sn ❑ M ( T ❑ W ❑ Th ❑ F ❑-S DRIVER'S LICENSE K PHONE ._,`):.��L.�.a-��f NATURE Of DISPATCH.ICI< GL•c' TYPE OF TRANSPORT: AMBULANCE OTHER 1.1 INCIDENT LOCATION: RESPONSE CODE: R�UESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - S.O. CALL RECEIVED' i •r 6 y, 14 IL Ill l A u;AA ❑ P.U. TIME 10-8 ' �-•-� PATIENT DESTINATION: O f-r .K rl 01 FROM SCENE- ❑ FIRE —_ TIME 10-97 L�t� :�-lL-_ ❑ PSAP TIME 10-49 11 Lcc t ' MILEAGE:. _ ❑ OTHER/PVT TIME 10-7 ��"3 1- •' END �� ' TIME 10-98 DOCTOR ' � PMD/ER START 2 TIME 10-22 HOW CHOSEN: TOTAL _ 1' STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME [PATIENT ❑ DIRECT ❑ OTHER CALL BACK K: AMBULANCE COMPANY: C.R _, PT. AMBULATORY? f PATIENT TAKEN TO AMBULANCE: { RESPONSE ZONE Z _ .YES ❑ NO WALKED ❑ GUERNEY ❑ OTHER l PATIENT CONDITION: DRIVER. _�_,i ` EMT-tA i.n TECHNICIAN 1? t S ���'_—_ PARAMEDIC Hx: AiAf0 Ie'cr!It c •i r I DISPATCHER: CHIEF COMPLAINT: IAtrd hr/A(*e. DRY RUN: ❑ YES -171XJO REASON FOR DRY RUN Cl pc I- (R) r• f h ' r-ci AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X—__— ICAL COVERAGE: INDUSTRIAL ❑ YES XNO NO. OF PATIENTS: :ism S. # Z_ - `/ZS_3 ., PRIVATE INS. C .: BASE RATE: �F-A�•` MULTIPLE PTS. BASE RATE EDf� BLUE CRO #: TOTAL MILES: �' X tCARE #: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �• CCHP/PPRP#: EMERGENCY RUN: ; MEDI-CAL K: CODE 2/3 OTHER: OXYGEN: (PER TANK) /V P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ' 11� 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: AL y RELATIONSHIP:-LZ�� 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: C.Jyr...,c.+ L cc A1. OCCUPATION: Am il If Q,' ! OTHER: ADDRESS: >}.� ►�cutL- ✓ r` •V CITY: STATE: 21P: )t 7,J COMMENTS: .1-4 nc t h Fat,`c' h" l r1jtL TOTAL'A,3!_•?d _3d PAI if:NT HEt:Ftvi 11 F!Y x J � r j . 002060 . . - r'..• :l.•r• rrI t�:,,... •.. ... r';Ir.N/L i r tilt r CONTRA COSTA COUNTY AMBULANCE 7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: ` �� -• PATIENTS NAMEM � 2 .�-�. _�.Q ❑ F COMPANY N_ ADDRESS ��` �� IeC s AGER CITY L 0�f r •QT=' STATE ��C< ZIP .( DOB_G��c_s_• 4( O Sn O M if T 0 IN Th 13 133 F 13S DRIVER'S LICENSE N __-_ _ �___ PHONENATURE OF DISPATCH. TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ - STATION 1(A) (B)_3(CI_4(D)_5(E)_-- jNCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR OCK� - �• 1 TO SCENE- R S.O. CALL RECEIVED 1� ' ❑ P.U. TIME 10-B PATIENT DESTIN O FROM SCENE- ❑ FIRE TIME 10.97 Z PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10.7 ENDTIME 10-96 DOCTOR PMD/ER STAR-T� TIME 10-22 HOW CHOSEN: TOTAL ~ STANDBY TIME " ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCF�yOMP�IY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: I RESPONSE ZON ❑ YES O NO ❑ WAL'(ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 1 TECHNICIAN PARAMEDIC �R Hx: yy DISPATCHER: CHIEF COMPLAINT: !`W�� �I DRY AUN:NKYES O NO REASON FOR DRY RUN ALIT RIZATION FOR DRY N(EMS USE ONLY) ' (� ) PATIENT REFUSED SERVICES: (SIGNATURE) X� 0 cg I M5Q�CAL COVERAGE: INDUSTRIAL ❑ YES 11NO NO, OF PATIENTS: .S. N f VATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE 1 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/PPHP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 ,1 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 sl DRUGS: (PER ADMIN.) X NAME: n r C 1 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR (IF NOT REPLACED) PHONE: WORK PHONE_ DRY RUN: (AUTHORIZED) _a1J.LL1u EMPLOYER: OCCUPATION: OTHER: - ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL r PATIENT RECEIVED BY:X - -•-C Provider rota!. whit, rr? n.. r.. �,•, (SIGNATURE) qIS-1 CONTRA COSTA COUNTY ( �. AMBULANCE / PRE-HOSPITAL CARE FORM I ;' UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME RJ M ❑ F COMPANY# ' I !. ADDRESS/ 3,3L�j �j-- �l NI ST-r AGE 31 Aolo(obl !- CITY_ RIC-9 STATE ZIP_ N501 DOB!Z 5-- 13 S 13M ❑ T JkW 13Th E3 ❑s.-. i, 1 DRIVER'S LICENSE# ______ PHONE 3NATURE OF DISPATCH c� Z`�"�`I ' •-• t TYPE OF TRANSPORT: AMBULANCE 9,OTHERO _ — . " STATION 1(A) 2(B)_3(C)_4(D)_5(E)_ -! INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOURC_K) TO SCENE- ❑ S.O. CALL RECEIVED `7 4� " l`�C_�� �/L � �- ❑ P.D. TIME 10-8 E , T + PATIENT DESTINATION: i ;,c FROM SCENE ❑ FIRE TIME 10-97 I ' ❑ PSAP TIME 10-49 MILEAGE: •� ppO��jH�R/PVT TIME 10-7 �+ n.I1END TIME 1.0.98 DOCTOR coKr[ fZ— PMD/ER START '7 ' TIME 10-22 •`: �J HOW CHOSEN: TO STANDBY TIME WNEAREST ❑ FAMILY ❑ TRANSFER WAR TIME !: ❑ PATIENT ❑ DIRECT ❑ OTHER � CALL BACK N: AMBULANCE COMPANY: ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ RESPONSE ZONE ( 1 .i[YES ❑ NO 19,WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER t / 7�oEMT-tA E TECHNICIAN PARAMEDIC ( - ----� Hx: _Al ct)A �a DISPATCHER: q,iC CHIEF/COMPLAINT: L'��2`�• �Ir � �IZ"@eDRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - PATIENT REFUSED SERVICES: (SIGNATURE) X rc MEDICAL COVERAGE: INDUSTRIAL ❑ YES J&NO NO. OF PATIENTS: - (;Z Ot a S.S. # 7 SS PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE �— �f BLUE CROSS#: TOTAL MILES: I MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO' ...._ a ❑ YES ❑ NO NIGHT: (19:00-07:00) Ho. o Ill,' g�iT• - CCHP/PPRP#: EMERGENCY RUN: /a•GD,,''�lv MEDI-CAL# O-u o n c_1545 7 3 9 14-5 1 ' ' CODE.2/3cl; OD OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL:.(INCUBATO DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X NAME:,IA��^��'•- DRUGS: (PER ADMIN.) X �— RELATIONSHIP E.O.A.: (IF NOT REPLACED) . ADDRESS: ' S - ST ORAL AIRWAY: (IF NOT REPLACED) CITY: Aict4 . STATE C'A, ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 23-5 'S�S`j WORK PHONE; DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION' OTHER: ADDRESS: CITY: STATE: .ZIP• COMMENTS:Gea)"`.,c CII` t 4e CG? 1 l`t. I '1, 7t�e. Tl�n�+ tr A�JRiLt931L1 T4 of w�iTyPT 11 APIA W 15` Ito PMO', I;° QRS ccL6, -Il-1, TOTAL' AtklZT t UQIEiJT�O X Y5-TH s; Ccx/01T1 Gin DI= ��CJNL?y_�_R_�� � —fes' PATIENT RECEIVED BY-X!� �7�P �•� ti• If AT• TT (SIGNATURE.) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 /, % UNIT AUTHORIZATION# �3�7 CHECK OA FILL IN APPROPRIATE SPACES �,J DATE: PATIENTS NAME �/ '"�Z O S H C,S l O M �F COMPANY# ADDRESS 381 V �D L AGE � Z CITY Pt N C L 4 STATE C W� ZIP _ DOB }�O Sn ❑ M p T D W O Th OF 05 DRIVER'S LICENSE# _ ____ _ PHONES.�_� 3�. NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE 1 OTHER❑ _— __- _. STATION 1(A)_2(B)_31C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) _ TO SCENE- ❑ S.O. CALL RECEIVED L '� J �,EJ �1�I�� �1(A- /✓ L �,'1 l L�,/b�i� 1 OP.U. TIME 10-8 U 1 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 14.97 I. 1 1 �; ( _ ❑ PSAP TIME 14-49 MILEAGE: �OTHER/PVT TIME 14-7 !' ` ✓",IIy�fit END TIME 10-98 DOCTOR aA�[Y/ER START "� TIME 10-22 HOW CHOSEN: TOTAL ( STANDBY TIME ❑ NEAREST O FAMILY 4gTRANSFER WAIT TIME -- t, ❑ PATIENT ❑ DIRECT /❑`OTHER J !.7 I CALL BACK#: AMBULANCE COMPANY: K ,I o• PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 4_ ' ( i: RESPONSE ZONE YES ❑ NO EQWAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER1! ! t •�� EMT-tA� _ TECHNICIAN I( �+ r I t J PARAMEDIC Hx: P7 0c DISPATCHER: lc-'> DISPATCHER: I Ir l CHIEF COMPLAINT: 5 f 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. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: -' X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ONO NIGHT: (19:00-07:00) J CCHP/PPRP#: EMERGENCY RUN: F MED AL#: CODE 2/3 a R: �' "I ( Yui OXYGEN: (PER TANK) 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 i AME: 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: Q STATE: ZIP: COMMENTS: i nJ r'X9 7 �- i L L t�c� I1 I» /Y�. L) -- TOTA4 X67 -5-0 -- - -- 2.6 PATIENT F4FCEIVFD BY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ' UNIT AUTHORIZATION 7 [ 1 / •�v`, CN[CR pA FILL IN APPROPRIATE S►AC[f DATE: ,,,!,,PATIENT'S NAME O M F COMPANY 0 ADDRESS Vl5 AGE CITY STATE ZIP DOB 1 J3 O Sn O M OT ❑ W OF OS DRIVER'S LICENSE M _ _ PHONE _.__ __—_ NATURE OF DISPATCH.-} TYPE OF TRANSPORT: AMBULANC OTHER O __ __ STATION I( 2(8)_3(CI_4(D)-5(EI_ ' INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) TO SCENE-R ❑ S.O. CALL RECEIVED C O P TIME 10-8 `1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 !I ❑ PSAP TIME 10-49 MILEAGE: -,$2L OTHER/PVT TIME 10-7 END TIME 10-98 DOCTORc w te44 0 FMD/E START TIME 10-22 ! HOW CHOSEN: TdTA STANDBY TIME ❑ NEAREST ❑ FAMILY `TRANSFER I .` WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER6 ) - 1 CALL BACK A: AMBULANCE 0 ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBUL ()(� jw��� i RESPONSE ZONE ❑ YES NO ❑ WALKED GUERNEY ❑ OTHE PATIENT CONDITION: DRIVER-,,I-,pLi CAO TECHNICIAN_ �� _ IC Hx: DISPATCHER: '1 f CHIEF C MPLAINT: DRY RUN: ❑ YES�NO` ASON FOR DRY RUN f QYr AUTHORIZATION FOR DRY RUN(EMS USE ONLY) T PATIENT REFUSED SERVICES:(SIGNATURE) X G z MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ' S.S. K PRIVATE INS.CO.: BASE RATE: KAISER*-� MULTIPLE PTS. BASE RATE t1C ROSS M: TOTAL MILES: X % f pICARE N 1 "`� E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) HP M: EMERGENCY RUN: i CODE 2/3 ER OXYGEN: (PER TANK) 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: RELATIONSHIP: E.O.A.: (1F NOT REPLACED) ADDRESS: ORAL'AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:—ZIP:— COMMENTS: TATE: ZIP:COMMENTS: TOTAL: ::i—_ -- PATIENT RECEIVED BY. X Provider r/toir• whit• vd ii,a •uFb, rturn h 'i.V t �• (SIGNATURE) q• t vhrnf:! inf 0064 J CONTRA COSTA COUNTY \) AMBULANCE 1 PRE-HOSPITAL CARE FORM I ` �. UNIT ) AUTHORIZATION it CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME_4j_�L_`_� ,.c f';; �t �'C_t' i-'_� (� -_� ❑ M 14� COMPANY q / ( �?_ n ADDR[SS _��-l.i______A ;4 �- - `(" '/"�-- - - AGE �f A J 4 G17YI- �L'.L_� � STATE ( �-`__-- ZIP------.---_._--.-- DOB. -.1�2^�11?❑ Sn ❑ M ❑ T ❑ W ❑ ❑ F ❑S DRIVER'S LICENSE a .... _ --._ _ PHONE '�.L ___4=�_L �NATURE OF DISPATCH- TYPE ISPATCH TYPE OF TRANSPORT: AMBI-h-ANCEC OTHER❑ INCIDENT LOCATION: (� RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) ? TO SCENE - 7 ❑ S.O. CALL RECEIVED ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 . _ 11PSAP TIME 10-49 _'.r. _!T�.'_ MILEAGE: I �SJTHER/PVT TIME 10-7 e� END TIME 10-98 DOCTOR _ ����'\ __---- PMD/ER START___�� TIME 10-22 HOW CHOSEN TOTAL - STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRF..CT C OTHER CALL BACK 1$: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: I �; I RESPONSE ONE YES ❑ NO ;I"WAC ED ❑ GUERNEY ❑ OTHER _ PATIENT CONDITION, DRIVER_ IAT-iA TECHNICIAN XL L PARAMEDIC Hx.: ISPATCHER CHIEF COh1PLAINT: _L�__C._L�' �C � /���'1fJDRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X j MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. PRIVATE INS. CO.:---. BASE RATE: KAISER q: - MULTIPLE PTS. BASE RATE BLUE CROSS#i _ TOTAL MILES: :/_/ X MEDICARE q: -_- _E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO So. L� ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 1 CCHP/PPRP q: _______ EMERGENCY RUN: MEDI-CAL++:-._- -_— CODE 2/3 OXYGEN: (PER TANK) P O E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: _______ - STANDBY: (OVER 15 MIN.) ��•' ' �'�1` E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY / I.V.: (PER ADMIN:) X DRUGS: (PER ADMIN.) X NAVE ''_;.a: '_:''_" '' _. . -'_f i�ELA>f10N81!!(P: E.O.A.: (IF NOT REPLACED) O, ADDRESS:= ORAL AIRWAY: ((F NOT REPLACED) CITY: ____,_____. STATE._._."ZIP:._ C-COLLAR: (IF NOT REPLACED) PHONE: _: _._ WORK PHONE:_ __._— DRY RUN: (AUTHORIZED) 1 EMPLOYER: __._ ____ OCCUPATION OTHER: ADDRESS: CITY: - STATE-, ZIP: COMMENTS:__ /' /�—� `' 0 L — TOTAL:6 r -- PATIENT RECEIVED BY:X _-- (SIGNATURE) -- --- - 0026x5-I CONTRA COSTA COUNTY AMBULANCE �) PRE-HOSPITAL CARE FORM I qUNIT AUTHORIZATION* CHECK OR FILL' INAPPROPRIATE SPACES DATE: PATIENT'S NAME_�,_�_ ,_i � 1 + ❑ M ❑ F COMPANY# ADDRESS AGE CITY-- STATE' ZIP DOB— 0 Sn 0 M ❑ T 0 W 0 Th lul 0 S DRIVER'S LICENSE# __ ___.__.._. . _____. PHONE_ NATURE OF DISPATCHr v+ S`•P 1� +. TYPE OF TRANSPORT: AMBULANCE CVOTHER❑ 4 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) ' !• }�_« TO SCENE i} ❑ P.D. TIME 0-8 RECEIVED PATIENT DESTINATION: FROM SCENE �- 0FIRE TIME 10-97 1 � ❑,, PP TIME 10-49 a MILEAGE: OTHER/PVT TIME 10-7 END �^�`r� TIME 10-98 DOCTOR .__..__ PMD/ER START TIME 10-22 .LZ --•I HOW CIH40:-t'N TOTAL STANDBY TIME ❑ NEAREST 0 FAMILY a TRANSFER WAIT TIME 4 :' ❑ PATIENT ❑ DIRECT 0 OTHER CALL BACK#: AMBULANCACJOMPANY: .� t PT. AMBULA AORY? PATIENT TAKEN T AMBULANCE: N RESPONSE ZONE 0 YES qA0 ❑ WAL"ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ �P'K --A501L) !� �EMT- TECHNICIAN 4 S PARAMEDIC DI CHIEF COMPLAINT.: _ __ RY�RUN: YE REASON FOR DRY RUN u b1f AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X, MEDICAL COVERAGE: INDUSTRIAL 0 YES '$-N0 NO. OF PATIENTS: S.S. # . ..� r PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDIC RE#: E.O.B. ATT. ROUND TRIP: 0 YES 0 NO 10-T. Frt 0 YES 0 NO NIGHT: (19:00-07:00) CCHP/PPRP#: _ EMERGENCY RUN: —ME�DI-CAC#7-,, /G r "� ��c� CODE 2/3 OTHER:- OXYGEN: (PER TANK) , P.O.E. STICKER 0 YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) t NEAREST RELATIVE/RESPONSIBLE PARTY: LY.: (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: `j 1. cr, ' TOTAL y ^` u PATIENT RECEIVED BY: X—.---.— -' '-- -- Pmvider re Laic Chiu rd Nn, rrr� 5rfur+ Fr'; rSir:NATIlFft,a• °" a, j / CONTRA COSTA COUNTY ' AMBULANCE PRE-HOSPITAL CARE FORM I I!(' UNIT AUTHORIZATION IV 0 0 CHECK OR FILL INAPPROPRIATE SPACES DATE: v F(J C S PATIENT'S NAMEJ_._NL.S�__�-,t-+�'•��1 �! L! ❑1 O F COMPANY M L a ADDRESS � Ll t 1.J u 93 A E r J �'�•� CITY CbZIP�" ZIP DOB_U qw ❑ M ❑ T 13W 13Th 13F E33 DRIVER'S LICENSE K __._ PHONE 4 � _.��1 NATURE OF DlS TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ — STATION A)!2 )_3(C)_4(D)_5(E)_ INCIDENT LOCATION: r RESPONSE CODE: RE TIME- (24 HOUR CLO K) �f TO SCENE- CALL RECEIVED —( Q�+ TIME 10-8 PATIENT DESTINATION: FROM SCENE DFIRE TIME 10-97 MILEAGE ' A ❑ PSAP TIME 10-49 • 7 _ : ❑ OTHER/PVT_ TIME 10-7 _� 2 END TIME 10-98 l7k DOCTORC� MD/ R START TIME 10 22 HO CHOSEN. TOTAL STANDBY TIME `/ _0 REST .�AMILY ❑ TRANSFER WAIT TIME ,... ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: - ..� PT. AMBULATORY? T ENT TAKEN TO AMBULA E: RESPONSE ZONE ❑ YES NO v :ED ❑ GUERNEY 0THER PATIENT CONDITION: DRIVER L-S dhJ EMT-1A TECHNICIAN Hx: _ DISPATCHER: 0 CHIEF COMPLAINT: 1') ky wY DRY RUN: ❑ YES �9�,NO R ASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL-COVERAGE: INDUSTRIAL ❑ YE NO NO. OF PATIENTS: \ PRIVATE INS. CO.: BASE RATE:- �v KAISER#: MULTIPLE PTS. BASE RATE ` BLUE CROSS p: TOTAL MILES: X SD 11D MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO d (� ❑ YES ❑ NO NIGHT: (19:00-07:00) Fl� n�•CCHwopk1P 71:C� � 3 �C(�� ry t d•' )b (-i EMERGENCY RUN: _L_ no �13 CODE2f 3THER: OXYGEN: (PER TANK) P. . STICKEES D NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE" ARTY: I.V.: (PER ADMIN.) X 1-NELATIONSH10 DRUGS: (PER ADMIN.) X NAM ^ �.__ `r"'ti 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-�;� V a C�✓'1 �' ) OI��C'S �. COMMENT C✓ TOTAL:/'44.6'a PATIENT RECEIVED BY. 1 Pmvidrr, rrr.7?r A-*r.. cr. $GNAT E) 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N - ;r,•'..' _c_- NE CK OR Fol INAPPROPRIATE SPACES DATE: PATIENT'S NAME—L l! r_: Ir (. M ❑ F COMPANY N I ADDRESS �� �- r : /i, L.-.,(" AGEYO I IA CITY ��!�1^ STATE r ZIP 17(,,`� DOB' 6:6:Sn) O M OT O W�O Th liC"F.1 . S.r►> DRIVER'S LICENSE w _--_____-__ PHONE._..___-____-- NATURE OF DISPATCH ' TYPE OF TRANSPORT AMBULANCE 0 OTHER❑ STATION 11( 2( )_31C1_41D1_51E1_. r',;! INCIDENT LOCATION: RESPONSE CODE:r REQUESTED BY. TIME - (24 HOUR CLOQA) ' ; -rPr TO SCENE- ; ❑ S.O. CALL RECEIVED ` --L' �-1 ;t.� -- ❑ P.U. _ TIME 10-8 PATIENT DESTINATION FROM SCENE- ❑ FIRE TIME 10-97 J ❑ PSAP TIME 10-49; --.VLg-lg - r IC �t10– MILEAGE. OTHER/PVT TIME 10 7 i ? r END r i C 'TIME 10-98•,`r,i�J s 1 •�' �•� ; DOCTOR _LSI .�. �.�'��_ I __ PMD/ER START w,Jr� TIME 10-22 z HOW CHOSEN: TOTAL — ty+_ STANDBY TIMET ❑ NEAREST. ❑ FAMILY E3 TRANSFER WAIT TIME ►: ❑ PATIENT ❑ DIRECT ❑ OTHER A� CALL BACK w: . AMBULANCE COMPANY:- PT. OMPANY:fPT. AMBULATORY? PATIENT TAKEN TO AMBULANCE:' I RESPONSE ONE O YES ❑ NO Q ANAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER__G - r jJ EMT-tAv T `' • TECHNICIAN _��� PARAMEDIC Hx: l N- -iC DISPATCHER. –_ o7. ( (�`. 'i + 'F 'i. J ; I CHIEF COMPLAINT: - % '� ` _ DRY RUN: ❑ YES � NO REASON FOR DRY RUN ' — AUTHORIZATION FQA"(ORV RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COYERA E: INDUSTRIAL ❑ YES t NO NO. OF PATIENTS: r }:�'•:' t t S.S. w / `� , _..� t. -PRIVATE INS. CO.: BASE RATE: t•: KAISER w: MULTIPLE PTS,BASE RATE t: ( BLUE CROSS N; TOTAL MILES: X (` MEDICARE IF� u�' - - �" c '<�.y i N E.O.B. ATT. ROUND TRIP: O YES O NO $10,11 T VC11 :%� . i i;i. •f ❑ YES 13NO NIGHT (1900-07:00) `-w"`��. x CCHP/PPHPw: // �7/ll / r, EMERGENCY RUN: �!T i.S'aF�:�...3;! w•b' MEDI-CAL ;7 ( ; �`�/ � r L CODE 2/3. OTHER: OXYGEN: (PER TANK)rY vYlLIGi'. ' �f (; P.O.E. ST(CKER_�YESY❑ NEONATAL: (INCUBATOR) ` �. } - r .. DATES BILLED: STANDBY: (OVER 15 MIN.).TH��a'�1 J-�L �(��_-��»iMj, r a E.K.G.: (PER EPISODE) NEAREST.RELATIVE/RESPONSIBLE PARTY;J,_.� I , I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) M. _ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) + } ADDRESS: ORAL AIRWAY:. (IF NOT REPLACEDJ, _ . CITY: STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZ_EO I 1r' L.-i.:��� ......� EMPLOYER: OCCUPATION: OTHE I,7 rt . ADDRESS: CITY: STATE: ZIP: L I+S COMMENTS: TOTAL' 1.. �.r •:, tar PATIENT RECEIVED BY:X ` N [ !, I `•�"' / ' TV Provider Iytair• cop} Return Ye': )., (SKIN TU E)� Vhite --d Pink uw m,^p �L^ when biZ•in# ( 4 .S dNT.TA I COUNTY AMHIII ANCt -73 �/ . 1' .t-HOSPA�IT . CARE FORM I ' iinnr 7—�t AUTHORIZATION� / _.OFlIL[ INAPCROPFIAI[ $PACCS DATE: ,•ATIFNT'S N ArIE�ft' ` 1 �'-I C�2 L 7 M ❑ F COMPANY N ADUH S.S AGE CITY_..0 1 0-L v '� � �1 Ll �^� ��'=l S ❑ M O T ❑ W ❑ Th ❑ F ❑ S __... STATE _ _.--- oftP7,, 1 SJ .� De `-( NATURE OF DISPATCHDRIVER'S LICENSE a .. O E / / TYPE OF TRANSPORT AMBULANC ; I OTHER❑ STATION 1( 1 )-31C1_4(0) _5(E)_ i INCIDENT LO ATION RESPONSE E: REOUESTED BY. TIME - (24 HOUR�K) TO SCENE ❑ S.O. .-_____ CALL RECEIVED .. � ---------...-_... .._.�-- ---� -- - - � - ---- -- ----- ❑ P L1 - ----- -- TIME 10-e ._... PATIENTDESTINATION- FROM SC ❑ FIRE --.-._._. TIME 10-97 P',AP TIME 10-49 MILEAGE`. -7 �THER:PVT TIME 10-7 END__S__--. _ TIME 10-98 DOCTOR C LC<_ �. �'_�.�' _. PMD/ER START__-�_� ^� _ TIME 10 22 HOW CHOSEN TOTAL ..__ _ _�!� __..-__.--.-. STANDBY TIME ❑ NEAREST C FAMILYTRANSFER_r l WAIT TIME )ti� -- i ❑ PATIENT ❑ DIRECT THER S 1 '>� `l CALL BACK K' AMBULANCE COMPANY: !` PT %IBULATORY? PATIENT TAEN�TO AMBULANCE. f'� `? RESPONSE ZONE ES ❑ NO �31_IERNEY ❑ OTHER -- PATIENT CONDITION DRIVER___. .. —__ C EMT- A --;--- ;, PTECHNICIAN ___ --rl FDIC Hx" DISPATCHED, �� y� 1 CHIEF COMPLAINT: "j� "� __�___.__ _ DRY RUN' ❑ Y S O REASON FOR DRY RUN AUTHORIZAT10 OR Y RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES (SIGNATURE) X 9C. �iED�_�A( ): RAG -INDUST IAL O YES O NO OF PATIENTS - .L-4- PRIVATE INS. CO. . _ BASE RATE I� S KAISER lv _-_. MULTIPLE PTS. BASE RATE WE -`B�OSS p' _ _ _ _ TOTAL MILES - - X 3a r „1E DICARE,6. O B. ATT ROUND TRIP ❑ YES ❑ NO \ _ j ❑ Y S ❑ NO NIGHT (19 00-07.00) _ _ C CC.fP.PPHP It �• ��' EMERGENCY RUN. 7)on [ �EDI-C�kL,a: V V _ - CODE 2/3 THER ._1 __..- OXYGEN' (PER TANK) P.o_E--$T//ICKER ❑ 'SES NO NEONATAL. (INCUBATOR) DATES Bit-LED: \1 — STANDBY: (OVER 15 MIN.) . E.K G- tPER EPISODE) NEAREST RELATIVE:'RESPONSIBLE PARTY1 I.V' IPER ADMIN), X \ J Y �� DRUGS. (PER ADMIN.) X V NAME. __ RELAJIONS - E O.A (IF NOT REPLACED) ADDR_ES�S ' J� ±r��t� 1��IJ , � ORAL AIRWAY' (IF NOT REPLACED) CITY �.-�-y�r �t „ .� �T� _ STATE-f-PIZIP--_ -_ C-COLLAR' (IF NOT REPLACED PHONE5_3S=_ `J2/__ WORK PHONE.—_—.._._._._. __ DRY RUN. (AUTHORIZED) EMPLOYER: _— _ _. OCCUPATION:____ OTHER: ADDRESS: -- ---- — — -------"-o.e:/I - �S L CITY: STATE:--ZIP._, -- COMMENTS. -- - --- -----_ TOTAL-- - �)�V OV - PATIENT RECEIVED BY: X �1 [ pie Provider rcc.,. . fi:i_.. .-:, r•: (SIGNATURE - .er:.r .. , tkva t:. ) LMS-1 00269 CONTRA COSTA COUNTY AMBULANCE 1 S � PRE-HOSPITAL CARE FORM i ` UNIT �L) AUTHORIZATION I CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME S S Z , O M gF COMPANY ln ADDRESS 21J��y� 6 ��C T AGE — 0 CITY wt / STATE G� • ZIP D0BP_� ' ' V - Sn ❑ M O T O W 13 Th 13F ❑ S DRIVER'S LICENSE R _ _ PHONE �'�„ g NATURE OF DISPATCH �+`F9 iL/S TYPE OF TRANSPORT:. AMBULANCE OTHER O _— __- STATION 1(A)_2(B)._3(C)_4(D)_5(E INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - O S.O. CALL RECEIVED t~) C- c� ' ` • � ❑ P.D. TIME 10-8 PATIENT DESTINATION FROM SCENE ❑ FIRE — TIME 10-97 Q6-1- :15� lI u /l O PSAP TIME 10-49 U/ 2_ :�- /y '1 I Y (1 1d C`�Cr`9"� �' D � MILEAGE:2 r.lJ ( OTHERJPV TIME 10-7 (2d- :=L r END J / TIME 10-98 DOCTOR 04e PMD/ER START_ TIME 1422 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY p<TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER + l CALL BACK w: AMBULANCE COM AN AN AMBULATORY? PA IENT TAKEN TO AMBULANCE: I i = RESPONSE ZON� YES O NO $WAL!(ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN _A10A VA DIC Hx: fT//L i'+9.• SGL•GfD E DISPATCHER: h c CHIEF COMPLAINT: e s s�o DRY RUN: O YES V(-NO REASON FOR DRY RUN rI AUTHORIZATION FOR DRY-SUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES XNO NO. OF PATIENTS: / S.S. R PRIVATE INS. CO.: BASE RATE: KAISER R L/ MULTIPLE PTS. BASE RATE UE R: 5 f.3 7� 010 TOTAL MILES: X MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO S OYES ❑ NO NIGHT: (19:00-07:00) ?o- U L CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL M: COD 2 k 3 OTHER: OXYGEN: PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ATES BILLED---- — STANDBY: (OVER 15 MIN.) L'2 Z12C/l��/ !l E.K.G.: (PER EPISODE) EAREST-RELATIVEJRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:1Eop�2� �1 RELATIONSHIP:A 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 ----" — —�— — PATIENT RECEIVED BY: X _ _ Nvuidor retain, Yhita ISI' ATTIRE) WS-1 . I,F rf�nt Y.•' .: ..1,., 1 �f.' v4o., 1 i 1 i.,,, CONTRA COSTA COUNTY AMBULANCE :`. • PRE-HOSPIT�IL CARE FORM 1 ' UNIT ® AUTHORIZATION ay $3 -/$•I.S`D "�;" /' .? 7/'/G / . CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME Sd-L vIL SO OF COMPANY N L_...,�.. ADDRESS V J AGE CITY Ca"f,yQ 1L STATE ZIP 008a - 0 Sn ❑ M OT OW ❑Th 8 � � DRIVER'S LICENSE If PHONE^l- ��pD A NATURE OF DISPATCH e t C q E TYPE OF TRANSPORT: AMBULANCE® OTHER❑ -- STATION rA) '21�)_3(C)-_41D)_6(E)-f..'•""•'� INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,•oil. D(� + TO SCENE- ❑ S.O. CALL RECEIVED 1 C. Q X O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 5 �1 ❑ PSAP TIME 10-49 J ] MILEAGE QrO HER/ VT TIME 10-7 It � Y � END G �' TIME 10-98 , DOCTOR �� e PMD START `S�• TIME 10-22 HOW CHOSEN: �v TOTALSTANDBYSTANDBY TIME NEAREST ❑ FAMILY O TRANSFER • WAIT TIME PATIENT ❑ DIRECT ❑ OTHER /-� CALL BACK 0: AMBULANCE C PANY: .� PT AMBULATORY? P�AIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1 YES ❑ NO WAL'<ED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER �`J v EMT-1A ✓ L e TECHNICIAN 33 PARAMEDIC Hz: sy:' v.re d.` ,'{CL'n 1�, VAIO—"-46SPATCHER: d O CHIEF COMPLAINT: V ; ho%KPS DRY RUN: ❑ YES *f40 REASON FOR DRY RUN 'D AUTHORIZATION FORRY RUN(EMS USE ONLY) + ( -�1� l: PATIENT REFUSED SERVICES: (SIGNATURE) X ' 6, r MEDICAL COVERAGE: INDUSTRIAL ❑ ES eNO NO.OF PATIENTS: S----� S.S. M PRIVATE INS. CO.: BASE RATE: i�v•vt�ll� KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X G.SU •- .SOS - 1 MEDICARE M: E.O.B. ATT. ROUND TRIP: 13 YES ❑ NO ^� ❑ YES ONO NIGHT: (19:00-07:00) 7 G CHP/PPH X31 L� EMERGENCY RUN: , MEDT-CALM:" CODE 2/3 OTHER: OXYGEN: +PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) •_;_, �) DATES BILLED: STANDBY: (OVER 15 MIN.) U" 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: . i ADDRESS: -' CITY: TATE: ZIP• C MENTS: A �� 4` T - -� 7 rn If c P, A ' TOTAL: �SQ•S U ; . . _.......__..,.... ... .._ - _..•fir-.; PATIENT RECEIVED BY:X Provider retain. Aitt Ind Pin: copy Return lr:lv+r copy t• DNS when bil:inp (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE I PRE-HOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION I j CHECK OA ML IN AMROMIAT!SPACES DATE: 1 L\. I 1 LA #_YTIENTS NAME a ! r OM IXF COMPANY• cf3s. ADDRESS �I�1 C'd u�1� 101 AGES 1 �CITYI��YY\fS,J \FO STATE ZIP DOB_ O Sn OM ❑ T O W •O TQR � S DRIVER'S 410ENSE I. " PHONE ' ` - NATURE OF DISPATCH `) W �`.TYPE OF TRANSPORIT: AMBULANCE OTHER - STATION I )A (BI_3(CI_4(01_5(EI_ `.INCIDENT L1.OCATION:--...... RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) i i - ❑ S.O. CALL RECEIVED I 0 .2�� TO SCENE z t-I 3 O P.D. TIME 10-8 -1 f;PATIENT DESTINATION: ! t FROM SCENE- ' ❑ FIRE TIME 10-97 : �''[�� �L ❑ PSAP TIME 10-49 �. MILEAGE: C}(1 � THE TIME 10-7 ` __ ENO `e_ TIME 10.98 DOCTOR S �Q2"L--)a__ PMD START t I/ TIME 10-22 'HOW CHOSEN: _ _ TOTAL 7 ( STANDBY TIME NEAREST C3 FAMILY O TRANSFER WAIT TIME RMCC PATIENT= '13 DIRECT O OTHER �� CALL BACK C AMBULANCE C?MPA Y" " � I E ULATORY7 PATIENT TAKEN TO AMBULANCE: (� RESPONSE ZONE__f O NO - O WALKED E3.6UERNEY O OTHER PATIENT CONDITION; DRIVERS �a�ti���+�`� I EMT,1A 1 . iRl1 ,• 1 TECHNICIAN , '(� PARAMEDIC I Hx: �� _ DISPATCHER: }, CHIEF COMPLAINTi�1� -- �Z'25QA• DRY RUN: OYES r O REA$Okl FOR DRY RUN �►=,,, AUTHORIZATION F R D RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X � iMEDICAL COVERAGE: INDUSTRIAL 13 YE 140; NO. OF PATIENTS: - "'S.S.r PRIVATE INS.C0.:J.1S BASE RATE: SD•GT� r-3i(KAISER I: A MULTIPLE PTS.BASE RATE r..rf. BLUE CROSS N: TOTAL MILES: '2 X 6"S I3-/I'D I MEDICARE r: E.O.B.ATT. ROUND TRIP: O YES O NO O YES .E3_ NO NIGHT: (19:00-07:00) CCHP/PPHP I: - EMERGENCY R}JTJ: .3O-Ga MEDT-CAL I: I CODE 2%3 J I ,. b OTHER: OXYGEN: (PE .TANK) P.O.E.STICKER O YES O NO . . NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 3O•G7�C'X f i^::�•t• E.K.G.: (PER EPISODE) 4�'= NEARS T RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X '` DE DRUGS: (PER ADMIN.) X • NAME:- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 4ADDREll ORAL AIRWAY: (IF NOT REPLACED) ySTATE- ZIP: C-COLLAR: (IF NOT REPLACED) CITY: PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION OTHER: ADDRESS: 'CITY: STATE• ZIP t COMMENTS: TOTAL:- L� PATIENT RECEIVED BY: X ••..�.�,r�..r (SIGNATURE) ProviQer retain Vhtite vId Pink Dopy , Return Ye:luw onpy t• Im when bilin, tis-1� Q02'72 / CONTRA COSTA COUNTY (�� 1 AMBULANCE PRE-HOSPITAL CARE FORM I I l UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAPE 6(- r 11 r s r C14 A 2 LF S T) M 1 F COMPANY« � Q ADDRESS c�DU 5 t �J 0 5f AGE ID S CITY 21c �,11'1�Inn STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W D Th 1133 DRIVER'S LICENSE N _ _ PHONE2_33_I 17 , NATURE OF OISPATCH_pl%%n 1Y\ '64GIC: TYPE OF TRANSPORT: AMBULANCE OTHER O _ — STATION (A) (B)_3(C)_4(D)_5(E)_- rr l INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) -I TO SCENE- Z O S.O. CALL RECEIVED ._-L l:Q� _3 r 0 S i J 1C 11 O P.D. TIME 10-8 r PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 I e ] Z ❑ PSAP TIME 10 49 N �5H MILEAGE: OTHER/CLt7 TIME 10-7 ICL END ( G•Z TIME 10-98 DOCTOR PMD/® START �,C� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER -7 CALL 8ACK C AMBULANCE COMPANY:^ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE X T ]'RESPONSE ZONE f } ❑ YES O NO O WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER Moo rt- .Z 7S�,7ns EMT-tA TECHNICIAN S �S PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: 73A r-%- � G'G%Y-1 DRY RUN: ❑ YE� ?-N/b RE SO \FOR DRY RUN j AUTHORIZATION O"RY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O ES �1J0 NO. OF PATIENTS One- S.S. ne-S.S. « PRIVATE INS.(0.: BASE RATE: J ! KAISER>t: _ MULTIPLE PTS.BASE RATE BLUE CROSS B: TOTAL MILES: X MEDICARE K: E.O.B. ATT. ROUND TRIP: ❑ YES )'�VO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: / MEDT-CAL M: CODO 3 t / OTHER: OXYGEN: (PER TANK) r P.O.E.'STICKER ❑ YES �JNO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) � I E.K.G.: (PER EPISODE) 1 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X �., NAME: e T TA RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: IIJJ��Ste/01 ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:�9 72i DRY RUN: (AUTHORIZED) EMPLOYERCI l/��1uL..5"OCCUP `ON:� OTHER: ADDRESS C. T-T1 h. (J CITY: STATE:-ZIP: COMMENTS:- SeL tj TOTAL y' J,J PATIENT RECEIVED BY:X s Provider noir, N►lite vld Pink copy Retur" Ye:lvw ropy t• INS when bil:inq (SI A URE) tatS�1 00273 r: f�. I.I,rlrn.� , 1,^,IA 1:clurllr _ -•� � AMIII1lANCC PRE-iios 11 AL CARE FORM 1 KNIT AUTHORIZATION N / l�0 CHECK OR Fn I INA rrn(rrnfA rr tr A Cf.- ) DATE: rn / PAlI NT'S NAMF. )4M ❑ F COMPANY N ADDRESS EAGu CITY\1:,• I�I'�'� -', _ STATEZIP DOB y ❑ M ❑ T ❑ W ❑ Th O p O S DRIVER'S LICENSE w __ _.__.. PHONE —_— -- NATURE OF DISPATCH ��•5—� TYPE OF TRANSPORT AMBULANCE OTHER❑ __ STATION (A )_3(C)_41D)_5(E).^, // I . INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: —1ME— (24 HOUR CLO K) 4� J TO SCENE- ❑ S.O. CALL RECEIVED `� l F-- - -- ----� ❑ P.U. TIME 10-8. P/� IENT DESTINATION FROM SCENE- ^ ❑ FIRE TIME 10-97 _ fI All / 1 ❑ PSAP TIME 10-49 C{ : / I I ( ✓ MILEAGE: - OTHER/PVT TIME 10-7 E END 0� • TIME 10-98 :-=A y DOCTOR / PMD/ER START,}— TIME 10-22 I �f� I I HOW CHOSEN:_ _ TOTAL r. ► STANDBY TIME 11 NEAREST ❑ FAMILY ❑ TRANSFER \ WAIT TIME O PATIENT ❑ DIRECT THER tom_1 CALL BACK N: AMBULANCE COM AN r PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO WAL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER-I �+ 1- ( MT 17l (> TECHNICIAN t 1 PARAMEDIC s I _11 Hx: DISPATCHER: _ CHIEF COMPLAINT: � • C— DRY RUN' ❑ YES WN REASON FOR DRY RUN AUTHORIZATION F DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)`)( t ; MEDICAL COVERAGE: INDUSTRIAL ❑ Y S NO. OF PATIENTS: S.S. - PRIVATE INS. CO.: BASE RATE: KAISER w: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: —,;2--X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES '❑ NO NIGHT: (19 00-07:00) H PID _ EMERGENCY RUN: MEDI L :U7 —SS`-1 �t7 _��� 70� T CODE 2/3 ER' OXYGEN: (PER TANK) P.U.E.- STICKER ❑ YES NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESP NSIB PITY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: — RELATIONSHIP: E.O.A.• (IF NOT REPLACED) ADDRESS:—_. 7 ORAL AIRWAY: (IF NOT REPLACED) CITY _.. y.._____ STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _ _ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY' STATE: ZIP: r� COMMENTS: TOTAL:_ C — PATIENT RECEIVED BY:X (SIGNATURE) Provider rota--'r-white I-nd Pin< ropy . Return 7e'IGL, -n�: t _tS when bil:inp 'DIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �,S AUTHORIZATION r Sl 3 r Gp CHECK ON FILL IN APPNOPNIATE SPACES DATE: r PATIENTS NAME Vit'!= t / '= �� %�"�.e+ �' t'�''– O M A F COMPANY M �/��^' ADDRESS J J 7' /_._ 1 r n t.. NI J AGE !� +� f-2- CITY�r �'_i� ✓IC>' STATE ZIP DOB_-5_LLL&!1 O Sn OM t3T Ow O Th OF OS DRIVER'S LICENSE>t _____ _ PHONE NATURE OF DISPATCH S TYPE OF TRANSPORT: AMBULANCE OTHER❑ — -- STATION 1(A 2(B)_3(C)-4(D)-5(E)-_- ..11NC[DENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) i jj� TO SCENE ❑ S.O. CALL RECEIVED r 2-2,c -Z ��,,, �.!)'L�'_CL ❑ P.D. TIME 10-8 5_. PATIENT DESTINATION: FROM SCENE- , ❑ FIRE TIME 10.97 -5 PSAP TIME 10-49 U MILEAGE: -d'OTHEan� TIME 10.7 �L END x- Al. TIME 10-98 DOCTOR k& ' C`� PMDeEg) START O i Z-- '�� TIME 10.22 HOW CHOSEN TOTAL ? J '' STANDBY TIME •!TNEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHERSCAL BACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: Cp�'� RESPONSE ZONET ❑ YES,- 13 WAL'<EQ-P!�_UERNEY 13 OTHER PATIENT CONDITION: DRIVER a7I EMT-1A TECHNICIAN 6`3PARAMEDIC = '�- Hx: �'� ,+� r2 L� .fr 5 ,f 7' i� c. L+l t.if"_ DISPATCHER: 4 1:- Q I!( CHIEF COMPLAINT: 11 DRY RUN: ❑ YES NO REA DRY RUN 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: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: •2 X G''SO _/9.0 MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO \1w\ O YES O NO NIGHT: (19:00-07:00) gtqHE/PPHP 0: EMERGENCY RUN: 30. Gd Lo y Cl S Cl' 3 1 3 CODE 2%3 1 1 1 OTHER: OXYGEN: (PER TANK) C % 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: Y TOTAL: f�3.0a 1 PATIENT RECEIVED BY:X Provider retair• White v+d Pink copL, Return Ye:Linn mpv t� SIS when bii:ing (SIGNATURE) 002'75' ` j • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 i'J UNIT ® AUTHORIZATION N _���� CHECK OR FILL IN APPROPRIATE SPACES DATE: w- ZU PATIENTS NAME �JM�11�czrtiAt l M�42r� 8�M ❑ F COMPANY N ADDRESS ` C� I c�'�i'i✓,- /'/ rJ ' c' AGE CITY �//yid/� STATE( '2 ZlP `^ ry�' DOB VI A7�3 ❑ Sn ❑ M ❑ T OW,,16 ❑ F 13S DRIVER'S LICENSE N __ _. PHONE NATURE OF DISPATCH__S Lq_ TYPE OF TRANSPORT: AMBULANCE OTHER❑ _- STATION 1 iA)_2(B)_3(C)_4(D)-5(E)_ ,,INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S O. CALL RECEIVED •01T ObX��' �3Q A ❑ P U. TIME 10 8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE _— TIME 10-97 LLQ AP TIME 10-49 MILEAGE OTHER/PVT TIME 10-7 T : _ END Dz:�T1`iX TIME 10-98 DOCTOR `P�11-�- PMD & START 7. TIME 10-22 HQWTOTAL , STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME `❑ PATIENT ❑ DIRECT ❑ OTHER - I CALL BACK N: AMBUL/jSL A MPANY: P MBULATORY? PATIENT TAKEN O AMBULANCE: i' RESPONSE ZONE_ /,.' ; iai YES Q NO ❑ WALKED IXGUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER G Uo r*3c EMT-1A f S�ZU TECHNICIAN UL _ P AME C-_L Hx: DISPATCHER: r 5)3 CHIEF COMPLAINT: CST cT)q L DRY RUN: ❑ YES ( NO REASON FOR DRY RUN r 11 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l 1 PATIENT REFUSED SERVICES: (SIGNATURE) X_ I MEDICjgggRA�G4: /.! ,SINDUSTRIAL ❑ YES'❑ NONO. OF PATIENTS: S.S. N ( (p(p 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 \couNM c1� „ , �2� ❑ YES ❑ NO NIGHT: (19:00-07:00) 4De"?Pf,FFPN: EMERGENCY RUN: EDI=CAC \ N 4 C Pc CODE 2/3 ( BOTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEJRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: SYZ-F 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:_J 5-p-9 P110 ki 2 7 6 _._.__. PATIENT RECEIVED BY X .2- � ? z:_'-_ L Pmvidar rA[air. Yhita viJ Fi.:e r. (SIGNATUREI copl, R.rh.ni 1'. '.. Its" ch., Fi I in;, fM•. 1 CONTRA COSTA COUNTY n' ) AMBULANCE PRE-HOSPITAL CARE FORM I 1N1 1 UNIT AUTHORIZATION 0 U � 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: O— - PATIENT'S NAME _/_z 0 M WF COMPANYCOADDRESS _� �'� ��L/ L AGE=L ``' 15910 CITY �`7U�� STATE ZIP DOB :27 -SY�O Sn O M O T O W..O Th O F �'S DRIVER'S LICENSE k ___^_-_ ,-_ PHONE_�'Z S a�PNATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE OTHER❑ ___,_ STATION I(A)._2(B)-3(C)_4(D)_5(E)_. Nat` INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR qLqCK) •` 1 ��C 8 - C=�� TO SCENE- Z ❑ S.O.—__ CALL RECEIVED ❑ P.D. TIME.10-8 PATIENT DESTINATION: FROM SCENE Z ❑ FIRE TIME 10.97 - N5� Q nr 11PSAP TIME 10-49 7 V D L _ MILEAGE: WTHER227"t-) TIME 10-7 �1,�, �� -• j� ! ENO 51 TIME 10-98 DOCTOR IS ��-S�w PMD/ER START r I TIME 10-22 HOW CHOSEN: TOTAL _ i C C H STANDBY TIME :�• i ❑ NEAREST ❑ FAMILY TRANSFER 7 ) WAIT TIME J ❑ PATIENT ❑ DIRECT ❑ OTHER ��.. CALL BACK M: AMBULANCE COMPANY: S- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: H y LA RESPONSE ❑ YES [)(,No ❑ WAL':ED O<GUERNEY ❑ OTHER } PATIENT CONDITION: DRIVER L 340 EMT-IA x TECHNICIAN NLQ?tEWPARAMEDIC 15 Hx: DISPATCHER: 1T 11" C) CC �/ CHIEF COMPLAINT: G DRY RUN: ❑ YES © NO REASON FOR DRY RUN 4 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j 7(/ PATIENT REFUSED SERVICES: (SIGNATURE) X, r ME�[1LGAL COVERAGE: INDUSTRI L 13 YES ❑ NO NO.OF PATIENTS: PRIVATE INS. CO.: BASE RATE: 0 KAISER k: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES:- MEDICARE k: E.O.B. ATT. ROUND TRIP: '❑ YES ❑ NO f D VES ❑ NO NIGHT: (19:00-07:00) p C CCHP/PPHP k: EMERGENC _fkUN: -� u 1 MEDT-CAL k: CODr2 3 -7 - i 1 OTHER: OXYGEN: PER TANK) - J�y1°'�`' 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 �/ /nJ DRUGS: (PER ADMIN.) X NAME: f•f tl/C/It� L Aa RELATIONSHIP: t4v 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: (� 1nn� l fJ LA J 1 Z I N 1 I Me_ TOTAL:.a`'``'` •-S PATIENT RECEIVED B -Cl Provider Mtair. white rrd Pi,:: ,\ Tt crt�r-t YP•,(•1.' •'r% t• ^tF when b-.7inQ (SIGNATURE) DIS-1 / CONTRA COSTA COUNTY i AMBULANCE PRE-HOSPITAL CARE FORM I UNIT E2 AUTHORIZATION It CHECK OR FILL INAPPROPRIATE SPACES DATE: LO PATIENTS NAME �� 1( �� %�'\ _F 6Z) M Ck Gl ��M 13F COMPANY N ' ADDRESS L�- S F;( ? �1 AGE - Lo 0 �O CITY STATE .2( ZIP 0, DOB"_�_('g6 ❑ Sn ❑ M ❑ T ❑ Th OF US DRIVER'S LICENSE K ___ PHONE NATURE OF DISPATCH SO 1� Co M!fin1 .0 i TYPE OF TRANSPORT: AMBULANC.K OTHER❑ _ STATION 1Wk�52( -31C1_4(D)_5(E), INCIDENT�OCATION: RESPONSE CODE: REQUESTED BY: - (24 HOUR CLOG I �{ i �) TO SCENE- ❑ S.O. CALL RECEIVED ❑ P.D. TIME 10-8 (y: PATIENT TINATION: FROM SCENE_ 11FIRE TIME 10-97 O PSAP TIME 10-49 MILEAGE:, _OTHER/PVT TIME 10-7 END �1 TIME 10-98 DOCTOR \- ,C`/ P R` START. c 1 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 0 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ,PATIENT ❑ DIRECT O OTHER t CALLBACK 0: AMBULANC�0 TY: PT AMBULATOR Y? PATIENT T KEN 10 AMBULANCE: QCT RESPONSE ZONE YES ❑ NO O WAL!<Et� ERNEY ❑ OTHER PATIENT CONDITION: DRIVER L4_ �`~�UMT-1A � TECHNICIAN c—� _ r 4ARAMEDIC /7 Hx: �1 t DISPATCHER: _ L CHIEF COMPLAINT: DRY RUN: O YEDArN( REASON FOR DRY RUN r AUTHORIZATIONY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X AL COVERAGE: INDUSTRIAL ❑ Y S-t O NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: L . KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X y G . MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ 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.) o- :To O 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: p/ TOTAL• ✓/! �� PATIENT RECEIVED BY:X Provider rwtcir, White and Pir.K copy Aetum Ye:Zvw ropy t• V!5 when biZ:inp (SIGNATURE) QiS t' 00278 r CONTRA COSTA COIr UNTY ILl!!II AMBULANCE �' Q PRE-HOSPITAL CARE FORM I �lr 1 UNIT C AUTHORIZATION It CHECK OR FILL IN APPROPRIATE SPACES DATE PATIENT'S NAME. L^_ L,_1"_1`_! ❑ M @'f COMPANY ADDRESS 12 AGE CITY STATEc A ZIP. 1q>�v .. /_ . �_.._ DOB' 03n OM OT 13 ❑ Th f4/F Os DRIVER'S LICENSE R __ �-A. •_.._._ _____ PHONE jJ � V, NATURE OF DISPATCH. CA A TYPE OF TRANSPORT AMBULANCE IVOTHER❑ _. ... STATION 11A)__21B)_.-31C)-4(D1_-51E)- - \INCIDENT LOCATION- RESPONSE CODE REQUESTED BY TIME -- (24 HOUR CLOCK) TO SCENE - ❑ 5.0 CALL RECEIVED Cl r•(.1 TIME 10-e _.► _ -._ ' ATIENT DESTINATION- FROM SCENE - ❑ FIRE _. _- _ TIME 10-97 '•�`cC 1 ,�' 1 ( - ---- O r'.,AP TIME 10-49 ��s � 1/[ Kms- LY._%1� MILEAGE C XTH R,PVT TIME 10-7 END._-. _b. �.. � �.{ _._.... TIME 10-98 " DOCTOR 11��_L�`_PJ _---_. PMD/ER START -_ � _. _.. _ TIME 1U 22 . ._— HOW CHOSEN' / TOTAL ._._'_ .�.. . _ ._ . STANDBY TIME - _- ❑ NEAREST O FAMILY p/TRANSFER WAIT TME O PATIENT O DIRECT ❑ OTHER C ( 3 CALL BACK I, AMBULANCE COMPANY PT fjNIBULATORY) PATIENT TAKEN O AMBULANCE. %�!� / RESPONSE ZONE=._,�-_ YES ❑ NO ❑ WAL':ED GUERNEY ❑ OTHER �_..._. ....__. PATIENT CONDITION. DRIVER_-_ PARAMEDIC �r?�as TECHNICIAN _ __.___..__. C (� . C i��S — DISPATCHER (_ CHIEF COMPLAINT: _C. F[ t u't'i.Iv` DRY RUN ❑ YES LY/tJ0 REASOa FOR DRY RUN 1W t 4 J �,___-__-" - AUTHORIZATION FOR DRY RUN(EMS USE UNLYI.__-_-_—_ PATIENT REFUSED SERVICES (SIGNATURE) MEDICAL COVERAGE: INDUST AL ❑ YES NO NO OF PATIENTS. _- r�,�• ' S.S. R t 7-3It PRIVATE INS.CO.: BASE"RATE LLQ �v KAISER K'. MULTIPLE PTS BASE RATE BLU RO K TOTAL MILES --___-_._ ..! _.... -. X SD .SU �E O B. ATT ROUND TRIP O YES ❑ NO nn ❑ YES O NO' NIGHT (19 00-07 001 CCHP/PPRP _7J EMERGENCY RUN OI-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 IPER ADMIN)— _---.-X us 1Qh E4 DRUGS. (PER ADMIN )----- X NAME: o I` - RELATIONSHIP:SLf o E O.A "(IF NOT REPLACED) -__— ° ADORES /1 p _ ORAL AIRWAY" (IF NOT REPLACED) _-- CITY L�_�-e-_ -__ STATEC_A�ZIP_-_-_-_ C-COLLAR (IF NOT REPLACED) PHONE: _ WORK PHONE. DRY RUN. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER. ADDRESS: -- — - -- - - - ------- CITY: STATE: ZIP. COMMENTS: -- - -"-- TOTAL PATIENT RECEIVED [3Y X f?vaidrr "tai,. whit, .r.11•1,.% .•r,T:,. w, . ' - I:iK:NATI)Rf.-I 00279 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I d UNIT AUTHORIZATION K CHECK OR FILL IN APPROPRIATE SPACES DATE. .--/ PATIENTS NAME M ❑ F COMPANY x /IV V) ADDRESS __moi iLs- L���L►� '—Q! `''` CITY STATE ZIP.!______.._ DOB.._ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F fqS DRIVER'S LICENSE>r ___ .__—.._._ _ PHONE _._.._ _ ._....._.-__. ... NATURE-OF DISPATCH/Cl�l�'/o TYPE OF TRANSPORT AMBULANCE OTHER O _._.. _�____ STATION I(A)_2(8)-.___3(C),4(D)_5(E)^ - INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY. TIME - (24 HOUR CLOCK) `/ /) n, TO SCENE- �f /h ❑ S.O. CALL RECEIVED 1 G /� --- --//y V ❑ P f1 -- - -. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE __.-._._. TIME 10-97 GVI�� W� ` ` ' �� rs _ _0.... ❑ PSA P TIME 10-49 o O MILEAGE. OTHER,PVT TIME 10-7 END _ __�____.___ TIME 1098 DOCTOR _ PMD/ER START__ _ ____ _ _ TIME 10-22 HOW CHOSEN: TOTAL —._._ ____ _�_ __ _____. STANDBY TIME ❑ NEAREST D FAMILY D TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R AMBULANCE COMPIN PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: I. RESPONSE ZONE_— ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER.�_�CS��f`F�!.___._ �L�_/_-�_. 1F► T-tA 1 TECHNICIAN PARAMEDIC 'Hx: DISPATCHER 77 I,,-- J C) L) CHIEF COMPLAINT: DRY RUNkYES ❑ NO REASON FOR DRY RUN I qq _ _ AUTHORIZATION FOR DRY RUN(EMS USE ONL Y) PATIENT REFUSED SERVICES: (SIGNATURE) X_ - 7 5;L_MEDICAL COVERAGE: INDUSTRIAL ❑ YES Cl NO NO OF PATIENTS. S.S. x 1 PRIVATE INS.CO.: BASE RATE- KAISER ATE KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS»: TOTAL MILES X _ MEDICARE R: E.0 S. ATT. ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19 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/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 Awvidur rttJ:q White ,rJ Ili,.; ,':q• t,•tpn. ISIGNATURf) e CONTRA COSTA COUNTY AMBULANCE' P -HOSPITAL CARE FORM I UNIT AUTHORIZATION* CN[CK 011 PILL IN A►NIoMIAT[SPAM DATE: U GIc�'�1 1��0 1�J 1�1�1O PATIENTS NAMEF COMPANY NS * p,.� ADDRESS 1 ' ��'1 11�" { AG CITY STATE . ZIP DOB -1 G-31 ❑ sI, O M D T O O F O.3 . DRIVER'S LICENSE N PHONE --- NATURE OF DISPATCH `'U� L1 (v%L TYPE OF TRANSPORT: AMBULANCE OTHER -• STATION 1(AI_2(B)_3(CI_4(D)._5(EI_ INCIDENT LOCATION: _ RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR O_CK) TO SCENE- ❑ S.O- CALL RECEIVED X ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 ❑ TIME 10-49 _ S-`�• MILEAGE: S r OTHER/ VT TIME 10-7 f END U TIME 10-98 DOCTOR P TART _17�1�T TIME 1D.22 ,HOW CHOSEN: TOTAL STANDBY TIME AREST D FAMILY O TRANSFER WAIT TIME O PATIENT D DIRECT O OTHER CALL BACK. : AMBULANCE COMPANY: 1-5 PT. BULATORYI PATIENT TAKEN TO AMBULANCE: �� RESPONSE ZONE S D NO O WAl`CED GUERNEY O OTHER 2 C !,PATIENT CONDITION: t', DRIVER L. ✓ J MT-1A TECHNICIAN l7 PARAMEDIC C. C,.Hx: S� DISPATCHER: l� J / CHI COPLAINT: t� DRY RUN: O YES { NO REASON FOR DRY RUN 510- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X / ' 152- MEDICAL CO INDUS RIAL O YES O NO NO.OF PATIENTS: ,.a y - 0 N O INS. CO.: BASE RATE: Ila, KAISER N: MULTIPLE PTS. BASE RATE /a 15LUE CROSS N- TOTAL MILES: MEDICARE N: E.0-B. ATT. ROUND TRIP: O YES ONO 160, OS O YES .O NO NIGHT: (19:00-07:00) cv CCHP/PPRP N: EMERGENCY/`.A N: .�•cv O8 ' .CAI M• COD- 2 j OTHER: OXYGEN: ER TANK) P.O.E. STICKER O 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 AOL""b DRUGS: (PER ADMIN.) X NODRESS: Z e�j•LATHIP: E.O.A.: (IF NOT REPLACED) ORAL AIRWAY: (IF NOT REPLACED) P CITY: STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) `- EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: k-,,LxJL`p rAI cAOeC-�'G (_ tll"r ,3 C�V\- Ca Yyr—t\J,No NTOTAL: L Gtr PATIENT RECEIVED BY: / Provider retain Yhit• vid Pink copy - Roturn Ye'1uw -opy t !N.S when Dil'inp SIl3NATUREI fl 5-1 y CONTRA COSTA COUNTY AMBU NCE . 3 PRE-HOSPITAL CARE FORM 1 UNIT VAUTHORIZATION 19 CHECK OR FILL IN APPROPRIATE SPACES J � DATE: PATIENTS NAME '"/ o � 97 M ❑ F COMPANY R ADD SS ��� / S 4, • AGE l` I c:• CITY - STATED - 21P DOB ❑ Sn O M ❑ W O Th O F O DRIVER'S LICENSE M _ PHONE , kATURE OF DISPATCH`�'1�!✓-Sr ��5 U l TYPE OF TRANSPORT: AMBULANCE OTHER 0 — -- STATION 11A)_2(B)_31C)_4(D)_5(E)_ INCIDENT LOCAT ON: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S.O. CALL RECEIVED 4LT_ ❑ P.U. TIME 10-8 C- ;• PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 [r fF (�20 MILEAGE: s P TIME 10-49 C .1 :, OTHER/PVT TIME 10`7 END "J .•^I ` TIME 10-98 ) DOCTOR T P /ER START TIME 10-22 HOW CHOSEN: TOTAL 1 1 T STANDBY TIME 13 NEAREST O FAMILY TRANSFER WAIT TIME O PATIENT ❑ DIRECT 11 OTHER CALL BACK R: AMBULANCE COMP Y: PT�. MBULATORY? PATIENT TAKEN, 6 AMBULA EE: �L ' %�� =� RESPONSE ZONE fd YES ❑ NO ❑ WALKED lb GUERNEY l� OTHER PATIENT CONDITION: DRIVER EMT-tA TECHNICIAN �� PARAMEDIC Hz: DISPATCHER: r ' CHIEF CO PLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) LPATI EN REFUSED SERVICES: (SIGNATURE) X l MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. C BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE 0: B. ATT. ROUND TRIP: O YES ❑ NO ut YES O NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCX-RUN: MEOI-CAL M: CO 2/,3 OTHER: OXYGEN: ER 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 I d DRUGS: (PER ADMIN.) X NAME1�• /mac L� L' R.E �T•IONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: 36)3 Q S A ORAL AIRWAY: (IF NOT REPLACED) CITY: L STATE- ``' ZIP: C-COLLAR: (IF NOT REPLACED) ( PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) YE1466 u-OCCUPA I /, 44eOTHER: ADORE •n !�/_` �'. C/ �!�/7 I;� (�., %, CITY: ` � STATE• V'J71, d ` COMMENTS: 1 iL�L u u% C.'!i' Lf .. TOTAL' - / -- PATIENT Ar-rFIVFn BY X L c' '`,.�c.//� C 0 t . r P� PATIENT'S NAME: Daniel Pokiyala ::-' ADDRESS: 430 1st it. #3 Rodeo, Ca. DATE OF SERVICE: 11-09-83 AUTHORIZATION NUMBER: 83-20033 AMOUNT DUE: $270.00 INCIDENT LOCATION: Richmond Mental Health Clinic PATIENT DESTINATION: Contra Costa County Hospital 3 " g No� 9 10 31 - 132526 PM 1 bu 9` lQ 31 PH '13' Nov l0 3� 77 • SO'NUMBER�.J'�*1t���J 3 I CAU RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 .� c� 'CALLED BY— CN INFORMATION cv h— 1 NAME ��y_ rl ._. .. - ---- CQ AGENCY: __.____ . ._.__ :�rn__.J`d_ COSTO a PT, 11: DOB 57 y DEPTlFLOOR/ROOM a: —__-.—_-_— _ NAME: n Q v m a CALLBACK $+ INS:'.T.YPE: PVT CAR MCAL HP PHP VA IND CHAMPUS u INCIDENT LOCAL[__l__��./ POLICY/MCAL 4: n .� Q m— MCAR#: m r m CROSS STREET: — VERBAL PRI o W Q JURIS: City �1 _ DOCTOR: o- r — DESTINATION: .S't PT.'I12 NAME: DOB: NATURE:S_ �.v _-___ CUST. # � p i C -- _. - - - — ---- PT. n3 NAME: DOB: c- o C✓D o TYPE OF CALL: EMG S TIME U T a CUST. # Zz m w CREW: r w` WAIT TIME: YES NO REASON: m �r i UNIT TYPE: Aly S WC RESPONSE CODE: 0 1 2 3 4 REASON FOR 10.22: p O INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 2 4 CANCELLED BY: m ~ a u BY: END MILEAGE: COMMENTS: p Z z TIME: BEG MILEAGE: � a m DIS AfT�C/H�ER TOTAL MILES: 00284 w XL-01 NOIIVIS IV 3DNVlflBwv 61.01 ONINdnl3M 3JNV1FIBWV 86.01 31OV11VAY 3DNvinowV L-01 1VIIdSOH 1V 3DNvinowtl £!� �� 09 AINEl, Wei ja SEW U 116 AM CONTRA dOSTA COUNTY AMBULANCE , ! PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N i I , CNlCL OR fltl IN AP►110PRUTf SPACES _ DATE: ATIENT'S NAME_idL_ ��—SC1.LSN_ 1�_ 0 M F COMPANY N �^ 1 / ADDRESS 1 I U i c�L t;' ' AG S ti CITY�1���� STATE ZIP qq j� DOB WI— ❑ Sn ❑ M ❑ T ❑ W ❑ Th .0'F ❑ S DRIVER'S.LICENSE N _ PHONE NATURE OF DISPATCH Lr'e� TYPE OF TRANSPORT: AMBULANCE,,Q OTHER❑ ____ STATION 1(A)S2(8)_3(C)_4(D)_5(E)_ C, INCIDENT L CATION: a RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE - ❑ S.O. CALL RECEIVED ❑ P U. TIME 10-8 1 ... t PATIENT DESTINATION: O�\] FROM SCENE ❑ FIRE.—_ TIME 10-97 r� T� ❑ PSAP TIME 10-49 t MILEAGE: •&'OTHER/PVT TIME 10.7 '. /1/, END _ TIME 10.98 DOCTOR ___AciQU'�1'J Cy til /s#f� ) START_ � !1! %J TIME 10-22 HOW CHOSEN: / TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILYRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER ,- CALL BACK N: AMBULANT C TNY: ) • / PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: [RESPONSE ZONE 4!W-YES ❑ NO 7?WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A r� TECHNICIAN _ r c ��� '-Q t PARAMEDIC Hx: �Lh ► 1 l`I S DISPATCHER: C IEF COMPLAINT: DRY RUN: Cl � YES -i NO REASON FOR DRY RUN 5� �� HC'S AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X �1MEDICAL COVERAGE: INDUSTRIAL ❑ YES JO NO. OF PATIENTS: �- S. PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE SS C TOTAL MILES: 1 `� X t� / E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO T; le ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP 4: c �j EMERGENCY RUN: EDI- C �/ V O / S eq-$0 �3 c/ 3 , h,;- CODE 2/3 OTHER: OXYGEN: (PER TANK) O.E. S KER ❑ 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, 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 yn 30 1, ��:`I� TOTAL.r,, 227 SO I _�. PATIENT RECEIVED BY: X_ 00285_ Provider rota:. White ,.nd Vin� '•Pb 4�•t�rn I,. :.;. ,�,. t•CI ink (SIGNATURE) 'r: vh.•i CMS-t CONTRA COSTA COUNTY. AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION• CHECK OR FILL INAPPROPRIATE SWAGES DATE: PATIENTS NAME. � ) f%lam O F COMPANY M p? 1 1 y �- .�,� 'M F ADDR SS �) �� / /i=�.�L,v E h n 13 y� ._ CITY 1ti STATE ZIP!&zr2/ DOB I � ❑ Sn O M ❑ TXW O Th O F D S DRIVER'S LICENSE A _ PHONE ?K2&l NATURE OF DISPATCH �t TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ -- STATION 1(A)_2(8)_3(C)_4(D)_6(E)_ j INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME-(24 HOUR FLDCK TO SCENE- ❑ s.o. CALL RECEIVEDI �� ' f��M �- L J►4P[� (�\ _ ❑ P.D. TIME 10-8 � , PATIENT DESTINATION: FROM SCENE,. ❑ FIRE TIME 1097 � t ^. - ❑ PSAP TIME 1049 L�L' "ry)"i lalMILEAGE: XOTHER/PVT TIME 107 A I END TIME 1098 DOCTOR ,�_►1Yc PMD/� 'START--J _ _ Q n.. �t Y [� TIME 1022 HOW CHOSEN: TOTAL ( ' ` STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER 'T CALL BACK N: A ULANCE COMPANY: - PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ONO WAL`CED O GUERNEY O OTHER i PATIENT CONDITION: DRIVER -'57a 3 3 C- FST- e7 TECHNICIAN _ C)s5� PARAMEDIC Hx: _ DISPATCHER: Cl c. CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 V PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL !RAGE INDUSTRIAL ❑ YES,40 NO. OF PATIENTS: S.S. # a _ PRIVATE INS. CO.: BASE RATE: %t KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X ;L O MEDICARE 1; 441 ?y'�< 7 r,�—E.O.B. ATT. ROUND TRIP: ❑ YES O NO (-P YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPHP A: EMERGENCY RUN: li �.;_? <�� S'(� CODE 2/3 MEDI-CAL N� - OTHER: i (� (( 1, "' OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I t E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �,, DRUGS: (PER ADMIN.) X NAME:I�(,)Lq L t ��E: R_ELATIONSHIP:i_LLt!1_ E.O.A.: (IFWOT REPLACED) ADDR S: ) ORAL AIRWAY: (IF NOT REPLACED) r +I CITY: '� 4�/�•�lyn�O STATE ZIPi'`ac/ C-COLLAR: '(IF NOT REPLACED) i PHONE:c�L_1 /�� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: , ADDRESS: CITY: STATE: ZIP:- COMMENTS: IP:COMMENTS: laWoo 1 TOTAL: PATIENT RECEIVED BY:X Pwvidor retain, Whits v+d Pink copy Return ye.Zvu ropy t• VfS uhen biVinp (SIGNATURE) D1S�1� 00286 t CONTRA COSTA COUNTY AMBULANCE ` PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR►ill IN A►►RO►RIA)L SPAM DATE- _3 ATE: PATIENTS NAME � _3f � O M F COMPANY N ADDRESS 1 r 42 A AGE CITY �' N' STATE Cf7 ZIP DOB L,2,6_5` 3 ❑ Sn OM O T O W D Th RCF O S DRIVER'S LICENSE M _ PHONE S _�S�S NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER _ -- STATION 1(A)_21B)_3(C)_4(D)_5IE)jK_- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S.O. CALL RECEIVED c C C H !t�/�/Z ❑ P.D. TIME 10-9 1 PATIENT DESTINATION: FROM SCENE-, 13 FIRE _— TIME 10-97 [cam y L Nc•r/ c 2 c,f".0 />�5 i' O PSAP TIME 10-49 ,' l �=- •v�'^'i•'�IL%p MILEAGE: � �.OTHER/PVT TIME 10.7 END 9 TIME 10-98 DOCTOR �F//INJ FF PMD/ER START �L _ ���C y TIME 10-22 HOW CHOSEN: TOTAtr`).�� STANDBY TIME D NEAREST O FAMILY Ia TRANSFER - WAIT TIME Cl PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: _ c' 43 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: -.� L` lI RESPONSE ZONE Jr 5t YES ONO WALKED AGUERNEY O OTHER ` PATIENT CONDITION. DRIVER L/3r-n7S _ EMT-1A TECHNICIAN ��L rN7- PARAMEDIC Hx: �ZPCZ�'77�!4/sn/tT/tYc� 7C- DRY yy.,,���'. I 1 CHIEF COMPLAINT: DRY RUN: ❑ YES w.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: s.s. N .5"6o- 9'1- 7'/'10 PRIVATE INS. CO.: BASE RATE: KAISER R: _ MULTIPLE PTS. BASE RATE QK`UE CRO CZ �' � AT TOTAL MILES: X M ARE M: E.O.B. ATT. ROUND TRIP: O YES O NO O YES n NO NIGHT: (19:00-07:00) C-' P P H P 0: S. -O EMERGENCY RUN: 1 J MEDT-CAL R: CODE 2/3 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER 13 YES .O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) �(1 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:— COMM ENTS: IP:COMMENTS: 2 7 AW TOTAL: r —. PATIENT RECEIVED BY. X Providrr retain Atte Ltd KnA vu N#Cum Y.'!••v a. 510NATUREI PY y, t H:. uhrn 6i( nth LMS 1 00287 rON1RA C1191A COUNTY '1 ) AM[1(ILANCE PRE-110SPITAI_ CARE FORM I ,(( UNIT AUTHORIZATION k CJI CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME.!/—��L�j M ❑ F COMPANY N ADDRESS _L-LES-tlr—� .1 �J/ -lt 'C I )C , AGE Ip r CITY S- ?�L�l C�' STATE 7 ZIP DOB ❑ Sn ❑ M ❑ Tom❑ W� 13 Th`❑ F ms.1 DRIVER'S LICENSE k �_______�._. _ PHONE 1 �NATURE OF DISPATCH j��t�f d ti TYPE OF TRANSPORT: AMBULANCE YIJOTHER❑ — STATION 1(A)_2(8)_3(C)_4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) No L C C C -� TO SCENE- ❑ S.O. CALL RECEIVED jaL ❑ P.U._ TIME 14.8 PATIENT DESTINATION: / I FROM SCENE- ❑ FIRE TIME 10-97 7 �?� ,t,_`, " O PSAP TIME 10-49 7 ib MILEAGE: �THER/PV TIME 10-7 ' G: ' �^T END— �� `� C Cf TIME 10-98 DOCTOR PMD/ER STARTZ(cQ TIME 10-22 HOW CHOSEN: 1 [TOTAL � STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME :' } ❑ PATIENT ❑ DIRECT ❑ OTHER ( 't CALL BACK k: AMBULAyCE COMPANY: ETT. AMBULATORY? PATIENT TA EN TO AMBULANCE: ( ,/(! RESPONSE ZONE - 'YES ❑ NO ❑ WAL"ED/EbGUERNEY ❑ OTHER PATIENT CONDITION: DRIVERC+/i 2C T •2 ?{ -1A - TECHNICIAN-7t UyC 1� ? (.� PRAMEDIC I x �l �1 zY/. )L �c L I Hx: % �. DISPATCHER' i .7 ! r // f L V L, MP AINT 7/L 13CHIEF C ►L1 DRY RUN: YES ❑ NO REASON FOR DRY RUN ' j._�1 r-1 I f t'� i �. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �7 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. PRIVATE INS. CO.: 22-1 t BASE RATE: KAISER k: MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: 4f X ��� . MEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES O NO I ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP k: EMERGENCY RUN: J MEDT-CAL k: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) J. v 1' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) CNEAREST RELATIVE/_AESPONSIBLE PARTY: S.V.: IPER ADMIN.) X -- "''�� DRUGS: (PER ADMIN.) X NAME: RELATIONS IP: E.O.A.: (IF NOT REPLACED) ADDRFS u �1a '� '�� ��' ORAL AIRWAY: (IF NOT REPLACED) ~ CITY:L �� -`' STATE61QIP: 5 C COLLAR (IF NOT REPLACED) PHONE:-Y / Y WORK PHONE -%� Z ��- DRY RUN (AUTHORIZED) EMPLOYER: OCCUPATION:Iyyj�'� / OTHER: ADDRESS:_ .CITY: STATE: ZIP: COMMENTS: 1 TOTAL: 52,7tl -v ;::PATIENT RECEIVED 8 Provider retain Vllite card Plink copy Return Ye:tvw ropy t, EMS when biking ($IpNAT an&-a C 00288 1 I� --�'• CONTRA COSTA COUNTY AMBULANCE RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N - 2 17G r.,.. - �l-`, �— CHECK OR Fite IN APPROPRIATE St•AC[t � DATE: s2 PATIENT'S NAM I C h�J�Lf C O F COMPANY 0 �3,� YC)c! ADOR AG CI7STATE /�IA 21P p0 � .L_� O Sn O M OT Ow O Th OF O S DRIVER'S LICENSE M _ PHONET2 NATURE OF DISPATCH TK►,a)1 ti 1 �"•- TYPE OF TRANSPORT: AMBULANCE OTHER _ _ STATION 1(A)_.2(8)_3(C)-41D)_5(E1, � INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR%OCK)/•�;J �7 [� TO SCENE- O S.O. CALL RECEIVED l '/ O P.D. TIME 10-8 PATIENT DESTINION: FROM SCENE O FIRE TIME 10-97 �) 1 O PSAP TIME 10-49 MILEAGE: t /J HER/PVT TIME 10-7 cp •�\ END f rt TIME 10-98 DOCTOR PMD/ER START 5 t I TIME 10-22 HOW CHOSEN: TOTALS STANDBY TIME O NEAREST O FAMILY 6NSFER WAIT TIME O PATIENT O DIRECTS LJ OTHER { LI ) CALL BACK M: AMBU OMPANY: PT. AMBULATORY? PATI NT TAKEN TO AMBULANCE: \l�, RESPONSE ZONE S ONO / W�'CED O GUERNEY ❑ OTHER ATIENT CONDITION:( DRIVER r� 'y I ' EMT-1A TECHNICIAN � �k ) `' PARAMEDIC C Hx: �� 1CiN� DISPATCHER: ) -- J 7 CHIEF COMPLAINT: DRY RUN: O YES ;O REASON FOR DRY RUN C 1 AUTHORIZATION OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X E ) AL COV RAGE: INDUSTRIAL O YE N NO. OF PATIENTS: .. BASE RATE: Iw LZ MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: � X MEDICARE R: E.O.B. ATT. ROUND TRIP: O YES ❑ NO JD (OC S O YES ONO NIGHT: (19:00-07:00) CCH P/PPHP0: EMERGENCRUN: MEDT-CAL M: COC 21/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEIRES NSIBLE PARTY: I.V.: (PER ADMIN.) X y� DRUGS: (PER ADMIN.) X NAME: 1 tjC'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:COMM NTS: TOTAL:, lz PATIENT RECEIVED B X hvvider stair. Vhit• r-,d link voIi Rotum Yo'i.a • $X: / 'sI�iNATURE) Y tishan hi7 i• 0 0 nn G • CONTRA COSTA COUNTY l AMBULANCE • ` PRE-HOSPITAL CARE FORM I )/ UNIT ,,l AUTHORIZATION 0 V CHECK OR FILL IN APPROPRIATE SPACES DATE: f� C PATIENTS NAME 6 c �a�'" I�^ O `` �^ O M t 3 !J�O XFC COMPANY N ADDRESS C a 4-1 L D'V AGE �� n / CITY 16 A 4 C'l STATE C ZIP Ys dd Q`*) DOB 1�� O Sn ❑ M O T ❑W O Th �O S DRIVER'S LICENSE K _ PHONE ,�V -�!�+G NATURE OF DISPATCH— TYPE OF TRANSPORT: AMBULANCE OTHER 0 __ STATION 1(A),2(B)_.31C)_4iD)_5(E)_V' INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL CK)G 2 n TO SCENE- O S.O. CALL RECEIVED -2-1 D P.D. - TIME 10-81' '? :-u PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10.97 O PSAP TIME 10-49 MILEAGE: aOTHER/PVT TIME 10.7 -2 l ENDq01G L TIME 10.98 DOCTOR ' t a h PMD R START i:ki TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER v� l WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER Com/ CALL BACK"M: AMBULANCE OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE F-YES ❑ NO O WALKED"Qf'GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN r, ' ' PA AM DIC Hx: L1`^�� k"OPV' °��`� DISPATCHER: - }-� CFjIV COMPLAINT: T rz 1nly ' to DRY RUN: O YES �2'NO REASON FOR DRY RUN O'_5 KI t?%,\Q '1 t` AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATI NT REFUSED SERVICES: (SIGNATURE) X 7qMEDICAL COVERAGE: INDUSTRIAL ❑ YES�JO NO. OF PATIENTS: S � PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE r� C' �T CROS,_ '� 3 t3 -�y 6 6 TOTAL MILES: X MEDICARE 0- E.O.B. ATT. ROUND TRIP: O YES O.NO I -- `� �►f t� �(O�l CJ O YES O NO NIGHT: (19:00-07:00) - �_ �. CCHP/PPRP i Q t G EMERGENCY RUN: j MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) l P.O E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 7y 77 DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: 9 E"O.A.: (IF NOT REPLACED) ADDRESS' z � ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP: C-COLLAW (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: _; �� ��� k CITY: STATE: ZIP: COMMENTS: f I �� �`c)14� TOTAL:-;I- _ /22 40. PATIENT RECEIVED BY: X .___�__._____� Provider Ntair, Aite Laid Pink copF iteturm Ya'Lw rmpl I, S>G• uhun bil ind ISIGNATURE) I 002 r� t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK 00 ML IN APPROPRIArt SPAM DATE: �j 3 PATIENTS NAME !7 M �❑(F COMPANY N ADDRESS S G AGE S 1 CITY STATE ZIP �a DOB 3 qo O Sn O M OT Ow 0Th O F es DRIVER'S LICENSE N _ PHONE 0 � NATURE OF DISPATCH� �� TYPE OF TRANSPORT: AMBULANCE Iff OTHER STATION I(A)_2(8)_3(C)._4(D)_5(E)A::'_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CQCK) TO SCENE O S.O. CALL RECEIVED , / ' f ❑ P.I� TIME 10-8 1 TAT,NT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 f� SAP TIME 10 49�'T D MILEAGE: -/ OTHER/PVT TIME 10-7 �0J C�� END V TIME 10-98 5. _ DOCTOR PMD@ START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME 0 NEAREST 0 FAMILY W TRANSFER /r WAIT TIME ❑ PATIENT 0 DIRECT ❑ OTHER /"/ CALL BACK N: AMBULANCE COMPAN PT MBULATORY? PATIENT TAKEN TO AMBULA CE: RESPONSE ZONE Off ES ❑ NO ❑ WALKED ❑ GUERNEY OTHERX" PATIENT CONDITION: DRIVER / I EMT-1A TECHNICIAN PARAMEDIC y Hx: / DISPATCHER: ' I �l CHIEF COMPLAINT: �-5 S��� DRY RUN: 11 YES" NO REASON FOR DRY RUN I •� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X J MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: !/G•G� K N: -� MULTIPLE PTS.BASE RATE`L TOTAL MILES: �7 X l) MEDICARE N: &P"YES ATT. ROUND TRIP: 0 YES O NO KYES 0 NO NIGHT: (19:00-07:00) EMERGENC RUN: C1) I MEDI-CAL N: COq ?/'/3 OTHER: OXYGEN: t(PER TANK) l P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY X C'ILl— - I'f�+ui r tutu Vhlt• r)tr) !•iri r;rrP kr[�rn Y.';,v ( NA1l1RE)I •,qy t !1c uhon f•i 7 ink ®®� 1 CONTRA COSTA COUNTY AMBULANCE - PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION CR 0R MI.IN APPROPRIATE SPACES •.. -1 DATE: Z $ • TIENT'S NAME "' L'�' ' ` , 1 I Mf COMPANY N ` hlry j AGE— ADDRESS � �� t CITY 027(hi lez STATE �� ZIR•c DOB �70 St, O T ❑W O Th O F'O S-DRIVER'S LICENSE N V PHONE _ NATURE OF DISPATCH scL�►S r f 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 LO K) f TO SCENE- ❑ S.O. CALL RECEIVED \a\ C--1�_ �i ❑ P.D. TIME 10-5 ' t PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97. O PSAP TIME 10-49 MILEAGE-.-7 -� '�1 THER/PVT Fi TIME 10-7 ',DISIil END� TIME 10.98 DOCTOR .s.G! ' `� PMDIER: START_[��L� TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY leTRANSFER , WAIT TIME r ❑ PATIENT ❑ DIRECT ❑ OTHER =q LCALLBACK 0: AMBULANCE COMPANY: PT. AMBULAORY7 PATIENT TAKEN TO AMBULANCE: - �y RESPONSE ZONE ❑ YES NO O WAL'<ED,<GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_L 'Aq� EMT-1A C TECHNICIAN riAPARAMEDIC f -� Hz: / t > DISPATCHER: 0 CHIEF COMPLAINT: � JmA DRY RUN: O YES KNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) G-J PATIENT REFUSED SERVICES: (SIGNATURE)X (.' MEDIC j O ERAG _� _INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 41 PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X --Yv MEDICARE . E.O.B. ATT. ROUND TRIP: O YES O NO J�� p❑ Y S O NO NIGHT: (19:00-07:00) CCH/P�PPRP N:0 / 2O -������ L' SZ EMERGENCY RUN: MEDT.CAL N: CODE 2 L 3 .,i , ,t , 7 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.: (PER ADMIN.) X Q DRUGS: (PER ADMIN.) X w NAME:,1��/�� `�J� 0 r RELATION HIP (L) E.O.A.: (IF NOT REPLACED) ADDRESS: 7l sVrC VY7n 1�- d ORAL AIRWAY: (IF NOT REPLACED) w' CITY: ^, STATE ZIP' C-COLLAR: (IF NOT REPLACED) PHONE: - t WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP' COMMENTS: TOTAL: ",, Z�i OD ►' . PATIENT RECEIVED BY:X �' `e M "��"'` �•lJ Providor main k%it• v,d Plink (SIGNATURE) ......af-1 roPY RPtYTi, 7e;2rnr ropy t+ W vlun et I:{np - 00292 CONIIIA COSTA COUNTY AMBULANCE. _ PRE-NOSPITAL CARE FORM I ,)NIT AUTHORIZATION 0 n 3 I _ _ Cl/ECK OR FILL INAPPROPRIATE` DATE: OaPACES I •�� /� V,-r-11.1 PATIENT'S NAME __.T.J�n..C1 53_C✓Lj- ❑ F COMPANY 0 T_z U_t� L- / OAOox �i � 1_ - h� / A�ADDRESS30 - -.. _ .. .,-----.. _ AGE _ STATE_.____-- ZIP---.-.--- DOB---------- ❑ Sn 'O T .❑ W ❑ Th E3�/IF 13 S DRIVER'S LICENSE a _-__.__ _ PHONE NATURE OFja1SpAT\CH TYPE OF TRANSPORT: kLl LANC 9_9-OTHER❑ — — TATION 1(A)X 20_3M)_4(D)_S(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) n _ X TO SCENE- ❑ S.O. CALL RECEIVED 1 ❑ P.U. __ TIME 10-8 G PATIENT DESTINATION: FROM SCENE - Cl FIRE TIME 10-91 11.1q C) ❑ PSAP TIME 10-49 MILEAGE: CS!OTHE TIME 10-7 1,._{1_ END TIME 10.98lz { _ DOCTOR �` �IL•a� PMD/ START 06• I n TIME 10-22 HOW CHOSEN: TOTAL �'(1 STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT 13OTHER o_ ! CALLBACK K: AMBULANCE COMPANY: L AMBULATORY [PATIENT-TAKEN TO AMBULANCE: RESPONSE ZONE YES D NO WA "ED ❑ GUERNEY ❑ OTHER - PATIENT CONDITION: DRIVER TECHNICIANEDIC Hx: _ VL I( DISPATCHER: _[1L' 4'a CHIEF COMPLAINT: VI l�� N'l FC IS ("7 DRY RUN: ❑ YES 'Q NO REASON FOR DRY RUN Tjri 'T �CVaCL�J IA�1IC AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_._ — MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: / KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a_ TOTAL MILES: X �✓� /..'S.�J . MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES O NO 3d.c� 4 j ❑ 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 ❑ 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) STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _ _ WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP COMMENTS: -Ic" _ 9 . _ TOTAL PATIENT RECEIVED BY: X Provider reto!r, White urd Pir.K copy .heturn Ye:tcw ^np_ t• 'MS when tiling (SIGNATURE) DIS-1 00293 CONTf1A CO'ITA COUNTY 1 AMBULANCE PRE-HOSPITAL CARE FORM i �(11 UNIT AUTHORIZATION M y 3 Z I ti L CHECK ON FILL IN APPROP10IATE SPACES - DATE: /( - Z SI rn[ ' PATIENT'S NAME�1L.CL�LL:.:.a��l..__L� t LL_':_ /�1 P�M O F COMPANY M I ADDRESS AGE 0 0.3 R CITY (j'4 it, STATE C12 ZIP DOB ❑ Sn OM ❑ T OW O Th OF O S DRIVER'S LICENSE K __ ______ __ PHONE_k, Pl-1 Qr_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE`.C�F OTHER❑ _— _ __.__- STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C sn I TO SCENE- ❑ S.O. CALL RECEIVED —� :, _ i i-/ 2 ❑ P.D. TIME 10-8 }I_ y PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 •1!�_ I � ` ❑ PSAP TIME 10-49 dl c 'a cl 1 R.f �LA4� MILEAGE: _ � OTHER/PVT TIME 10-7 / END TIME 10.98 DOCTOR - PMD/ER START_ 3 3 Y TIME 10-22 + HOW CHOSEN: TOTAL ' ' / STANDBY TIME ❑ NEAREST O FAMILY TRANSFER , WAIT TIME ❑ PATIENT ❑ DIRECT '❑ OTHER ( I CALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 ��� ! RESPONSE ZONE + VES 13 NO WAL': Z ED 13 GUERNEY ❑ OTHER \� PATIENT CONDITION: DRIVER ��_MT-l• TECHNICIAN -A TECHNICIANt}c`It f-� L.3_'PARAMEDIC ) Hx: . ell]i DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ , IC ) • � .I v MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: f � - 11� / S.S. K PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE 1� BLUE CROSS k TOTAL MILES: 21 X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES ❑ NO NIGHT: (19:00-07:00) �3 0� 0400' CCHP/PPRP M: _ EMERGENCY RUN: �MEDI CAL k:-. 5`�` - O y 7 t -7 Y x- V- Z( CODE 2/3 TNER: 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: 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: Ssr,r �r }r, �t►'I ,5 L,4 K g r ;J til:n;, TOTAL: 540 . JZ 1-,. te r '� i' C11 PATIENT RECEIVED BY:X Provider retain white vd Pink copy Return Ye:tow mpy t, f0fS when bit-ing (51GNATURE) Q1S-1 ' l 00294 - CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N CHECK OR Illi IN_APPROMATE SPACES DATE: PATIENTS NAME tr_ ��'L" '� �M Ci F COMPANY ADDRESS /// AGE//4_tki CITY STATE_` -- ZIP DOBD Sn ❑ M ❑ TM Th ❑ F O S DRIVER'S LICENSE N PHONE NATURE OF DI ATCH - TYPE OF TRANSPORT AMBULAN OTHER O _—__ _ ___,_ _. STATION 1(A) 2(8)._3(C)_4(0)._5(E)_ 1� INC ENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME— (24 HOUR CLOCK) TO SCENE- os-O-__ CALL RECEIVED �t C3,-Q ��: ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCEN O FIRE -__ TIME 10-97 - `�� �r ❑ PSAP TIME 10-49 -9 CC-1 r- ^w i �) - MILEAGE: - ER/PVT TIME 10-7 n (� END �) _ TIME 10-98 G DOCTOR 7Ck C- PMD ER START__JkL )1 11, I TIME 10-22 HOW CHOSEN: TOTAL .! STANDBY TIME ❑ NEAREST O FAMILY Q ANSFER _ WAIT TIME O PATIENT ❑ DIRECT OTHER i CALL BACK N: AMBULANCE COMPAN � EES BUL.ATORY? PATIENT TAKEN TO AMBULANCE: I [;I)I . � RESPONSE ZONE 0 NO ALKED 0 GUERNEY D OTHEF)_--- PATIENT CONDITION. DRIVER sem__ ' "'- 1." OAT-1A TECHNICIAN - P IC Hx: 1 C - t' "`��- ¢'�-- DISPATCHER: _ r' C}'t3 MP AINT: 0 DRY RUN: ❑ YES C3REASON FOR DRY RUN �— A HORIZATION aRUN(EARS USE ONLY) r! PATIENT REFUSED SERVICES: (SIGNA URE) X_ ICI AL CO A E: v I TR�YES ❑ NO. OF PATIENTS: VATE INS. CO.: BASE RATE: KAISER#: o _ MULTIPLE PTS.BASE RATE BLUE CROSS M _ TOTAL MILES:_._ X DICAR E.O.B. ATT. ROUND TRIP: Q YES ❑ NO ,/�a( /i „fl it c'G �'.� ❑ YES D NO NIGHT: (19:00-07:00) �L t }� CCHP/PPRP N: EMERGENCY.RUN: MEDT-CAL C 2 CODg'2/3 OTHER: OXYGEN: PER TANK) P.O.E. STICKER ❑ YES NEONATAL: (INCUBATOR) DATES BILLED:ED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS. (PER ADMIN.)_- X NAME: ELATIONSHIP: E.O A.. (IF NOT REPLACED) ADDRESS. ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- 21P: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHO DRY RUN: (AUTHORIZED) EMPLOYER: OCC ATION: OTHER: ADDRESS: ----- �:i.Ll�� q--_ 1 `CITY: STATE:---ZIP:—.-- —�- --_.---_.._-�- COMMENTS: --- -------_—�— TOTAL - - - -- -- IIV{S114Y (r Lru:Nnttnir, . 29ICL14N1111 (.1 f'PrVirlo r• roLltr, Vru to .n•) YI.:; r.q•p u•I r,r+, r. . r. I , - CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT � ,—� � AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: —�� PATIENT'S NAME_1,kroJo") r(c k _ M O F COMPANY R_! / ADDRESS �?� -- -,-- .'� : '._ � /..'l2trLS'_.-._ AGE3-(p-- CITY-_LLG �`�_ STATE. ZIP.-_��_-__'-_ p081_ ` _�'� O $n O M O T LW O Th O F OS DRIVER'S LICENSE K ._ _. PHONE. NATURE OF DISPATCH-0.0- TYPE OF TRANSPORT AMBULANCE OTHER❑ ___ __�__ . __ _ STATION 1(A42(B)_3(C)_4(D)_S(E)_ INCIDENT LOCATION RESPONSE CODE REQUESTED BY. TIME - (24 HOUR CLOCK) TO SCENE ❑ S.O. ._-____ CALL RECEIVED �? ----- - -- - L - - ---- - O PL) TIME 10 8 PATIENT.DE NATION FROM SCENE 011 FIRETIME 10-97 Z� 1 h 13 FIRE TIME 10-49 -�1 MILEAGEOTHE PVT- TIME 10-7 _�E END A---?o TIME 10-98 DOCTOR .__— L' Cc�``!.L ._. PMD/6? START_39, Zt. _._ _.--- TIME 10-22 HOW CHOSENTOTAL __�_._l .__ -___.____ STANDBY TIME NEAREST O FAMILY ❑ TRANSFER . __._-___, WAIT TIME PATIENT ❑ DIRECT D OTHER J,, CALL BACK M AMBULANC My ANY: PT AMBULATORY1 PATIENT TAKEN TO AMBULANCE. \ RESPONSE ZONE-tike ❑ YES NO ❑ W!L':ED I(GUERNEY O OTHER — i PATIENT CONDITION: DRIVER.___ .__ �``..rg�,` EMT-lA AV,/1 TECHNICIAN ___t_.. A�� PARAMEDIC Hx C _---. ^ DISPATCHER L �_4_{:-__ / CHIEF COMPLAINT DRY RUN ❑ YES ,Q NO REASON FOR DRY RUN y ----------- / AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) X.-___ MEDICAL COVERAGE. INDUSTRIAL O YES 'N0 NO OF PATIENTS SSS PRIVATE INS.,C�O••.'. BASE RATE KA15ET2 : Il:y- MULTIPLE PTS BASE RATE BLUE CROSS 0' TOTAL MILES -.,___.—_X L�- __dl—.50 MEDICARE R: E O B. ATT ROUND TRIP O YES O NO Ga 65,O YES O NO NIGHT (19 00• 07:00) ��11 LL CCHP,'PPHP R. __ _ -- EMERGENCY RUN - �' OA i M _ L K j CODE 2 3) GO E _p_rj? S {1.(- _— OXYGEN (PEE ANK) _ - 'Gy O 7 4n PO E. STICKER O YES ❑ NO NEONATAL (INCUBATOR) V DATES BILLED: STANDBY (OVER 15 MIN.) "FL E.K G. (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY:. LV (PER ADMIN)_- X _ l DRUGS (PER ADMIN.) X • - NAME: �n�i RELATIONSHIP; E O A (IF NOT REPLACED) ADDRESS: ORAL AIRWAY (IF NOT REPLACED) CITY -.______..__. _ STATE--ZIP C-COLLAR (IF NOT REPLACED) PHONE _ WORK PHONE._ DRY RUN (AUTHORIZED) EMPLOYER:(_ OCCUPATION __ OTHER �-. . <-2- CITY: STATE: ZIP. COM�� ENTS.�� J ------ -------- �� USG e --- - -- 7/! _S_U - PATIENT RECEIVED SY )SIGNATURE) / ►. Provider reco:� .�:i:e ..rd.M*.% .•oµ FecLr rv';;p• --;7? �.�; chert FeT'in,; fJ15-1 "' 00296 s 6F ,' ✓1 CONTRA COSTA COUNTY AMBULANCE 7 t( PRE-HOSPITAL CARE FORM I UNIT l.� AUTHORIZATION 1 ?3 c � �r / CNECK OA/ILL(N APPROPRIA fE!PACES DATE:. 1 { PATIENT'S NAME M ❑ F COMPANY M_ ADORES �- <]O cl/�. - -- qGE _ J Z- ... J CIT Y ( l!- STATE ZIP. _._ DOB?_I �.7 ❑ Sn ❑ M ❑ T ❑ W 13Th 13F 13S O �r / y_�/ NATURE OF DISPATCH l S 1 6t Q-A ) PHONE 2-6/ -e..`e - � T- DFiIVER'S LICENSE M ______-. --- -..-_-.. - _-- , TYPE OF TRANSPORT AMBULANCE OTHER O _-__ __ _ ._- STATION 1(A),_21B)_3(C)._4(D)_5(E)_. . INCIDENT LOCATION. �� . RESPONSE CODE: REQUESTED BY. TIME - (24 HOURCL K� �Jn 9 1 TO SCENE- ❑ S.O. —____ CALL RECEIVED ❑ P D _ TIME 10-8 PATIENT DESTINATION: FROM SCENE • ❑ FIRE �._._..._ TIME 10-97 - C ❑ PSAP TIME 10-49 MILEAG i OTH R/PVT TIME 10-7 7� END TIME 10-98 ` D - PMD/ER START�i .__ DOCTOR .- _�_ ___._ _ ..__.-._-_-_. TIME 10-22 HOW CHOSEN TOTAL . STANDBY TIME —_ ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ATIENT ❑ DIRECT ❑ OTHER CALL BACK M AMBULANCE COy1PANY: T AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON J ES ❑ NO WAL"ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER___( if_n LI l v EMT-IA LG� ( TECHNICIAN PARAMEDIC Hx ' ��J"'Do DISPATCHER L CHIEF C PLAINT: _L DRY DRY RUN ❑ YES XNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE UNC Y) PATIENT REFUSED TRANSPORT (SIGNATURE) "5 MEDICAL COVERAGE. INDUSTRIAL O YES ❑ NO NO OF PATIENTS. .-- S.S K / A) PRIVATE INS. CO.' BASE-RATE L "-' KAISER w: MULTIPLE PTS, BASE RATE BLUE CROSS 4. TOTAL MILES —. C'e_-X " MEDICARE M: E O.B. ATT ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19 00-07 00) Z / CCHP;P HP N: EMERGENCY RUN: J�-CALE CAL :n CODE 2/3 - OXYGEN PER TANK l� P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) ( /Y DATES BILLED: STANDBY: (OVER 15 MIN.). i E.K.G. (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V." (PER ADMIN)— X c C DRUGS. (PER ADMIN.) X NAME:J&Y [Y `C �I_ RELATIONSHIP: )•�' E O.A.• (IF NOT REPLACED) - 1 ADDRESS _ ORAL AIRWAY (IF NOT REPLACED) CITY: STATE__ZIP: C-COLLAR (IF NOT REPLACED) PHONE t' gF_ 7 sY WORK PHONE. DRY RUN (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY STATE: ZIP.— COMMENTS: IP.COMMENTS: —T TOTAL _ PATIENT RECEIVED BY X S� Providor Ivr�i- *;•� ,ti P;•: '1:� brtor io";;• -,, �• chin t:7 in: (SIGNATURE) [JIS-1 00297 h . 1+ 03 I ?Yi CUNTRA CO^STA COUNTY AMBULANCE E " PRE-140SPIT/1L CARE FORM I UNIT,[j—]� AutHORIZATION N CHfCIf OR/ILL IN APPi1OPRl47[SPACES DATE: _..� •�• +/ PATIENT'S NAME L '�ti�`-'__y_ Iff M O F COMPANY 0 ADDRE S _L _Vj _ . 11L�i_✓.._ -1 � -V`�-- —--- AGE._.O _ / ?1 i . STATE . �—_ zip. /_ DOB _ U�_�` ❑ Sn ❑ M ❑ T ❑ W Th 13'F ❑ $ /( � .. . DRIVER'S LICENSE w ..._ -..__�_ PHONE 10.!�-. . ATURE OF DISPATCH � TYPE OF TRANSPORT AMBULANCE OTHER❑ _.______ _._ _ STATION I(A)_2(B)_3(C)_4( )_5(E)_ + - r . IN (DENT LOCATION. RESPONSE CODE REOUESTED BY. TIME — (24 HOURCIL CK)/ TO SCENE - ❑ S.O. .—__.__ CALL RECEIVED -- —• ❑ P r� _ __. _ _. TIME 10-8 _ PA IENT DESTINATION: 1 0�1�� ;��• �/ FROM SCENE - ❑ FIRE __._._ TIME 10-97 _ SAP TIME 10 49 I I Z_ r (� M LEAGE. 4Q OTHER/PVT TIME 10-7 I�- N VVV 9 END_ __'1 -__ TIME 10 8 1� i DOCTOR _ Y___ /ER START_ _'_. TIME 10-22 HOW CHOSEN VTOTAL STANDBY TIME C7 ❑ NEAREST O FAMILY TRANSFER �____.___ WAIT TIME —_ O PATIENT ❑ DIRECT ❑ OTHER CALL BACK It AMBULANCE COMPANY PT AMBUL Y'7 PATIENT TAKEN AMBULANCE: Ny RESPONSE ZONE ❑ YES NO ❑ WAL:EO GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER._... __. EMT-1A �� �TEC`HNICIAN _.�_ PARAMEDIC �"`f+�4�1` - d� �f `XTCHER❑ --- �t- � r CHIEF COMPLAINT ! . — DRY RUN: YES NO REASON FOR DRY RUN - �; =� - (�� AUTHORIZATION FOR DRY RUN(EMS USE (JNLY) PATIENT REFUSED TRANSPORT (SIGNATURE) X�__.___.-.__.______—_—__ _ W9 MEDICAL COVERAGE: IND_USTRIAL O YES NO NO OF PATIENTS. _ CRIVATE INS CO t-'L- -f BASE RATE KAISER M: MULTIPLE PTS. BASE RATE � � BLUE CROSS M T TOTAL MILES' —•�X L� EDICARy O.B. ATT ROUND TRIP O YES O NO / a u'l 4 4 T YES ❑ NO NIGHT (19-00-.07:00) ICCHP/PPHP N EMERGENCY RUN: - �/MEDI-CALM I �� `•_ —. CODE 2/3 TKE-6' OXYGEN: (PER TANK) ^�- P.O.E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR) - - - DATES BILLED. STANDBY: (OVER 15 MIN.) E.K G. (PER EPISODE) NEAREN NSIBLE PARTY:. I.V• (PER ADMIN; X DRUGS: (PER ADMIN.) X NAME: _. RELATIONS IP E O A. (IF NOT REPLACED) ADDRE �i ORAL AIRWAY (IF NOT REPLACED) CITY ST )?_ZIP__. C-COLLAR (IF NOT REPLACED)PHONWORK PHONE.— DRY RUN (AUTHORIZED) EMPLOYER OCCUPATION OTHER: ADDRESS -- CITY: STATE: ZIP _ COMMENTS. Ct TOTAL�� PATIENT RECEIVED BY X -sG Provider rtrrr whrte sd Mme.:. o c (SIGNATURE) .• p ct�r— is"..�• .n�� � >•+� when L'ilia,; "S-I 0298 CONTRA COSTA COUNTY AMBULANCE Z Z 3 O PRE-HOSPITAL CARE FORM1 UNIT ® AUTHORIZATION I / CMItk OR FILL IN A►IRO►RIAT!J/ Cre - DATE: — 1�dt CeAfIENT'S NAME r e- vs ' "=11?yM O f COMPANY I $ � )Qq� E93 -�--- - - .5 4_�AGE 3 060 / ./ ;�tIVER*S Y STATE _. ZIP � DOB. . �(.! ❑ Sn ❑ M O T W O Th., F O S LICENSE N �_.-_ ..__. _-_ PHONE �P.__ -_-_ NATURE OF DISPATCH t TYPE OF TRANSPORT: AMBULANCXD OTHER ______- .__ _ ._. STATION I(AI�C�(B1_3(CI_41D)_5(E)_ �INCIDENT LOCATION: J RESPONSE CODE: REQUESTED BY. TIME - (24 HOURC,LQCK}.!� �cS TO SCENE- �- _ 11S.O. _-____ CALL RECEIVED D ❑ P _____._.__ TIME 10.8 ."' (((T PATIENT DESTINATION: FROM SCENE - ❑ FIRE —_._ TIME 10-97 _ ❑ PSAP TIME 10.49 6:4C, - MILEAGE. TH ;PV TIME 10-7 END_r(p - -__-_. TIME 10-98 DOCTOR PMD/ER START---c - - --- ._. TIME 10.22 HOW CHOSEN: TOTAL �' STANDBY TIME r.: C3 NEAREST ❑ FAMILY! ❑ TRANSFER _- __-_ WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER �i CALL BAG M AMBULANCE COMPANY: PT_ AMBULATORY? PATIENT TAKEN TO AMBULANCE: IJ IT RESPONSE ZONE 1-- ❑ YES ONO ,.- D WALE<ED ❑ GUERNEY ❑ OTHER I - . j PATIENT CONDITION: DRIVER_f__ _ EMT-tA TECHNICIAN _ _ PARAMEDIC Hx: 7 , / +'1.t.��1 DISPATCHER. --. 01-��a CHIEF COMPL INT: DRY RUN: ❑ YES NO REASON FOR DRY RUN �j•/✓. AUTHORIZATION FOR DRY RUN (EMS USE ONLY) 73-7 3I:'` PATIENT REFUSED TRANSPORT ISIGNATURE) X_ ,0�� MEDICAL COVERAGE: - INDUSTRI L 13 YES ❑'NO NO OF PATIENTS: S.S. N � � �R- _ PRIVATE INS. CO.: BASE RATE �SD•UU KAISER N: MULTIPLE PTS. BASE RATE _ BLUE CROSS N: TOTAL MILES �.—_ X 1F•� � �D ME ICARE N: E.O.B. ATT. ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT- (1900-07:00) 1 C HP/PPH EMERGENCY R / CODE 2/3') ' OTHER: OXYGEN (I ANK) P.O.E. STICKER ❑ YES ❑ NO +. NEONATAL: (INCUBATOR) ► DATES BILLED: \' STANDBY: (OVER 15 MIN.) EPISODE) --NEAREST RELATIVE/RESPONSIBLE PARTY:--a ' 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_,!Sn �_ - PATIENT RECEIVED BY X - 00299.. _._�jSIf1NA T'1pF1 fht 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION It 50r- 3bv CHECK OR fllL IN AIPROPRIATE SPACES DATE: t ry PATIENT'S NAME�jC C `�x'�.,.��C'1�v�L� •.`_� �M ❑ f COMPANY R ADDRESS I(�C UC1���_2� AGE.l:?-or-5A--- UUI CITY_T. STATE ZIP.------ DOB.-_4 1'Q-.. O Sn OM OT O Th OF: O S DRIVER'S LICENSER __, __-__...____ PHON00-0 �) .�_._ NATURE OF DISPATCH c✓el °� TYPE OF TRANSPORT AMBULANCE OTHER❑ _-___-_ .__ _ .._. STATION i(A)7K2(B)_3(CI-4(D)-_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME- (24 HOUR C}QCI�^� TO SCENE-� O S O. __ CALL RECEIVED .of` `.L -_ - --- --- ❑ P U ---- -- TIME 10-8 I PATIENT DESTINATION: FROM SCENE -� O FIRE -_._.__ TIME 10-97Z� :-_IP= O PSAP TIME 10.49 1 ~^ MILEAGE. g(OTH R/PVT TIME 10-7 ..�.�-')--- g - END, _ _ TIME 1098 „ a_!_ (� DOCTOR _ 5. �'� - PMD/Eo START-si;-'IZZ,3.__ _._____ - TIME 1D-22 HOW CHOSEN TOTALSTANDBY TIME O NEAREST 0 FAMILY Cl TRANSFER ._-_ WAIT TIME �---�- 5(PATIENT 0 DIRECT O OTHER CALL BACK R- AMBULANCE r.. .. " PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ._ . YES ❑ NO 9WAL"ED ❑ GUERNEY Cl OTHER tt.. ( �} PATIENT CONDITION DRIVER_ Ylkl-5r-VL- EMT-1A TECHNICIAN _ PARAMEDIC k - -� �--- Hx: GrC!�,S,MC DISPATCHER: L- J 3 CHIEF COMPLAINT: �� tle SI! SLN-f DRY RUN: 0 YES NO REASON FOR DRY RUN -27 ,- — — AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED TRANSPORT (SIGNATURE) X�-__-._-..__ MEDICAL COVERAGE. INDUSTRIAL ❑ YES qKNO NO. OF PATIENTS: S.S. R -- PRIVATE INS. CO.' BASE RATE KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS R: TOTAL MILES- -.X I •B0 -- MEDICARE R: E.O.B. ATT. ROUND TRIP " O YES ❑ NO ❑ YES O NO NIGHT" (1900-07:00) CCHP/PPRP R: EMERGENCY RUIOIF' MEDT-CAL R: CODE 2/� --- " 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: :(r IN.: (PER ADMIN.) � � X V I l� QyAB �rN DRUGS: (PER ADMIN.) X NAME: III) 1 RELATIONSHIP: 01` E O.A: (IF NOT REPLACED) ADDRESS" SAI t V ' ORAL AIRWAY' (IF NOT REPLACED) CITY: CS Y1 _ STATE-l' ZIP:L(.,2_ C-COLLAR• (IF NOT REPLACED) PHONE;;" -/c& WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: 61eC lIIS- OTHER: ADDRESS. rr CITY: STATE: ZIF•. _ I i COMM NTS: A cF�� TOTAL : ?�-3 1 -.. PATIENT RECEIVED BY X -' Penni d•� .v. yy..,. �! n... ..r �r h.r-' .. ice. (SIGNATURE) f r:« CONTnA COSTA COUNTY AMBULANCE c� 2 PRE-HOSPITAL CARE FORM tuNlr Z -� AUTHORIZATION M 3- 3 IZ -�7-g3 I— ICHECK OR FILL IN APPROPRIATE SPACES - DATE: PATIENT'S NAME ❑ M 9,F COMPANY M_ vy ADDRESS ,7 5 :1(_' F,`% ''_ F l l_.L_ P LVJ_ -�-- --- AGE. 3 CITY. -I-( N _- STATE_C''-l__. ZIP. __--_.__._ omB l-x�—yq ❑ Sn ❑ M XT 0 W O Th O F O S -2 4(�S � slSo DRIVER'S LICENSE >' —_ PHONE __. ___-_ NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER .__ _ _._ STATION 1(A)_2(B)_3(C)_-41D)_5(E)_ INCIDENT LOCATION RESPONSE CODE: REOUESTED BY. TIME — (24 HOUR L CK) t r TO SCENE - ❑ S.O. ._____ CALL RECEIVED :a3 " —_ 1L c1�1sl-S ----- -- - -- ❑ PU --- — TIMEIOB �t�V PATIENT DESTINATION FROM SCENE -2 ❑ FIRE ____ .._ TIME 10-97 :t. ��. ._- --_._-- -.— - — �❑,5 PSAP TIME 1019 C.C__ ✓�. — r t,c��\�� MILEAGE. OTHER/PVT TIME 10-7 Z O y — -- ENp— TIME 10-99 (Pica}. CI(rrS15 DOCTOR -_�_—__—�_.__ PMD/ER START—._ TIME 10-22 HOW CHOSEN TOTAL _ �.-L_ ___—__—___. STANDBY TIME ❑ NEAREST ❑ FAMILY )t_JRANSFE rWAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M AMBULANCE COMPANY: - PT AMBULATORY PATIENT TAKEN TO AMBU RESPONSE ZONE) I� YES ❑ NO ❑ WAL'CED �GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER Ke-4&/._ ��CL0 TECHNICIAN __1L(�_ PARAMEDICHz: ..�� �11g11_ _ ___ __ DISPATCHER _.I va C �_(�l I CHIEF COMPLAINT _CTo f L1—�Lv L�N� DRY RUN ❑ YES LID-NO REASON FOR DRY RUN T AUTHORIZATION FOR DRY RUN(EMS USE ONLY) _ PATIENT RE FUSE DTRANSPORT(SIGNATURE► X—_—._ ..__.__ _______._. _ MEDICAL COVERAGE INDUSTRIAL ❑ YES>dNO NO OF PATIENTS./ .__^_—____ Ssa . - ----- — - I PRIVATE INS CO.'._. __ BASE RATE .�'f. KAISER R MULTIPLE PTS BASE RATE BLUE CROSS r< __ TOTAL MILES --. r. X MEDICARE R: _E O B. ATT ROUND TRIP ❑ YES ❑ NO 5 OYES ONO NIGHT (19 00-07 00) HP;PPHP M EMERGENCY RUN MEDI-C�+L M. ❑-7 - -S����z 7(08, 3 CODE 2/3 - THEI _ —___._.—_ OXYGEN (PER TANK) - ( P.O.E. STICKER ❑ YES ca-NO NEONATAL (INCUBATOR) 1 ' DATES BILLED:. _ STANDBY. (OVER 15 MIN.) E K G (PER EPISODE) NEAREST RELATIVE/R P t AR IV. (PER ADMIN)—. X DRUGS: (PER ADMIN.) X NAME _` ')'� ELATIONSHIP: E O A' (IF NOT REPLACED{ ADDRESS. _. ORAL AIRWAY- (IF NOT REPLACED) CITY .._—._ _ �___—. _.___ STATE__ZIP: C COLLAR (IF NOT REPLACED) PHONE _—_ _.- WORK PHONE ._._ DRY RUN (AUTHORIZED) 'EMPLOYER ---._— _ OCCUPATION. OTHER: ADDRESS CITY: — STATE: ZIP, COMMENTS. ��k�L p JL? �,�:�I 1�•�3 . 001, tt-)q ) Nor I;IvC /. jw, __— TOTAL _! PATIENT RECEIVED BY X l NATURE) r Provider rrr:rc Vh;rr rrd N,:; .•:p� !•et�r !v'_..� •,;. r "I.. uhP� t:1 ice,_; U15-1 ' r CONTRA COSTA COUNTY AMBULANCE Q 3 ' S 5 3 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# Q -- 11 111 . Iz - g3 CHECK OR Flit IN APPROPRIATE PAbES � DATE: .. PATIENT'S NAME— 1 =_c, } ��'"`�O S - 6/m ❑ F COMPANY R ._ ADDRESS J ® G�'1 tet'^ S I G�-- S-t—_t I AGE CITY— STATE `' ZIP LL/1-1 ./— DOB��'_1_...J C� ❑ Sn ❑ T ❑ W ❑ Th ❑ F ❑ S ��77 -- DRIVER'S LICENSE M --_-___._____....___ .. PHONEyz.-3� ..�. NATURE OF DISPATCH--_.[!_=_L� TYPE OF TRANSPORT AMBULANCE❑ OTHER❑ INCIDENT LOCATION: ' RESPONSE CODE: REO�JESTED BY: TIME - (24 HOUR CLOCK) �---.0 /� K r TO SCENE S.O.—___..._.. CALL RECEIVED — — f a a �!y /\ _ ❑ P.U.- --- TIME 10-8 4 PATIENT DESTINATIO FROM SCENE- ❑ FIRE --- TIME 10-97 ❑ PSAP TIME 10-49 :T— 1v� ✓ MILEAG ❑ OTHER/PVT TIME 10-7 END 5 .. TIME 10-98 DOCTOR �1J—_ PIv45) START__qz z- -- TIME 10-22 HOW CHOSEN: TOTAL . _..— -- STANDBY TIME ❑ EAREST ❑ FAM Y ❑ TRANSFER _ WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER (Z/ CALL BACK q AMBULANCE COMPANY: PT. AMBU ORY? PATIENT TAK N AMBULANCE: i RESPONSE ZONE ❑ YE NO ❑ WALKED GUERNEY 11OTHER -- ,.PATIENT CONDITION: DRIVER r C' 1EMT-tA TECHNICIANI - 1 Q _____ PARAMEDIC Hz. _ DISPATCHER: - 1 CHIEF COMPLAINT: D�1 �_-- _.� DRY RUN: ❑ YES 40 REASON FOR DRY RUN I _—__.__ AUTHORIZATION FOADRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEbICAL C VERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �6 o� CH ----- S.S. « _ PRIVATE INS. CO.: VI e S BASE RATE: KAISER.. r�� -�_�.�P 7 // MULTIPLE PTS. BASE RATE LUE CROSS#: !.0 • 0- 0 /A, TOTAL MILES:_ 7 __X I DIQARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT. (19.00-07:00) CCHP/PPHP#: EMERGENCY RUN MEDI-CAL x: CODE 2 3.) OTHER: _ OXYGEN: (PE 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 �7 _ DRUGS: (PER ADMIN.) ,---X NAME:_L`L f� t-.�a (,en — RELATIONSHI0L_—__I�! E.O.A:(IF NOT REPLACED) ADDRESS: �jr ` — ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: — C-COLLAR: (IF NOT REPLACED) PHONE: WORK PPH�1pN 2 f ) � `7t' DR RUN: (AUTHORIZED) EMPLOYER: d DCCUPATO SJfLr"( SER: ADDRESS:. �! CITY:__ I ` STATE:_—_ZIP: --- :�� /4• COMMENTS: 79 _ '> - ------ -- TOTAL '� 62 - -- - PAI If NT ilf (:F IVI O fSY X _._ -.0030-2' •••n',IN,I1INI CONTRA COSTA COUNTY AMBULANCE _ t r� RE-HOSPITAL CARE FORM i UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES _ DATE: PATIENT'S NAME C-o R C' -{ c /9 K r• n r N /M ❑ F COMPANY# �" 7 ADDRESS L! f�pper) AGE q'II at a CJTY STATE ZIP un k ry ..A1 DOB L, S(❑ Sn O M O T ❑W ❑ Th ❑ F.�O' DRIVER'S LICENSE# _ag k_n�_ �� PHONE 1/3 Z E,3 7 9— NATURE OF DISPATCH_ L'SA • �T TYPE OF TRANSPORT: AMBULANC OTHER❑ _ i.I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) \ TO SCENE- S.O. CALL RECEIVED1; nil '�- � ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 f ❑ PSAP �., TIME 10-49 r j CCCN MILEAGE: ' 11OTHER/PVT TIME 1D-7 ' I END °L, Z TIME 10-98 DOCTOR �L"l �1 . PM START— - TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME - ❑ NEAREST ❑ FAMILY 11 TRANSFER WAIT TIME ❑ PATIENT C DIRECT ❑ OTHER �% CALL BACK#: AMBULANCE COMPANY:-T`" _ c �•� . ..gam, : : PT. AMBULATORY? PATIENT TAK�N TO AMBULANCE: S� V RESPONSE ZONE ^� + ❑ YES ❑ NO ❑ WAL:,ED L� GUERNEY ❑ OTHER v PATIENT CONDITION: DRIVER �70 EMT-1A - 'nu 8 C 1 TECHNICIAN OIC J/ Hx: in f7g lr C •�7��T 2 -75 CcAsPATCHER: CHIEF COMPLAINT: /�A/n FAClI»• DRY RUN: ❑ YESO REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) q5� PATIENT REFUSED SERVICES: (SIGNATURE) X__ _E`DI-CAL COVERAGE: INDUSTRIAL ❑ YES NO NO, OF PATIENTS: S.S. t1� —'SCS PRIVATE INS. CO.: BASE RATE: •`� KAISER#: MULTIPLE PTS. BASE RATE =�-T BLUE CROSS#: TOTAL MILES: Cie' X'') � • '�_�C MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) !13 a )I� S CCHP/PPHP#: EMERGENCY RUN: e MEDI-CAL#: CODEr21(3 { r1�3 �.r.�� . . ::. OTHER: OXYGEN: ( TANK) P.O.E. STICKER ❑ YES ❑ NO ' NEONATAL: (INCUBATOR)) dDT7S' DATES BILLED: BILLED CO. STANDBY: (OVER 15 MIN.) •. .. (n� pp np� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PAPRIY:O 19 I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) NAME: L-II 7 A)n c-f h nIc Y•.RELATIONSHIP 4nc't),NK 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:-4e—k. JxPI'l_ g4- Cv u,9 t)/ jan TOTAL -' ilLtA� PATIENT RECEIVED BY:X J, _ frcuider rctcir• White rd Pink ropy , Return Yfllm' ropy t, EMS when bik (SNATURE)'— ^" ing Dlf� 00303 I CONTRA COSTA COUNTY AMBULANCE Q 15 3 PRE-HOSPITAL CARE FORM 1 UNIT 2` AUTHORIZATION, Q 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: 3112- I v 3 r� PATIENT'S NAME_UCLjl i-) LDoL-f it V (A P_ L ❑ M F COMPANY N /�2 ` / " -A ADDRESS 17 A t�I 2 �_-u AGE _1-�l / ' 11 nn ((�� CITY Y)(� 1=;,(I f)i;> STATED— 2IP DOB 1 7 ❑ Sn x M ❑ T O W O Th.O F OS-- DRIVER'S LICENSE ___�_ PHONE `tet l_2. 5�� NATURE OF DISPATCH �y� It='T�M r - TYPE OF TRANSPORT: AMBULANCES OTHER❑ _. STATION 1(A)_.2(B)_3(C)�(D)-5(E)_ , INCIDENT LOCATION: O w� RESPONSE CODE: ,R?OUESTED BY: TIME- (24 HOUR OCK) S + /� TO SCENE-'7 RQ S.0. CALL RECEIVED u �_ i S.LL I _A_y� - "[_ L- ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-Z 13FIRE TIME 10-97 Z� n ❑ PSAP -TIME 10-49!,S• ��'r' " Smml-I e- ` MILEAGE: ❑ OTHER/PVT TIME 10.7 ; END TIME 10-98 DOCTOR` ��V (An Iti`��Ir� ��t,$� START •� TIME 10-22 ----�{f---+++���•• ,.• HOW CHOSEN: TOTAL STANDBY TIME - --� ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER j / CALL BACK N: AMBULANCE COMPANY-e 5-•� t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: (� RESPONSE ZONES YES ❑ NO ❑ WAL"ED GUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER LI LATA _>>1 C) EMT-1A ._. TECHNICIAN rCYS '2 �J PARAMEDIC c \ L Hx: JL�r 17>/iD� DISPATCHER: 7/ T-( A E." ' CHIEF COMPLAINT: t(Er1 ) l�lel L1 n til Tin DRY RUN: ❑ YES lirNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES Pl�NO NO. OF PATIENTS: S.S. # �s._�pw� _ PRIVATE INS. CO.: BASE RATE: .LLSI—i�•-• KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: J TOTAL MILES: X S Co 7/•'SD MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES )d NO l ❑ YES ❑ NO NIGHT: (19:00-07:00) �GGJ L' CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL C CODE®/3 J. t 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:f�����( I ��� �� RELATIONSHIP: IA 010 E.O.A.:(IF NOT REPLACED) / ADDRESS:_-1 fT� _. ORAL AIRWAY: (IF NOT REPLACED) CITY: —_ STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: W0 1 PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: (dr mpl -yP CCUPATION:• OTHER: , -- u ADDRESS / 7 CITY: STATE: ZIP: A COMMENTS: DLY AL- i , 1�1:.r r QL / 1�� 1.� 2 r Y•» TOTAL:,; C/ L h t' ; f;r,nr>>�(t•1 �- /1')Q ST 2PATIENT RECEIVED BY (SI aNAAL4R *-Provider rctair, Nhitc (.rd Pint r::pp 9etur+ Ye'! nr whrn ti. :n.j (1 �Jtl 0 ' RCON?TIA COSTA COUNTY AMBULANCE F'iE-HOSP'TAL CARE FORM I UNIT AUTHORIZATION# CHECK OA FILL IN APPPOP.RMA F SPACES DATE:_ �P (.J PATIENT'S NAME /'d'M 13F COMPANY# ADDRESS 1-- -- -- - ' _ AGE CITY L...- ---- -..------ STATE ZIP_L-- ---- DOB- ❑ Sn l M ❑ T ❑ W ❑ T71 ❑ F ❑S DRIVER'S tACENSE# .. _ PHONE./l'_3 __._�-__1 C/ NATURE OF DISPATCH / TYPE OF TRANSPORT: AMBULANCE G'l�OTHER INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) ' �+ l'• /l TO SCENE- ❑ S.O.. CALL RECEIVED ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE-_- ❑ FIRE ' TIME 10-97 ❑ SAP TIME 10-49 °� 4 w MILEAGE: �s THER/RVT TIME 10-7 END �I L. c�-C ff! TIME 10-98 : za DOCTOR _ __.____ ._.__ PMD/ER START_ /r,? TIME 10-22 HOW CHOSEN: TOTAL -- ': L' STANDBY TIME 0 NEAREST ❑ FA!"ILY `( -RANSFER WAIT TIME _ :,Vvl/N O PATIENT ❑ DIRECT OTHER ( CALL BACK#: AM$U�,ANCE COMPANY: C-%�'C-moi PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �_� L` C� RESPONSE ZONE %YES ❑ NO .0.LI'4.L':ED D GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_41EMT-1A � fI• , TECHNICIAN - - PARAMEDIC ?: Hx: --- - --t<-- DISPATCHER: =!! _ CHIEF COMPLAINT �`'-'.``` "" :?= �`"__ DRY RUN: ❑ YES NO REASON FOR DRY RUN "1 17 - -I—� '` ___-__.. ___.____--_ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES i{0 NO. OF PATIENTS: Z �, S,S. # --- - ------._._.. / PRIVATE INS. O.. BASE RATE: _ - '\ KAISER�: �` f �� -fir ( > MULTIPLE PTS. BASE RATE BLUE CROSS 40:-- ___ TOTAL MILES: �1 X -So• MEDICARE#: - E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) C CCHP:'PPHP#:__ EMERGENCY RUN: 2_0 �oU4. MEDI-CAL ;': - CODE"2/3 OTHER, _ -_ OXYGEN: (PER TANK) •� , ; P.O E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:- STANDBY: (OVER 15 MIN.) co 0�/ ----� E.K.G.: (PER EPISODE) NEAREST RELATIVEr'RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) _X -."k"/ _'RELATIONSHIPI_) _r_._. E.O.A.: (IF NOT REPLACED) ADDRESSORAL AIRWAY: (IF NOT REPLACED) CITY _T-_ STATE-_—ZIP:_—. C-COLLAR: (IF NOT REPLACED) PHONE _.. _- WORK ttPHONE: DRY RUN: (AUTHORIZED) EMPLOYER.�l=f"_Ifl (I fv `_ OCCUPATION:/r'1& I��/ OTHER: ADDRESS:/- CITY: __ -__ _________ STATE._.___L ZIP: _ 1 COMMENTS:L� TOTAL: _. PATIENT RECEIVED BY: X AM ._ . 'R!r'rNATUAE) r h I CONTRA C(1 CA COUNTY AMDULANCE p_t5 g 6/ PRE HOSPITAL CARE FORM I UNIT AUTHORIZATION# l Y, CHECK OR FILL IN APPROPRIATE SPACJ` 2— Es . DATE: PATIENT'S NAME___-._l.�� 5 _ J S A M ❑ F COMPANY# /v. ADDR[.SS ZZ -,g- -/V-' -- - --- AGE_ I q-1 / S CITY -H'!. �_`�r](?-'J STATEA-(--- ZIP___—_ DOB _.J� ❑ Sn ❑ 7 ❑ W O Th O F O S • DRIVER'S LICENSE # _... _._. ._ .__^.. PHONE_JS1 --1 i )— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ I INCIDENT LOCA RESPONSE CODE: REO STED BY: TIME- (24 HOUR CLOCK) q y/ fr,7LTO SCENE- S.O. CALL RECEIVED r,4-12C��� O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 .. ❑ PSAP TIME 10-49 r7 MILEAGE: O OTHER/PVT TIME 10-7 n,� END TIME 10-98 [J�� DOCTOR ___ �_ ___ PM �f START TIME 10-22 HOW CHOSEN TOTAL STANDBY TIME tpl� ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY:04 S PT AMBULATORY? PATIENT TAKE TO AMBULANCE: �1 RESPONSE ZONE ❑ YES NO ❑ WAL. ED IGUERNEY ❑ OTHER . -- PATIENT CONDITION: DRIVER" ` EIAT-1A TECHNICIAN k' )_ PARAMEDIC H. --lJ- +—�------- -- -- -- - DISPATCHER: I(n(, !: CHIEF COMPLAINT: _._- .-._.! __-_ _— DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SI(_'3NATURE) X____—_____ MEDICAL COVERAGE INDSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # --- �.5 9 7_. PRIVATE INS. CO.:_ ______— BASE RATE- KAISER ATEKAISER x: __—. MULTIPLE PTS:BASE RATE // BLUE CROSS#: _ TOTAL MILES: `� X / MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO �o•Gt7QS O YES ❑ NO NIGHT: (19:00 07:00) ' �J 0- oto •l CCHP/PPRP#: EMERGENCY RUV: J Y`M_EDI-CAL#: ___-_—_ CODE 2 9 -7 i1 OTHER _ ______ OXYGEN (PER TANK) 0 y, 0 P.O.E. STICKER ❑ YES O NO NEONATAL- (INCUBATOR) ? l 1 1 DATES BILLED. __ ___ STANDBY: (OVER 15 MIN.) 0. E.K.G.: (PER EPISODE) 50. W _ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �^o.ca 3 3 DRUGS: (PER ADMIN.) X NAME:-- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) •62) 3.2 CITY -__. ___.____ _- - _. STATE_._ZIP: _ C-COLLAR: (IF NOT REPLACED) PHONE: __ WORK PHONE DRY RUN. (AUTHORIZED) EMPLOYER ...__-____-.__.-___.. OCCUPATION:_._._-.______ OTHER: 17 ADDRESS:_-- ------ J ► ", /t7.�S6 CITY _-___ - __ STATE:- ZIP:___ o '^ j t'/!� /S fes' COMMENTS.__ J TOTAL: f_ 00306 PATIENT RECEIVED BY: X_ r�•..::, ,, (SIGNATURE) CO TRA OSTA COUNTY AMBULANCE ' �� PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION N ' ,CHECK OR FILL IN APPROPRIATE SPACES DATE: ` ~ 7 PATIENTS NAME72� ❑�M ❑ F COMPANY N 1L`l 7 ADDRESS? I AGE C b ar CITY STATE_ _ ZIP_ DOB -❑ Sn O M /"' T ❑W ❑ Th O F O S • ,� ;, �•, DRIVER'S LICENSE N J PHONE NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 STATION 1(A)e2(8)_3(C)-4(D)_5(E)_. INCIDENT.40CATION:r S',"i RESPONSE COD REOUESTED BY: TIME- (24 HOUR CLOCK) r GyAA A(0 Ahi7 � tit {�r/ L 0 rI no n TO SCENE- %S.O. CALL RECEIVED �_ :1f/ h/Ad za• aF MIbg 2 ❑ P.D. TIME 10-8 Q-O- ;:L� Q PATIENT DESTINATION: - FROM SCENE- OFIRE TIME 10-97 ❑ PSAP TIME 10-49 �� �Qt1 i 7 1111 I T~1 MILEAGE: ❑ OTHER/PVT TIME 10-7 I �' '�'•—T^ - ••- f END�_ TIME 10-98 S?-DOCTORTYR'xI i PMD/ER START TIME 1D•22 HOW CHOSEN: _ TOTAL STANDBY TIME - Z'�'j"❑ NEAREST(' ; O FAMILY ❑ TRANSFER WAIT TIME J O PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I RESPONSE ZONE ❑ YES. ❑;NO,,:., ❑ WALKED ❑ GUERNEY ❑ OTHER " I f L' ' PATIENT CONDITION;-� "-) DRIVER LICATA EMT-1A �►�1 F" TECHNICIAN t7O 6T•t41 PARAMEDIC Hx: DISPATCHER: 11 d.( f3 C L 0 y�b CHIEF COMPLAINT: DRY RUN: V YES ❑ NO REASON FOR DRY RUN NOT G I VEn) �y • AUTHORIZATION FOR DRY RUN(EMS USE ONLY) SIO Lilf/ I ly ;IA,, PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. ._._ INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 1-40NE � -- r' S.S.N - PRIVATE INS.CO.: BASE RATE: x' KAISER N: "• I I MULTIPLE PTS. BASE RATE s ' t BLUE CROSS N: TOTAL MILES: X 4. +i: MEDICARE N E.O.B. ATT. ROUND TRIP: ❑ YES WNO ) ❑ YES ❑ NO NIGHT: (19:00-07:00) �~ CCHP/PPRP N:^ ' - EMERGENCY RUN: 4 MEDI-CAL N: CODE 2 1 OTHER: '" OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ N NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'f""J-` NEAREST RELATIVE/RESP NSIBLE 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) J•� +.: "-EMPLOYER: -• OCCUPATION- OTHER: - �r:a= ADDRESS: CITY: STATE- ZIP: `"COMMENT : -- TOTAL:- u0• ` �-- _ PATIENT RECEIVED BY.X 00307 J " CONTRA COSTA COUNTY AMBULANCE SJ• I SpD PRE-HOSPITAL CARE FORM I �l UNIT Z' AUTHORIZATION N i 13 CHECK OR FILL INAPPROPRIATE SPACES ' DATE:- CI—' — S 1 PATIENT'SNAME ❑ M ❑ F COMPANY ADDR SS -2-1z/ N /�o . )L1J`/� x �,�L �4<-Q- AGE// STATE+L L! ZIP DOB b-�O J�D Sn 0 M D T 11 W D Th D F D$`_ DRIVER'S LICENSE __ _.__ __ _ PHONE %3:-j45S-)--. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE` OTHER❑ __ _ -- STATION 1(A)_2(B)_3(CI (D)_5(E).j,. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- INS.O. CALL RECEIVED y � ClP.D. TIME 10-8 :J PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 Q ❑ PSAP TIME 10-49 J II�I f L cG 1� (=P MILEAGE: _ ❑ OTHER/PVT TIME 10-7 Ila— DOCTOR � —+ END h 7 g TIME 10-98 :3 a-_ DOCTOR __2ACT• PMD/I& START �•Z TIME 10-22 HOW CHOSEN: ITOTAL ) -�� STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER , -, WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY:A, PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: p RESPONSE ZONE S CH YES ❑ NO WALKED ❑ GUERNEY ❑ OTHER 1 I PATIENT CONDITION: DRIVER LICA 1-10 EMT-1A L/ t 1 TECHNICIAN ' PARAMEDIC Hx: S r t �� c` DISPATCHER: � ) CHIEF COMPLAINT: �`]lll�-I »I Tl ODAnC -W4-RUN: ❑ YES 'D 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 R: MULTIPLE PTS, BASE RATE _ ^ ' BLUE CROSS p: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ANO ❑ YES ❑ NO NIGHT: (19:00-07:00) ��- CCHP/PPRP#: EMERGENCY RUN: _�� �_d0� MEDT-CAL R: CODE(&3 i t......: G OTHER: OXYGEN: (PER TANK) � P.O.E. STICKER ❑ YES CYNO 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: DO[)A(-r7 RELATIONSHIP: , ro. E.O.A.: (IF NOT REPLACED) - - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: I--,] _ STATS ZIP: C-COLLAR: (IF NOT REPLACED) - - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: IILL-VaL� OCCUPATION�����CT INS OTHER: - -----�-�-- ADDRESS: �1 n K1 CITY: Sl � A fn1 C n STATEN. _ZIP:— COMMENTS:- IP:COMMENTS:- (} no r• -•i —r TOTAL: _ PATIENT RECEIVED BY: p-•� �c`' .S� 1 Provider rata?r.. Vhitr vd Nn; r,pp Return+ 1'v'lc:t �np� t OI" when bii"inp SIGNATURE) 00308 CONTRA COSTA COUNTY AMBULANCE /1 FqE-HOSPITAL CARE FORM I I- UNIT AUTHORIZATION k / _] CHECK OR FILL INAPPROPRIATE SPACES DATE: r — <6, l � PATIENT'S NAME�1_ �11���ly, �O BERT" M ❑ F COMPANY k .•1 �1 /1 -7 ADDRESS �'L; •a�" 'T. !% AGE n�L _ STATE ZIP_/ DOB _,/_ ❑ Sn ❑ M� ❑W O Th.,❑ F CITY I �J7 � (' r� 1 IJ L' �r{"f%-7L5 DRIVER'S LICENSE K __ PHONENATURE OF DISPATCH I I 7 e ice• TYPE OF TRANSPORT: AMBULANCE_ OTHER❑ _ — STATION 1(A).YY 2(8)_3(C)_4(D) 5(E)_ -. r- INCIDENT LOCATION: RESPONSE CODE: �EOUESTED BY: TIME- (24 HOUR CLOCK) : ~' / ,� � /� (-� �/ TO SCENE- S.O. CALL RECEIVED , / / -• . l r .� Y P.D. TIME 1D-8 (� / / ..` P LENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 l ry� �// 11PSAP TIME 10-49 / — �` ,l/' — MILEAGE: T ❑ OTHER/PVT TIME 10-7 44 END TIME 10-98 t.-- DOCTOR� t c,�.� PMD ER START - TIME 10-22 :ter--• HOKHOSEN: TOTAL STANDBY TIME EAREST ❑ FAMILY ❑ TRANSFER 1 WAIT TIME ATIENT ❑ DIRECT ❑ OTHER �j CALL BACK k: AMBULANCE OMPANY: I «. PCYMBULATORY? PATIENT TAK TO AMBULANCE: S U RESPONSE ZONE S ❑ NO ❑ WAL"ED UERNEY ❑ OTHER ///P.i r PATIENT CONDITION: DRIVECom"-R � � / EMT-1A ' f(l TECHNICIAN C^Lo .`k�+ (ate t PARAMEDIC I l / Hx:CriktL_.. S+ 'LI-!_ I DISPATCHER: [ ra(p-� CHIEF COMPLAINT: (. I u DRY RUN: ❑ YES X-NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) _ PATIENT REFUSED SERVICES: (SIGNATURE) X— ' MEDICAL COVE�R9 G INDUSTRIAL ❑ YES 6'6'NO NO. OF PATIENTS: ' S.S. k _ PRIVATE INS. CO.: BASE RATE: KAISER><-�� MULTIPLE PTS. BASE RATE LUE CROSS:`� � J�r '� /(-�+ 7� TOTAL MILES: L^ X 'IMEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) I V CCHP/PPRP 4: EMERGENCY RUN: -G- MEDI-CAL k; CODE 2/3 - OTHER: OXYGEN: (PER TANK) „ - P.O E. STICKER DYES ❑ NO NEONATAL: (INCUBATOR) ' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEfRESPONSIBL£PARTY: I.V.: (PER ADMIN.) X -' - _ ��������� DRUGS: (PER ADMIN.) X NAME: GL�y� '�'�� ''t) 'RELATIONSHIP: 1' E.O.A.:(IF NOT REPLACED) - ADDRESS: '!�)%` ORAL AIRWAY: (IF NOT REPLACED) ' CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) �•uJ=r( PHONE: — WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:ST /cyI"T3 �` OCCUPATION: s"t{'rI �� OTHER: ADDRESS: * `r ���� i= ^Jo!ia� C /.��cfJ G - CITY: STATE: ZIP: COMMENTS: 1 TOTAL: � '��ZJ �•C!D _ _ PATIENT RECEIVED BY:X� Pravider rrt,7ic White •j•i P,.;: rnpp FrCUrn yr'I,:w -n; SM.^ wham DiI:inp (SIGNATU9 ) ENS-1 0►0309 CONTRA COSTA COUNTY C 41 AMBULANCE 'L 7 RE-_HOSPITAL CARE FORM 1 UNIT AUTHORIZATION#-f3_5 f CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME __ , v `�-��� ❑ M F COMPANY# L ADDRESS - �d !�(�L.• AGE _�- CITY� �_5..�_ STATE� - ZIP__-____- DOB/ _ � � ❑ SnM ❑ T ❑ W ❑ Th ❑ F ❑ S y Q Q i DRIVER'S LICENSE# ___ _ �____.____ PHONE.L. " ..!I- - NATURE OF DISPATCH__-_�I - TYPE OF TRANSPORT: AMBULANC OTHER❑ INCID NT LOCATION: Q � RESPONSE C EOUESTED BY: TIME- (24 HOUR CLOCK) � T� ��Q"� TO SCENE- .0. CALL RECEIVED - / ' ❑ P.U. TIME 10-8 PATI NT DESTINATION: n ,FROM SCE ❑ FIRE --- TIME 10-97 r ❑ PSAP TIME 10-49 'ItV MILEAGE: q f ❑ OTHER/PVT TIME 10-7 END�L-•l� _. TIME 10-98 G DOCTORPMD/ER START,�0_� TIME 10-22 HOW CHOS N: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER �- WAIT TIME -_ ATIENT ❑ DIRECT ❑ OTHER ��� CALL BACK#: AMBULANCE COMPANY: PT. AMB RY? PATIENT TA O AMBULANCE: RESPONSE ZONE C—�- YES O ❑ WAIKED�UERNEY ❑ OTHER n -.-- PATIENT CONDITION: DRIVERS l' -n � EMT-1A TECHNICIAN al. AA4 -ALISPARAMEDIC at_cA_ ISPATCHER: (• CHIEF COMP AINT: DRY RUN: ❑ YESO REASON FOR DRY RUN y' _AA A HORIZATION P R DRY R N(EMS ON - PATIEN REFUSED SERVICES (SIGNATURE) X._ J D L COVERAGE: INDUSTRIAL D YES NO. OF PATIENTS: _ +j`. }Ila 11) S.S. _ PRIVATE INS. CO.' BASE RATE .;- dy KAISER#: - MULTIPLE PTS. BASE RATE OF BLUE CROSS#: TOTAL MILES: - X t 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 O NEONATAL. (INCUBATOR) �D DATES BILLED. STANDBY: (OVER 15 MIN.) J C E.K.G.: (PER EPISODE) EAREST ELATIVE/RESPONSIBLE PARTY I.V.: (PER ADMIN.) X Sv DRUGS: (PER ADMIN) X NAME: RELATIONSHIP: E.O.A.. (IF NOT REPLACED) ADDRESS C r ORAL AIRWAY. (IF NOT REPLACED) -- CITY: STATE-_ZIP: - C-COLLAR: (IF NOT REPLACED) PHONE: 20 '��.2'9 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER -61 11 _ OCCUPATION: OTHER: ADDRESS: CITY: - STATE: ZIP:--- COMMENTS: ��• -c' �"t�^ __- - --- ---- --- - �?. r-•t.r= -- -'--- -- -- TOTAI 00310 , CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ��� ' AUTHORIZATION ar� AZ CHECK OR FILL IM APPROPRIATE SPACES DATE: � "PATIENTS NAVEC/ OM OF COMPANY N �5/" U�'/� - ' '� ADDRESS" :? r ' AGE~�_ G✓R G(N _ . . _� CITY -STATE ZIP DOB ❑ Sn ❑ M 4 T Ow O Th ,O p O g DRIVER'S LICENSE IV -- PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:;AMBULANCE 0 OTHER 0 _ STATION 1(A)�L2(8)-3(C)-4(D)_5(E)_ INCIDENT_LtOCATIOWI f)•' 'RESPONSE CODE'r fflEQQESTED BY: TIME- (24 HOUR CLOCK) -� / If TO SCENE- S O. CALL RECEIVED C � ❑ P.D. TIME 10-8 _ _ PATIENT DESTINATION: • -_i CT FROM 13SCENE FIRE TIME 10-97 1 A /C� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 GdOCTOR _`• I' PMD/ER START TIME 10-22 HOW CHOSEN: r _ ., TOTAL STANDBY TIME ❑,NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULA `CE OM ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1!� RESPONSE ZONE YES ,❑ NO ❑ WALKED ❑ GUERNEY O OTHER i PATIENT CONDITION; " DRIVER EMT-tA -.iT&( �(jS::-P`TECHNICIAN i PARAMEDIC_¢ `l'1 l Hx: DISPATCH I✓k A CHIEF COMPL'AIN'T: DRY RUN YES ` NO REASON FOR DRY RUN -19 AUTHOR!ZA OR DRY RUN(EMS USE ONLY) j A AJ U::1-PATIENT REFUSED SERVICES: (SIGNATURE)'X ! zr MEDICAL COVERAGE_. INDUSTRIAL ❑ YES 11 NO NO. OF PATIENTS: S.S. 0 t; PRIVATE INS.CO.: BASE RATE: , KAISER N:� MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X -J MEDICARE M; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) -� CCHP/PPHP M: EMERGENCY RUN: 1 MEDI-CAL 0: ) i CODE 2/3 ) OTHER: OXYGEN: (PER TANK) P.O.E.STICKER ❑ TES ❑ NO NEONATAL: (INCUBATOR) i DATES BILLED, STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) EAREST RELATIVE/ ESPONSIBLE 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: ' civ PATIENT RECEIVED BY:X _Sc CONTRA COSTA COUNTY l AMBULANCE '931 S9 r� PRE-HOSPITAL CARE FORM I1 UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: 9 PATIENT'S NAME C�l I O ) John I ' XM ❑ FF COMPANY N / �U �.� 1 (moi �I�\n GI - AGE 2 / / ..... ADDRESS - ' CITY C o h a��� STATE ZIP /�DoBBt2 37_5 ❑ Sn O M 10"TT O W E3 Th O F O S DRIVER'S LICENSE N _ PHONE 52!, 6 56-Y1. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 13 STATION 1(A)_2(8)_31C)_4(D)_5(E)_j.. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED _ Itr)5"5T17L '� ��[l)}�� 1(/ (��C� ❑ P.O. TIME10-8 f.i • PATIENT,DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 : )q,_ I i J}� �( ❑ PSAP TIME 10-49 I MILEAGE: 0 1 13 OTHER/PVT TIME 10-7 ENDTIME 10.98 :rw .DOCTOR h�v PMD/e) STARTS TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME .. NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ': ! . l _ O PATIENT O DIRECT 13 /OTHER 1, JCALL BACK N: AMBULANCE COMPA Y: ES0-YEM BULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONEr-- ❑ NO O WAL!(ED/O'GUERNEY ❑ OTHER y} PATIENT CONDITION: DRIVER +Cyl r/L) EMT-1A TECHNICIAN PARAMEDIC J 1 +7 Hx: DISPATCHER: CHIEF OMPLAINT: _il_ ' DRY RUN: O YES ❑ NO REASON FOR DRY RUN f AUTHORIZATION FOR DRY RUN(EMS USE ONLY; - PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL YES PNO NO.OF PATIENTS: S.S. N '�])`� y - --- PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: �� X '� 4� >�_) MEDICARE M: E.O.B. ATT. ROUND TRIP: .❑ YES ❑ NO O YES ❑ NO NIGHT:,(19.00-07:00) f - r- CCHP/PPRP N: EMERGENCY RUN: -.AJC d Y MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P �W�j? 1 Pj P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) _ {r ` DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �U" J 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) ITY: STATE,_ZIP: C-COLLAR: (IF NOT REPLACED) - HONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER�� tea_ �aL(6'Nf PATIONC�PPIA► L OTHER: � -- ADDRESS: EEO-SS L4day w,-, Ila.d� /17 CITY:, G ' STATE, ZIP - -- - COMMENTS: ���� �11' D'I` - TOTAL: Oml-ro a. I __ _ PATIENT RECEIVED BY: X v>t 1:5• A�vidrr Mtut. Nli r� .r l f .;: . tF krfuni ►r',o�' rnly t "r' uhrn Fi 1 inp (S NATURE) gms-1 ,f. ;f Dixie Allan PATIENT'S NAMME, ' 1891 Truman #3 �:_� . ADDRESS: Richmond, Ca• DATE OF SERVICE: 09-13-83 ! AUTHORI?ATION NUMBER: 83-15909 } F . AMOUNT DUE: $254.50 INCIDENT LOCATION: 1839 4th st. Richmond PATIENT DESTINATION: i Y.r. . .p,4 . �. 5.. . Q 0 313: tk ♦ tr. TT rFFF : EP 13 3 n cll I ';EP 13 3 39 PM 183 SO NUMBER - I "I O' CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10-8 n I CALLED BY-- PATIENT INFORMATION > W QNAME: _� ------- : /., ---- - A t/tJ ! C J AGENCY: _ CUSTOMER u PT. DOB: y W DEPT/FLOOR/ROOM p; _ NAME: I�I 1 i Y I C^�i n , ' U ----- m - -� a CALLBACK a - INS. TYPE: PVT MCAR MCAT KHP/ (ZHV -VA-iNt3--CHAMPUS t; -p v INCIDENT LOC: s=sY"` - POLICY/MCAL#: n 1 L�{��i ?J C5] CROSS STREET: _ ! VERBAL PRIOR-1_ o Q JURIS: Gfy: v __ ti DOCTOR: 1 -- — DESTINATION: _ -7 - -R C PT. a2 NAME: DOB: NATURE: CUST. $1 3 ao PT. k3 NAME: DOB: c O D o TYPE OF CALL: EMG TRANS TI E UNIT CUST. # Z rn m w CREW: _ _ WAIT TIME: YES NO REASON: m Z UNIT TYPE: ALS i WC RESPONSE CODE: 0 1 3 4 REASON FOR 10-22: p W c Q INCREASE/DECREASE CODE:2 3 10-49 CfrOE: 0 1 6 3 44 CANCELLED BY: m v BY: END MILE �, COMMENTS: p w to e TIME: BEG MILEAGE: �,` _ C31 DISPATC�K, TOTAL MILES: 00314r a 4 XL'01 NO `d 61-01 ONIN8n138 3DNV1(18Wv 86-01 319V11VAV 3DNV7T19WV L-01 1V11dSOH 1V 3DNV1f18WV W n LT r , d?*' r ' -3 t a CONTRA COSTA COUNTY AMBULANCE .� I PRE-HOSPITAL CARE FORM I J UNIT ® AUTHOR17ATION#_-21L I�Z_� • - CHECK ON FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME ❑ M ❑ F COMPANY NAmuw _ ADDRESS;; ( s AGE cL .... ___, CITY —� STATE- ZIP DOB O Sn Om Ow O Th F ❑-S DRIVER'S LICENSE'M L----- �- PHONE NATURE OF DISPATCH J'``• TYPE OF TRANSPORT:iAMBULANCE 0 OTHER 0 STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ _. ! INCIDENT LOCATION:( —_� q RESPONSE CODES Esp. /UESTED BY: TIME— (24 HOUR CLOCK) ,rt TO SCENE- 0. CALL RECEIVED ;L `� + D. TIME 10-8 �� t PATIEN ESTINATIOKI: . ._ J f/j1 Z FROM SCENE ❑ FIRE TIME 10-97 ,, �•— ' . ❑ PSAP TIME 10-49 ��'% ra..� i I.`.:�C� y � MILEAGE: ❑ OTHER/PVT TIME 10.7 I �r END TIME 10-98. ?J� '—T— ."OCTOR'T'r'i' '- _ PMD/ER • START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME �2I`L ❑ NEAR EST ❑ FAMIL� ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER G CALL BACK k: AMBUL E AN J PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: + �) RESPONSE ZONE O YES ❑,NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 �1. PATIENT CONDITION: L ` O DRIVER v �'/`� EMT-1A _a�,j/�oa �G v TECHNICIAN j. ,�C1c�JP.t/�C' , P� PARAMEDIC Hx: 7—` ""'� ISPATCHE c' i yyq CHIEF COMPLAINT: I DRY RUN: YES ❑ NO REASON FOR DRY RUN C� AUTHORIZ FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO N0. OF PATIENTS: `5r� ! S.S.K + f' PRIVATE INS.CO.: BASE RATE: + KAISER K: i MULTIPLE PTS.BASE Fj _1 BLUE CROSS M: TOTAL MILES: X 1 1 MEDICARE K: E.O.B. ATT.. ROUND TRIP- YES ❑ NO ❑ YES ❑ NO NIGHT: :00-07:00) _J "d CCHP/PPRP 0: I EM ENCY RUN: fr MEDI-CAL N: CODE 2/3 4A OTHER: I OXYGEN: PER TANK) _) P.O.E. STICKER ❑ YES ❑'NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) + E.K.G.: (PER EPISODE) it—NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X '"NAME: ATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) '.Y..—CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ORK PHONE: DRY RUN: (AUTHORIZED) w EMPLOYER: OCCUPATION: OTHER: - ADDRESS: CITY: STATE: ZIP- -.--COMMENTS:, • TOTAL: PATIENT RECEIVED BY: X Iq(;+Al I InFI 1 T/. ��- CONTRA COSTA COUNTY AMBULANCE 5,y�ti PRE-HOSPITAL CARE FORM 1 UNIT 21 AUTHORIZATION N I' ^• CNECK OR PILL INAPPROPRIATE SPACES DATE: ' TIENTS AME'­1 ' O M O F COMPANY N CID A ADDRESS ' I AGE CITY STATE ZIP DOB ❑ Sn O M �ZT ❑W O Th O F 0S- -j . 1 f \ DRIVER' LICENSE N ) PHONE �, NATURE OF DISPATCH 1 A 1"►e-r►C G/rm TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 1(A)_2(B)_3(6)y94(D)_5(E)_ INCIDENT).00ATION:�y _-) RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED \ Zq CE '2Q K GT;� ^ 11 P.D. TIME 10-8 PATIENT DESTINATION:.__ FROM SCENE- ❑ FIRE TIME 10-97 1 : og ,p Y ❑ PSAP TIME 10-49 I ~ ' f VIZ R lel tl �. MILEAGE: 0 OTHER/PVT TIME 10-7 END TIME 10-98 , p JI DOCTOR 7.I „ ' — PMD/ER START O TIME 10.22 :.L�--J HOW CHOSEN: _ TOTAL STANDBY TIME ' O.NEAREST,:�L0 FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY AS ) PT. G AMBULATORY? PATIENT TAKEN TO AMBULANCE: SRESPONSE ZONE .S f! 0,YES O NO.:,,) D WALKED ❑ GUERNEY 0 OTHER 1 PATIENT CONDITION:' - DRIVER I_1r q 174 11 u EMT-tA TECHNICIAN 1'0:5�er -2 ms's PARAMEDIC -7� Hx: DISPATCHER: C E�Cl O�. CHIEF COMPLAINT: 1 DRY RUN: Z-YES ❑ NO REASON FOR DRY RUN O*ZZ g{ (f�/I[ -- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4>t) 5 L 1 `f `/1: N .:.Ll PATIENT REFUSED..8ERVICES:(SIGNATURE) X MEDICAL COVERAGE. INDUSTRIAL YES 0 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:• 1 E.O.B.ATT. ROUND TRIP: 0 YES VNO ❑ YES '0 NO NIGHT: (19:00-07:00) CCHP/PPRP N:*" EMERGENCY RUN: MEDT-CAL N: CODE 2�3 OTHER: i OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 13 NO NEONATAL: (INCUBATOR) 0 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) ITY STATE ZIP: C-COLLAR:"(IF NOT REPLACED) •) PHONE: WORK PHONE DRY RUN: (AUTHORIZED) 'w "..",6—EMPLOYER:-AOCCUPATION: OTHER: ADDRESS: "CITY: STATE:— COMMENTS: TOTAL: PATIENT RECEIVED BY:X ISirt4hTIir�Fi CONTRA COSTA COUNTY AMBULANCES�,• / X917 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M ( 7 w S AI. CNECK OR FILL INAPPROPRIATE SPACES DATE: " PATIENT'S NAME � /���� �;y O11;2 b2 �v�(� M' l7 F COMPANY 0 /� ` ADDRESS ;; ) AGE'N. CflR l'( CITY STATE ZIP—r_ DOB ❑ Sn O M T O W O Th O F O S DRIVER'S LICENSE N _- -' PHONE NATURE OF DISPATCH` TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 1(A)_2(8)_3(C)_4(D)_5(E)-_, INCIDENT LOCATION}! RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOCK) iTO SCENE- S.O. CALL RECEIVED<C,K�i ❑ P.D. TIME 1D-8 1-2 PATIENT DESTINATION: _, FROM SCENE- ❑ FIRE TIME 10-97 1121� U Q ❑ PSAP TIME 10-49 I MILEAGE: ❑ OTHER/PVT TIME 10-7 ` END TIME 10=98 f Ss DOCTOR.' ' YI tv PMD/ER START---/ TIME 10-22 :n HOW CHOSEN: ,-,__ .� TOTAL STANDBY TIME ❑ NEAREST;- O FAMILY ❑ TRANSFER WAIT TIME D PATIENT O DIRECT O OTHER CALL BACK 0 AMBULANCE_r.( MPANY: C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �U RESPONSEZONEEE ❑ YES,.❑ NO__ D WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �-A Ll -� EMT-tA DiI3Ig1 1 L I TECHNICIAN P AMEDI Hx: s— DISPATCHER: , CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN-A JAM UTHO ZATION FOR DRY RUN(EMS USE ONLY) Qqq q/.j!J.. PATIENT REFUSED SERVICES: (SIGNATURE) X `1 MEDICAL COVERAGE: INDUSTRIAL ❑ Y ❑ NO NO. OF PATIENTS: S.S.N PRIVATE INS.CO.: 1 BASE RATE:- i KAISER 0, MULTIPLE PTS.BASE RATE BLUE CROSS 0: j TOTAL MILES: X MEDICARE 8:, E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -0 NO NIGHT:(19:00-07:00) r � CCHP/PPRP N^ I EMERGENCY RUN: f MEDT-CAL N: " f '�� f � CODE 2/3 J OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO �" NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -'NEAREST RELATIVE/RESPONSIBLE PARTY~ -~ I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X '-'-NAME: 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 ' TOT�� • PATIENT RECEIVED BY:X O O 3 1 6/ Pmoidir rltai► Whit. ,rd ^ink.,•nrf I$IONAT1iRE) 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION IF t 3 CHECK OR FILL IN APPROPRIATE SPACES DATE: 5 -1-3 -Sr3 PATIENTS NAME ❑r)) 12 ^ ❑ M ❑ F COMPANNY a ADDRESS AGE 1. Ammol CITY STATE .ZIP DOB ❑ Sn ❑ M � T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH ( -S TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 0 TO SCENE- 1$S.O. CALL RECEIVED E= A!cd 13 -ss 1) 3 ❑ P.U. TIME 10-8 :L / PATIENT DESTINATION: FROM SCENE- ❑ FIRE — TIME 10-97 ) ❑ PSAP TIME 10-49 /Uri i'?I'ck •..- �l/ MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 3 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBU,�LAT�Y? PATIENT TAKEN AMBULANCE: SCS RESPONSE ZONE I ❑ YES 0,440 ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION:! DRIVER F4 )► �>�>�_ EMT-tA TECHNICIAN 12G—6h 7 PARAMEDIC -� Hx: DISPATCHER: E"r I'6 e— CHIEF COMPLAINT: DRY RUN:.L2YES ❑ 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 N: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 7 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBAT j DATES BILLED: STANDBY: (OVER 15 N.) E.K.G.: (PER EPISOD NEAREST RELATIVE/RE/Ps BLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER AD IN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT R PLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: —_ STATE_—ZIP: C-COLLAR: (I NOT REPLACED) PHONE: WORK PHONE: DRY RUN: ( THORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: .n TOTAL: 00318 �D PATIENT RE 13Y X..... -- ISMNeTUnF i M• z CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FOR RMI UNIT A T D 5 y C L ( U HORlIZ,ATIONp w CHECK OR FILL INnAP,�PROPRIATE SPACES DATE: -i 1 3 i 3 PATIENTS NAME I"' C1U'Qt !j - �-TU� �I�pl ❑ F COMPANY p ADDRESS 2 _5 I ( AGE CITY6 PIA `'AOU STATE_ ZIP 2 Cp�D''OB ❑ Sn ❑ M O T `9'W O Th O F O DRIVER'S LICENSE p — PHONE 2 I� LJ��L—� NATURE OF DISPATCH f'7 r TYPE OF TRANSPORT: AMBULANCE OTHER O _ —___ STATION 1(A)-2(8)_3(C) 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- 2 �S.O. CALL RECEIVED ? = f roc, O WS,y,,D yc% t� LAP ❑ P.D. TIME 10.8 Z. , PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ l� n 2 ❑ PSAP TIME 10-49 /— Z1 SS / MILEAGE: ❑ OTHER/PVT TIME 10-7 2.3 : IS END— �ay'� TIME 10-98 2 '` 1. DOCTOR - ' PMD/ER START TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER /�1 WAIT TIME ❑ PATIENT O DIRECT $6 OTHER P6 AMBULANCE COMPANY:C�s PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE $OYES ❑ NO I WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER Li c-A EMT-1A TECHNICIAN S r - PARAMEDIC Hx: &4r P2, m DISPATCHER: ()� ) CHIEF COMPLAINT: A/� al" Le�'� DRY RUN: ❑ YES PPNO REASON FOR DRY RUN 51 nm AUTHORIZATION FOR DRY RUN(EMS USE ONLY) V PATIENT REFUSED SERVICES: (SIGNATURE) X ME L V RAGE: INDUSTRIAL 13YES NO NO. OF PATIENTS: PRIVATE INS.CO.: BASE RATE: ria'u-J KAISER p: MULTIPLE PTS. BASE RATE -BLUE CROSS#: TOTAL MILES: �� X MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES NO O YES ❑ NO NIGHT: (19:00-07:00) CHP/P P p: EMERGENCY RUN: '�T CODF�3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ASE-ABY c' DRUGS: (PER ADMIN.) X NAME: ,+�nSV RELATIONSHIP: 1219 E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: '(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHE ADDRESS: CITY: STATE: ZIP: �' 7J y , COMMENTS: �� J 1 TOTAL:__FS�Q•�� _ _ — -- PATIENT RECFIVFD ITV X CONTRA COSTA COUNTY AMBULANCE Q/ i PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N J( [ �� CHECK OR FILL IN APPROPRIATE SPACES DATE: �3 PATIENT'S NAMEC3M COMPANY N (� Y ADDRESS ' ' AGE. CITY TATE ZIP_r____�� DOB - -❑ Sn ❑ M OLT O W ❑ Th OF O Sp,� DRIVER'S LICENSE N PHONE NATURE OF DISPATCH( �C+{Tum �`M 0%1 TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION I(A),2(8) (C)_4(D)_5(E)_• INCIDENT LOCATION:, i RESPONSE CODE' REQUESTED BY: TIME— 124 HOUR CLOCK) TO SCENE- O$•S.O. CALL RECEIVEDC i O P.D. TIME 10-8 �-�`��- PATIENT DESTINATIO FROM SCENE- ❑ FIRE TIME 10-97 �--� O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 .. ENDTIME 10-98 •` _DOCTOR r PMD/ER STAR- TIME 10-22 J HOW CHOSEN: _ TOTAL STANDBY TIME ,Z;jl*:.0 NEAREST ❑ FAMILY ❑ TRANSFER ` WAIT TIME 0 PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANC COMPANY: Y C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c RESPONSE ZONE K,YES 0 NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1r+ Sv( (A `t PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN n ' `^ 5 PARAMEDIC _ p+ Hx: � "'t"""LiM �S` l L% DISPATCHER: I gJ CHIEF COMPLAINT: DRY.RUN:X YES ❑ NO REASON FOR DRY RUN ` A RIZA ION FOR DR UN(EMS USE NL Y) f:J •.!�: PATIENT REFUSED SERVICES:(SIGNATURE) X 95a- MEDICAL COVERAGE: INDUSTRIAL O YES O NO N . OF PATIENTS: I-,- S.S.N PRIVATE INS. CO.: BASE RATE:' KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: - E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES 'O NO NIGHT: (19:00-07:00) CCHP/PPRP N`• ' EMERGENCY RUN: MEDT-CAL N: J ' 1 CODE 2/3 1 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER O YES O O 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: i TOTAL: CV - PATIENT RECEIVED BY:X O Provider retain White card Pink oopl, . Nitum yo":,o (SIGNATUF F) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I J UNIT AUTHORIZATION k_ {� CHECK OR FILL IN APPROPRIATE ePACES DATE: PATIENT'S NAME .... ..- I �G 1 /. '`S.L O COMPANY A ` (' c2 `,� �� 1/ ���I �L AGE V ::7 ADD_ 1j CITY- _. Si ZIP _ OB.I/� ❑ Sn ❑ M T ❑ W 11Th 0 F O S DRIVER'S LICENSE a _ / K P� • PHONE_.�/�•�!� �..___— NATURE OF DISPATCH - -r TYPE OF TRANSPORT: AMBULANC OTHER❑ INCID T LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR C#0 K) TO SCENE- .,C7 O. CALL RECEIVED ❑ P.D. TIME 10-8 ,r 3 r. PATIENT DESTINATION: FROM SCENE ❑ FIRE -- TIME 10.97 �3 ❑ PSAP TIME 10-49 (I � _ — MILEAGE: ❑ OTHER/PVT TIME 10-7 END ����TT� TIME 1.0-98 DOCTOR _— _L]L� .� PMD ER START--!T l� TIME 10 22 ;9��EARESTT 6) .TOTAL — �. STANDBY TIME 13 FAMILY ❑ TRANSFER WAIT TIME 4�ATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE C0WAbiY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. ^ /-1 ' RESPONSE ZONE ❑ YE O ❑ WAC',ED�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ 9141 Z 14 JI H EMT-1A / TECHNICIAN 'S PARAMEDIC �� f Hx: • ��h L _ f_'_ 1/ —_ ISPATCHER: 7 E 'o CHIEF COM AINlt(� //_ �W�_. J • l�DRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION FOR RUN(EMS USE ONLY) 11 I PATIENT REFUSED SERVICES: (SIGNATURE) X C! �' MEDICAL COVERAGE: INDUSTRIAL ❑ YENO NO. OF PATIENTS: S.S. a — PRIVATE INS. CO.: BASE RATE: �c . KAISER It: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES:— X � MEDICARE #: _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ; ❑ YES ❑ NO NIGHT: (19:00-07:00) � J O CCHP/PPRP a: __—. _ EMERGENCY RUN: --a• MEDI-CAL a: CODE 2/3 'O7 OTHER: _ OXYGEN: (PER TANK) � �:,•� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) O 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: 7y c.� '%r `c) CITY: _—_ — STATE: ZIP`. I Com +� __ q TOTAL:— S PATIENT RECEIVED ( NATURE) -� :7•:I,. ,f r(, ar•' �r r•L• ^O�� n'. .;4r.1 t:. 1•:J � �� L. CONTRA COSTA COUNTY '� AMBULANCE 3 PRE-HOSPITAL CARE FORM I UNIT L Z AUTHORIZATION M 1'5 T L� /YG tt11 CHECK O FILL INAPPROPRIATE SPACES ff DATE' PATI*LICNSE � Xe h� - 01M ❑ FCOMPANY It ^ADD "S See- P AGE 1 - / ' /CITYSTATE ZIP_ - DOB " ❑ Sn ❑ M ❑ T �W ❑ Th ❑ F ❑ S DRIV __—_--_--...-__--_ PHONE_._-._..__ ."- _-_..- NATURE OF DISPATCHSe C If rO,41 A l TYPE OF TRAN PORT: AMBULANCEJF OTHER❑ INCIDENT LOC TION: RESPONSE CODE: REOUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE- XS.O._—.____. CALL RECEIVED r� ✓�L C �/ V�-�tJ r ❑ P.U. --_--- TIME 10-8 PATIENT DESTI TION: FROM SCENE - ❑ FIRE -_ TIME 10-97 f L� - o _ ❑ PSAP TIME 10-49 / tv, Alt �� �_ MILEAGE: ❑ OTHER/PVT TIME 10-7 END.__� _" TIME 10-98 DOCTOR ���- PMD/ER START—.p_ TIME 10-22 HOW CHOSEN: TOTAL - _. STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- 4iy'PATIENT ❑ DIRECT ❑ OTHER 'I CALL BACK#: AMBULANCE NY: s PT AMBULATOR PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 0 YES ❑ NO WAL`<ED ❑ GUERNEY ❑ OTHER - - PATIENT CONDITI N. DRIVER ��-;;pp�� TECHNICIAN AC -7i PARAMEDIC Hx: p.� DISPATCHER: I ' 1. j 5 5 CHIEF COMPLAINT: -_L.1��1 -�� k' Q� DRY RUN: ❑ YES W NO REASON FOR DRY RUN C�1 eT v -- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) _- PATIENT R FUSED SERVICES: (SIGNATURE) X- -- :r �� MEDICAL COVERAG INDUSTRIAL ❑ YES ANO NO. OF PATIENTS: S.S. K—� �o r j.. PRIVATE INS. CO.: BASE RATE: �,:I \ KAISER n: MULTIPLE PTS. BASE RATE �] BLUE CROSS a: TOTAL MILES: X _ MEDICARE a: — E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO .� ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP A POT A P KEN 1 EMERGENCY RUN: C I d 0763031 S00 8803 CODE 2 r 3 OTHER: 099 3 P h4 MN OXYGEN: (PER TANK) P.O.E. STICKE NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G : (PER EPISODE) NEAREST RELATIVE/RE ^SIBLE PARTY: I.V.: (PER ADMIN) __ --___—X c/1C {� — DRUGS: (PER ADMIN.)_—_-.- _ X NAME: P )9 p�� , — RELATI SHI : -ct E �� E.O.A.. (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) — CITY: / STATEjA ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 9 La! WORK PHONE:-. DRY RUN: (AUTHORIZED) _ EMPLOYER: OCCUPATION: OTHER: ADDRESS: -- -- CITY: STATE:- ZIP: - COMMENTS: 12- y " - 90 CA.J - - TOTAL OCE!/ 0"✓r _- ---0'0322 _.__ ... PATI( PIT Rf"CrIVI h Ilv x �( �• l ' PATIENT'S NAME: _ Vel da Mitchell AKA Porter ., ADDRESS: 524 Dubois Ave Richmond, Ca .� � DATE OF SERVICE: AUTHORIZATION NUMBER:8315 934 AMOUNT DUE: $237.50 INCIDENT LOCATION: 886 9th St. Richmond PATIENT DESTINATION: Brookside .HOSpital f- .v s l_ i?-T.4 T ' te' 0f32-0 . -r h• 4e r• ,..r 1.rt.•..�t.. rn � .14(9(3 2, � tr i l ��� SEP I� 4 us ;'A 3 SEP 14 4 48 X_ ct SO NUMBER 8315 r3 q CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10-8 � N1,C.fLLED BY— ----- -- � �PATIENT INFORMATION E? NAME: V�7 � w y` ?I AGENCY: �__J CUSTOMER#(`PT. 1): 008:3 ,' ', ' D n v DEPT/FLOOR/ROOM ` l p:.-- NAME: � (-ht- I 1y( ( C1CZ n '� m Cr y ' a CALLBACK It INS. TYPE: PVT MCAR 09ZAL> KHP PHP VA IND CHAMPUS >4 W v c� 'L INCIDENT LOC: 86 5- POLICY/MCAL a:Q/1&CST"� 3U 3 b'L 6-3 ► V m MCAR#: m 43 m CROSS STREET: t.-�-� __ VERBAL PRIO f Q JURIS: _ City: DOCTOR: ��A t Z v ------ DESTINATION: PT. #2 NAME: DOB: NATURE: a-6 CUST, If D 3 a ' o --._.-- ----- ------- --- -- -- PT. #3 NAME: DOB: t o TYPE OF CALL: �C TRANS TIME UNIT# ;?2 CUST. 1t - - m C WAIT TIME: YES NO REASON: m T ,J, CREW: Z O UNIT TYPE: ALS WC RESPONSE CODE: 0 1 © 3 4 REASON FOR 10-22: p a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 © 3 4 CANCELLED BY: m v = t zBY: END MILEAGE: a 63 COMMENTS: p CJl Q tA TIME: _ BEG MILEAGE: ? -:2i C]` DIS CHER: m 00324 '�� N ' c TOTAL MILES: 0 0 3 2 4 o r" y• X1-0 NOIIVIS 1V 3JNVN19wV 61-01 0NIN2ll113H 3JNVlnBwV 96.01 319VIlVAY 3DNVU19wV L'OI 1V11dSO4 1V 3DNY1f19wV W -o ITS - h I d3j '• i !!!� _ rte �� 7� 6 � c JL '.t.t .ii ref+v �•..e:..t.�.NW!'•::f•&- t,"�; .r... rti°Jtr }+� bid. IA f AIV a,/y.�:X� ... .'ji'mq'►'�` j��Vf'W;a,.+/ei�i7C.d��+��r�' � .4 ':c," T a:,_� ,r :- __.._�._...��.._.-�.r�.... - ..1.,� .,..... ---•--� t x+ ' i+� �': t,tt �` a ?=.,,, � t '��'s' ' +y• 't ,j„lk r ♦ `*/4►i r r4 �'.(� °r-t..� ,*� l ..3i'4 i ., wry•.. � j r i. y', +t .4 ,j .,,,r. 1• „A ` 14 06 0 iisE —6 tii !7.'r tt♦, f ?{j a t !► Cr 41 i r w pie a1Y -H F � 3'. ��}•' -��•>• �. no 3-�� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION B S( 3 " IS f,11.2 4 . CHECK OR FILL IN APPROPRIATE SPACES DATE: i PATIENTS NAME �ty kur ❑ M ❑ F COMPANY$$-1_2 ADDRESS AGE CITY STATE ZIP DOB__- ❑ Sn ❑ M ❑ T 9'W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ _ PHONE —_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCA ON: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) J�Q�Iv�-�►-< TO SCENE- S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTIN TION: N 1)o FROM SCENE ❑ FIRE TIME 10.97 ^ (' - :- ` ❑ P$APTIME 10-49 NL- �2 22 qnn e MILEAGE: TIME 10-7 I END TIME 10-98 .y DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE CA Y- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONED ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER U i EMT-tA clff:� Pt. 1tTECHNICIAN G PARAMEDIC Hz: I m 2 P . , C�orl- DISPATCHER: I < � � I CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN id AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (J 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YESVNO NO. OF PATIENTS: Al�� ( � S.S. a PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS 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: MEDT-CAL N: 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/RESPON IBLE 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: RK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: CCUPATION: OTHER: ADDRESS: CITY: ;StKLTE: ZIP: COMMENTS: ���----�� — TOTAL:__moo PATIENT RECEIVED BY: X..___.._-- �_ .....- • ,;,+,.,. ,. (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z.. AUTHORIZATION10 I ' • CHECK OR fill M APPAOPRIATE SPACES DATE: +_l 1+9-3 •PATIENTS NAME r O M O F COMPANY p I "- ADDRESS • - AGE CITY STATE ZIP DOB O Sn OM O T G W O Th OF O j DRIVER'S LICENSE N t PHONE NATURE OF DISPATCH 11- 75 TYPE OF TRANSPORT: AMBULANCEA OTHER D — STATION i(A)_2(8)_3(CUe4(D)_5(E)_ INCIDENT LOCATION:) ; = RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �/ TO SCENE- A S.O. � CALL RECEIVED C No G en ,IQ Snu-/,)7 IYIQ fn A O P.D. TIME 10-8 : PATIENT DESTINATION: FROM SCENE- ❑ FIRE _ TIME 10-97 ,Q5- 1\11 rO n p Y1 O PSAP TIME 10-49 T `^ r K n N t�UE: ❑ OTHER/PVT TIME 1D-7 ' END TIME 10-98 �— DOCTOR ''}` + I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER G CALL BACK N: AMBULANCE COMPANY: e A5 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE S- ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER I PATIENT CONDITION: DRIVER .•/cq TA I `J EMT-tA TECHNICIAN d5 « '7 PARAMEDIC Hx: DISPATCHER yo� CHIEF COMPLAINT: DRY RUN: YES 13 NO REASON FOR DRY RUN )- Z AUTHORIZATION FOR DRY RUN(EMS USE ONLY) q4q ,, i PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL YES ❑ NO NO. OF PATIENTS: I S.S. « i 1 PRIVATE INS.CO.: BASE RATE: KAISER N: 1 MULTIPLE PTS. BASE RATE BLUE CROSS N: ' TOTAL MILES: X - MEDICARE N: E.O.B, ATT. ROUND TRIP: O YES 1^' NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRPN: EMERGENCY RUN: MEDI-CAL N: ! ' CODE 2/10 OTHER: r 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/RESPONSIB 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: J rl TOTAL: 26 PATIENT RECEIVED BY:X _ (SIGNATtinE) CONTRA COSTA COUNTY AMBULANCE 53 - 5 9 ti PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION N CNECK OR ML INAPPROPRIATE SPACES DATE: S �ATIENT'S NAME 1��'7 ��� OIM ❑ F COMPANY ADDRESS ' AGE /R- PA-4 CITY STATE ZIP DOB - ❑ Sn OM O T OW O Th O F ❑S DRIVER'S LICENSE M - PHONE NATURE OF DISPATCH 0 Ar Too_- k ' I TYPE OF TRANSPORT:• AMBULANCE OTHER 0 STATION 11A)-2(B)_3(C)-4(D)_6(E)_ INCIDENT LOCATION:I i 41. RESPONSE CODE REQUESTED BY: TIME–(24 HOUR CLOCK) ' I / I - J TO SCENE- S.O. CALL RECEIVED l ir� C� mI o 506r c',nxc.Ir0rIAAA � ❑ P.D. TIME 10-8 . PATIENT DESTINATION. .. - r FROM SCENE- ❑ FIRE TIME 10-97 p ❑ PSAP TIME 10-49 D~ ?mss 1 �(L Nv MILEAGE: ❑ OTHER/PVT TIME 10-7 1• 1;,J END TIME 10.98 Sr OCTOR' '^cPMD/ER STARTTIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 7-71.,❑ NEAREST + O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: - DRIVER U CA TA I U EMT-11A t� 0 r I}y U 1I /I TECHNICIAN 62S c2 J �'� PARAMEDIC Hx: �(� (J ��'�- 11Uh �i�C' DISPATCHER: 1•i c' Ic' I t C C-�( CHIEF COMPLAINT: DRY RUN: )Z YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `nu TL r ��1 �. `...t ." . PATIENT REFUSED SERVICES: (SIGNATURE)X `� q'sa.. MEDICAL COVERAGE: , _ ,I INDUSTRIAL S ❑ NO No. OF PATIENTS: S.S.N i 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 ,ONO ❑ YES 'O NO NIGHT: (19:00-07:00) CCHP/PPRP N:" EMERGENCY RUN: MEDT-CAL M: �' CODE 2 It 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/R 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) PHONE: WORK PHONE- ORY RUN: (AUTHORIZED) G.�S —EMPLOYER: OCCUPATION: OTHER: ADDRESS: --CITY: STATE: ZIP: COMM TS: TOTAL: 15v• Ce 00327 27 ( ` PATIENT RECEIVED BY: X (SIONA;tinrl CONTRA COSTA COUNTY AMBULANCE r� _ PRE-HOSPITAL CARE FORM i UNIT r, AUTHORIZATION M rl\` CHECK OR FILL IN APPROPRIA IF SPACES - DATE: '�'lS/'L� PATIENT'S NAME.-�/C� 1`►'��"Lys--- ----- -- -- ❑ M q1-F COMPANY#- ADDRESS .l�a-----�L-- -�. .tiL( �� --�\✓_-- - AGE — n l �� STATE C�I--- _ ZIP �i1 DOB,,1A.'�gKQ'1❑ Sn O M O T P-W O Th O FI O S i DRIVER'S LICENSE a _. - _ _- _.- PHONE /-Z_ff 72m333L-_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: L'�� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK I {( / TO SCENE - $.O. CALL RECEIVED I Q _ C v e( �� Lv-- --- - - ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE —_ TIME 10-97 (l ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 l C ` END '_ TIME 10-98 DOCTOR �.__.. _. ^ , y _ ��__ .>.i.-Y-�+-_�_ MD ER START_—_� TIME 10-22 HOW CHOSEN: TOTAL -�_�: STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER I�.. CALL BACK N: AMBULAN.C5.CQMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. J�� RESPONSE ZONES_ -YES ❑ NO ❑ WAL• ED "UERNEY ❑ OTHER PATIENT CONDITION: DRIVER_t 7eLLL l 1-? EMT-tA ��— r� - 1 TECHNICIANPARAMEDIC Hx: �I��� --�'r--- -�C_1. G�_. IZe'��uL k�. - DISPATCHER: j CHIEF COMPLAINT: _jL:�sCa - --L.�Lnt f�f� DRY RUN: ❑ YES ANO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES. (SIGNATURE) X T I MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. CO.:_-- BASE RATE: KAIS�EAxMULTIPLE PTS. BASE RATE ! 1 (SLUE CR6§§'#c 6 AJ.2_' _ 31 Q _ TOTAL MILES: X =� o`)e%•60 1 MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO j ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPHP#: EMERGENCYIUN: MEDT-CAL a:__ CODE 2;!3 C157HER, OXYGEN: IPER 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 _G`I' L7 _LI I-ii%r.y -jam RELATIONSHIPI&S, E.0 A.: (IF NOT REPLACED) ADDRES: _� j17 .../-..-_ _--__ ORAL AIRWAY: (IF NOT REPLACED) - CITY _. __. _.._ .... _._ . _._- STATE___ZIP:___— C-COLLAR: (IF NOT REPLACED) T PHONE 731_:._13 ,_ - WORK PHONE .-------.- DRY RUN. (AUTHORIZED) EMPLOYER: —__._..___.._____. _. OCCUPATION: .-- OTHER: ADDRESS: CITY: STATE: ZIP; COMMENTS:_— _ -- -- --- — TOTAL:�l - Dd 328 PATIENT RECEIVED BY: X 00 a r�t (SIGNATURE) 1'r•va•,^• : _ � �h� .r:.r n. ..4,. til i•� OIS-1 CONTRA COSTA COUNTY AMBULANCE S3 PRE HOSPITAL CARE FORM 1 , 1 UNIT �� AUTHORIZATION If 1 15-4/4 l ( D I ••') ' CHECK OR FILL IN APPROPRIATE SPACES - DATE: PATIENTS NAME ❑ M ❑ F COMPANY- jn' ADDRESS AGE K CITY STATE 'ZIP —_ DOB_—_ ❑ Sn ❑ M ❑ T w W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M — �— PHONE —____-_.-___ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Or OTHER❑ INCIDENT LOCATION:- r RESPONSE CODE: RE(_11ESTED BY: TIME- (24 HOUR CLOCK) _ �`-' _ '�� l �'�l �Q�tQ ��V�• sti,t� �o( TO SCENE 0 P.D. RECEIVED . --- TIME 0-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE -_— TIME 10.97 ❑ PSAP TIME 10-49 l MILEAGE: ❑ OTHER/PVT TIME 10-7 / END TIME 10-98 DOCTOR PMD/ER START_ TIME 10-22 I 1 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY: �5 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c�C RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERuS� _-t C' MT-1 i aTECHNICIAN ) I�� PARAMEDIC — Hz: DISPATCHE. 1 i l 1I�0 CHIEF COMPLAINT: _ DRY RUN: YES -Q NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Q1 1 PATIENT REFUSED SERVICES: (SIGNATURE) X q 5� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. R PRIVATE IN BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP q: 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/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: STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: ESTATE: ZIP: COMMENTS: -- -- TOTAL. - --- - - _._ 00329 , PATIENT RECEIVFD BY: X r.....rI,r ree 0.,.. tSlrNArtjnF) .. CONI RA COSTA COUNTYI AMFIULANCE j7 { �� PRE-HOSPITAL CARE FORM I IINil y� AUTHORIZATION#�C'NNN v CHECK OR FILE.IN APPROPRIATE SPACES DATE: ;� - /�• ��'� Q / PATIENT'S NL\1,11_ L t/ M ❑ F COMPANY# ItoADDRESS _�_ --�-�- --'"- i_IL��_ _ AGES --- t CITY STATE� -! _ ZIP__`--.- DOB 1�7_� O Sn O M O T W O Th O F 'D S DRIVER'S LICENSE N PHONE( ._?_r __ t':-r._ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)o n TO SCENE - 11S.O.—__— CALL RECEIVED 1^2 O P.D. __ TIME 10-8 / .0 3 PATIENT DESTINATION: FROM SCENE L� ❑ FIRE -_— TIME 10-97 1 1 -- O PSAP TIME 10-49 lty_� 3 MILEAGE: �- :OTHER/P.V/T TIME 10 7 END 3 ,I d �J TIME 10-98 N_ DOCTOR ____1L.__�..._.___... _ _f PMD ER START__., TIME 1022 HOW CHOSEN: \ - TOTAL - __ STANDBY TIME ❑ NEAREST ❑ FAMILY (L7,TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT (❑ OTHER I CALL BACK#: AMBULANCE COMPANY: --��� J PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: + !{/ RESPONSE ZONE 2- G)YES ❑ NO ❑ WAL'CED ISJ-�GUERNEY ❑ OTHER it PATIENT CONDITION DRIVER S ��C S� 1) (�"� _ EMT-tA TECHNICIAN V'" �� i ) ' PARAMEDIC -T_ Hx: - t ) DISPATCHER: A ( I I CHIEF COMPLAINT: -�_ � DRY RUN: ❑ YES 'KNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- J MEDICAL COVERAGE. INDUSTRIAL ❑ Yr bij�0 NO. OF PATIENTS: PRIVATE INS. CO.:.__. BASE RATE: KAISER# MULTIPLE PTS. BASE RATE BLUE CROSS TOTAL MILES: y X MEDICARE#: - E.O.B. ATT. ROUND TRIP: ❑ YES O NO I` C ❑ YES O NO NIGHT: (19:00-07:00) y CCHPip�HP a -_-_ EMERGENCY RUN: C ` C_MtDI-CALJiS'�! _�__.�a_ __=�� % —_ CODE:2 /3 OTHER: _ OXYGEN: (P.ER TANK) 424 P.O.E. STICKER Cl YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: ____. STANDBY: (OVER 15 MIN.) r - E K.G.: (PER EPISODE) 1 NEAREST RELATIVEIRESPONSIBLE PARTY: I.V.: IPER ADMIN.) X n 1 DRUGS: (PER ADMIN.)_ X NAME r 7`�:r,_�".r, , )." f_1� RELATIONSHId.1_."'_,"`_!( / E O.A : (IF NOT REPLACED) ADDRFS)S- ORAL AIRWAY: (IF NOT REPLACED) CITY: L' i_��'_C-'�� STATE--_ZIP: _ C-COLLAR: (IF NOT REPLACED) PHONEWORK PHONE:- DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:_ _- OTHER I . ADDRESS:-- -- -- --- fD. STATE:--._-- 21P: - --- -- -- COMMENTS — TOTAL %� __-_ t...., •-� ___ 00330 -_ 0 PATIENT RECEIVED BY: X (SIGNATURE) - a�-1 CONTRA COSTA COUNTY Y AMBULANCE PRE-HOSPITAL CARE FORM I ` UNIT ® AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE. PATIENTS NAME �a�"l "�' - ❑ M OF COMPANY# ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M OT�W ❑O Th ❑ F ❑ S DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH —,:)SZti.I N( TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR LOCK) 1 c TO ENE- CALL❑ P.U. TIME a8 RECEIVED PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 N � ❑ PSAP TIME 10-49 f F MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START— TIME 10-22 ( Ll HOW CHOSEN: TOTAL, STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COOMPA CA J PT. AMBULATORY? PATIENT'TAKEN TO AMBULANCE: J� RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER `�� EMT-1A TECHNICIAN (rC' aM F L PARAMEDIC X U Hx: DISPATCHER: _f_k_ �q� CHIEF COMPLAINT: �Q^ DRY RUN: O YES ❑ NO REASON FOR DRY RUN q I _ q AUTHORIZATION FOR DRY RUN(EMS USE ONLY) '1 yttPATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 iC S.S.# / \ IVATE INS. CO.: BASE RATE: I KAI C MULTIPLE PTS. BASE RATE BLUE C SS#: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (P ANK) P.O.E. STICKER ❑ YES ❑ NO �=BY: (INCUBATOR) DATES BILLED: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELA.F NSHIP: Q.O.A.:(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF•tgpT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL. -- `/ �- --------- _ � � - ; 0 3 1 , PATIENT RECEIVED BY:X_ Pnividnr rotofr, Ndifn ,aril Pin, —pp Rrf,.rn Y. 'I f o„ (SIGNATURE) CONTRA COSTA COUNTYAMBULANCE Q PRE-HOSPITAL CARE FORM I UNIT F�?� AUTHORIZATION# J t , Y� CHECK OR FILL W APPROPRIAI E SPACES DATE: 1 � O • i PATIENT'S NAME__.: .LLS'YLb.L!2.t�(�tt__-LGJ a n n_ O M �F COMPANY p �2_R ADDRESS / — AGE �_ O CITY_ �lyt_�LS,_ STATE- Q/1 ZIP�_j _Z�- DOB 1LS/ ❑ Sn OM D T W O Th O F,O S DRIVER'S LICENSE M 41766 Z Y_Y.7- ____. PHONE_tYZC�- <_%>. _z NATURE OF DISPATCH s-d TYPE OF TRANSPORT. AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) t' TO SCENE- _ S.O. CALL RECEIVED L2 ❑ P.D. TIME 10.8 PATIENT17r- DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 _ Z O PSAP TIME 10-49 c C-C '4 _ MILEAGE: ❑ OTHER/PVT TIME 10.7 END � � TIME 10-98 1 a/ : DOCTOR - J<_Lf ! PMD/ R START:::] ,' TIME 10 22 HOW CHOSEN: TOTAL - STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT DIRECT ❑ OTHER ( I CALL BACK 4: A U NCE COMPANY: _. , J P AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_cl YES O NO WAL'<ED ❑ GUERNEY O OTHER PATIENT CONDITION. DRIVER (� ~�� I C) EMT-1A 1 TECHNICIAN <� I C PARAMEDIC + Hx 1[ -> DISPATCHER: b I CHIEF COMPLAINT:NT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN -_l'1=LLQ- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PAT NT REFUSED SERVICES: (SIGNATURE) X MEQICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: C.S.S.tl PRIVATE INS. CO.: BASE RATE: Z&2_1 J KAISER 1t: MULTIPLE PTS. BASE RATE BLUE CROSS#: _ _ TOTAL MILES: X S O I�3.lti MEDICARE C E.O B. ATT. ROUND TRIP: OYES ONO I ❑ YES ❑ NO NIGHT: 119:00-07:00) CCHP/PPRP Ji: EMERGENCY RUN: 3ax MEDT-CAL b: CODE 2)3 I - OTHER: _.__-_.__ OXYGEN: (PSR TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_ STANDBY: (OVER 15 MIN.) LoI ��r:t�' E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V,: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME..Lc. G.c, ---l1� . ___--._ RELATIONSHIP: __ E O A.: (IF NOT REPLACED) - - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: �Jt•1cc c�u.A_—_- STATE-p.A ZIP:1.iVi2i C-COLLAR: (IF NOT REPLACED) PHONE: y L ' 'Y_-_Z_'lj_7_WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: _ CITY:_._ __- STATE: ZIP: COMMENTS:_-- TOTAL:� 3•G7 -ice PATIENT RECEIVED BY:X IGNATURE) ry CONTRA COSTA COUNTY , AMBULANCE ��_�� �/ PRE-HOSPITAL CARE FORM 1 UNIT (-J*-T-I AUTHORIZATIO M ' � CHECK OR FILL IN APPROPRIATE SPA CFS •.- , DATE: PATIENT'S NAwl�_ _ ���_`' 0 I 1 M Cl F COMPANY M ADDRESS J V AGE 0 N CITY OW V'OV) 'STATE (44 ZIP 1 jG DOB3 ❑ Sn 13 M ❑ T AW O Th El F ❑S ` DRIVER'S LICENSE# — L '�_ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ _ STATION 1(A)_2(8)_3(C 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOAK) 33 i 11 (j(td J{ TO SCENE- p P.D. TIME 0-8 S.O. CALL RECEIVED .� �, PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 ( MILEAGE: ❑ OTHER/PVT TIME 10-7 END_ r7 -7 TIME 10.98 DOCTOR. PMD/ER START TIME 10-22 - HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER 1 WAIT TIME PATIENT O DIRECT ❑ OTHER ( ) r CALL BACK k: AMBULANCE r[IMPANY: _. PT. AMBULATORY? P TIENT TAKEN TO AMBULANCE: S�� RESPONSE ZONE P,YES ❑ NO 2WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER_ -Tfj I ,a %,l. EMT-1A // rTECHNICIAN �{<- ' PARAMEDIC Hx: � � ��> N�� DISPATCHER ~'' ,. !. CHIEF COMPLAINT: - u+-Q - DRY RUN: ❑ YES kNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ! PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COV R c�E: , q�sTIAL ❑ YES �NO NO.OF PATIENTS: S.S. a 4?? °� -.� '/-`t % r •-a �L:_ PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS p: 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: MEDI-CAL M: CODE 2/3 ,eerAr ' e, OXYGEN: (PtR TANK) 1 '-PO-1. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) y- NEAREST RELATIVE%RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: e REL. I S . E.O.A.: (IF NOT REPLACED) ADDRESSORAL AIRWAY: (IF NOT REPLACED) CITY: W C _ S T C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: 11�s6C— DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:- '�' O --- PATIENT RECEIVED BY:X Provider reta`n White wd Pin.'.. ropy AEtum ➢v'iwr �npp t, CH^when bi):ina (SIGNATURE) sms-1 ' s CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION N •CHECK OR FILL INAPPROPRIATE SPACES DATE: � � • PATIENTS NAME ❑ M ❑ F COMPANY It D D R R,u ADDRESS AGE CITY STATE ZIP DOB— O Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N __ _ PHONE NATURE OF DISPATCH �J - TYPE OF TRANSPORT: AMBULANC OTHER❑ IN (DENT LOCATION:` i RESPONSE CODE: RREOUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE� N -es q� .0. ____ CALL RECEIVED -17 ❑ P.D. TIME 10-8 !7 PATIENT DESTINATIO FROM SCENE- ❑ FIRE —_ TIME 10-97 -S/ C ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 /1:y : �•� END 6-1 TIME 10-98 9 aj(_ 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: J RESPONSE ZONE .. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-tA TECHNICIAN - `PARAMEDIC f Hx: _ DISPATCHER: i (� CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN /(11ORI � ZAT ON � DRY RU (E S•USE ONLY) J ''(�( PATIENT REFUSED SERVICES: (SIGNATURE) - / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDI-CAL II: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 Mi N.) 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: 1'1 � rpATIENT OTAL: L�• —RECEIVED BY: x - --- -- r � (SIGNATURE) .r^: r .W r. .•k .t 1: i, ) EMS-I i CONTM COSTA COUNTY �� AMBULANCE ` 7 PRE-HOSPITAL CARE FORM I UNIT F_q] AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES PATE: 1 PATIENT'S NLA,ME �!_.7E_ ___ �M ❑ F COMPANY# ADDRESS +�`- —(� i r -��(lJ AGE 50 O 14 1 CITY_ STATE__PA. ZIP� � DOB ❑ Sn ❑ M ❑T ❑W 0 Th O F O S DRIVER'S LICENSE is ______._. _. __ _._..___. ___ ------- PHONE _. NATURE OF DISPATCH-( TYPE OF TRANSPORT AMBULANCE THER❑ _.______.__ -� , _ . -•. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) �1 TO SCENEb*--s.o. CALL RECEIVED/ i ❑ P.D- TIME 10-8 ! PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 I-( ❑ PSAP TIME 10-49 -.1 MILEAGE: ❑ OTHER/PVT TIME 10 7 oz. _� END _� TIME 10-98 DOCTOR PMD/ER START__��- TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME V(-NEAREST Cl FAMILY ❑ TRANSFER 1 WAIT TIME ❑ PATIENT Cl DIRECT ❑ OTHER { CALL BACK C AMBULANCE COMPAN ^7� PT AMBULATORY? PATIENT TAKEN TO AMBULANCE 7n RESPONSE ZONE_ _S I UOES. ❑ NO ❑ WAL':ED (20GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVE�'� EMT-1A /� tl TECHNICIAN �-�C� & PARAMEDIC _ Hx: -.I � � "� DISPATCHER �� �� ({ E_ { {, { l U/�• CHCOMPLAINT: -.�� �Jl _ � DRY RUN: 13 YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l _ PATIENT REFUSED SERVICES: (SIGNATURE) Xto MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO. OF PATIEN � S.S. PRIVATE INS. CO.: -_ BASE RATE: KAISER x: __- _.-- __ MULTIPLE PTS" BASE RATE ��'•�o BLUE CROSS 4: TOTAL MILES: X _ MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ElYES ❑ NO NIGHT". (19:00-07:00) V, -- CCHP/PPHP#:— EMERGENCY RUN: o� 1 1 MEDT-CAL a: CODE 2/3 '7 OTHER: OXYGEN: (PER TANK),9, / 0/ i�.O.E. STICKER ❑ YES Cl NO NEONATAL" (INCUBATO 3Q?f/.7�; DATES BILLED: _ __ STANDBY: (OVER 15 Iroa _ E.K.G : (PER EPISODE) �U NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) .X CA�C A DRUGS: (PER ADMIN.) X NAME. X44__:.______ RELATIONSH1P:Jr5._- E O.A.: (IF NOT REPLACED) + ` 10111 - ADDRESS Z_ _LV_.L�_ Y ^.___._l.�.__— _ ORAL AIRWAY: (IF NOT REPLACED) CITY: _� ___Im M�!___ _ STATE--h-.._ZIP:__-_- C-COLLAW (IF NOT REPLACED) i'HONE.7,_��_ _7_ WORK PHONE .__-__._-- DRY RUN: (AUTHORIZED) EMPLOYER OCCUPATION.--_ - OTHER: ADDRESS: - ' - �� �� 7 CITY: _--._____ STATE:,__ZIP: COMMENTS... -----'_ - -- - TOTALS-: -- 01 3 3 5 C_ PATIFNT RECEIVED BY: X P, � M},�lR.• �~ CONTRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I UNIT [=I AUTHORIZATION A f CHECK OH TILL INAPPROPRIATE SPACES DATE: 9 r ,5 PATIENT'S NAME C, _. _— _ _ M ❑ F COMPANY k ` ADDRESS ( L7v--- '{t`— LAGE — l , I ( ' STATE__t�—_� ZIP_ � DOBL1 Sn ❑ M ❑ T ❑ Th;:O F E3 DRIVER'S LICENSE if .. . _ PHONE ��—{J_�Z� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEOTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- Q .O. CALL RECEIVEDy ❑ P.D. TIME 10-8 f_ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 s.L_ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10 7 L _ ) END 'S1'-- TIME 10-98 DOCTOR -_ .L �_/ PMD/ER START 3 TIME 10.22 N. HOW CHOSEN: TOTAL _--__— STANDBY TIME f i.q /19 NEAREST ❑ FAMILY ❑ TRANSFER 1 WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER �. I CALL BACK N: AMBULANCE COMPANY: NE - PT AMBULATORY) PATIENT TAKEN TO AMBULANCE. O RESPONSE ZONE ES ❑ N C wAl':ED ❑ GUERNEY OTHER,_____4 01 r N PATIENT CONDITION. DRIVER _ —� 6. EfMT-1A l( TECHNICIANS OPARAMEDIC _ P 1 Hx _ f�".CD�1�__� ,� _ C — DISPATCHER: ' _ ( ✓I CHIEF COMPLAINT: ��t DRY RUN: ❑ YES 6 NO REASON FOR DRY RUN _. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) _ _�nFl PATIENT REFJSED SERVICES: (SIGNATURE) X _ �a MEDICAL COVERAGE INDU ❑ YES ❑ NO NO. OF PATIENTS: Z� Z ), j p S.S. a�_L _ZC{f 'T/ J 1� )� PRIVATE INS. CO.:_ BASE RATE: _ v� KAISER x: _ _ MULTIPLE PTS. BASE RATE BLUFF CJaQS.S tt. _ TOTAL MILES: X rm�DICAR' �L4 -�_. E.O.B.ATT. ROUND TRIP: 13YES ❑ NO 1 - YES ❑ NO NIGHT: (19:00-07:00) /S O• cv CCHP/PPHP,1r:_ / - EMERGENCY RUN: �G•SO / / - o. cvNC , i .,• r- , t� MEDT-CAL rt. ^ CODE 2/3 _ _ .30- L� (` f' OTHER:----- OXYGEN: (PER TANK) ����C'''� )j ✓�•r.:l I ) P.O E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ,;f+ DATES BILLED'.__ __ _.___ STANDBY: (OVER 15 1drN)"�'`�' 7 _. FRE I E.K.G.: (PER EPISODE)' NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X DRUGS: (PER ADMIN.) X ��f _ RELATIONSHIPr� f.O.A.: (IF NOT REPLACED) I, ADDRESS--.-- _._ ___— ORAL AIRWAY: (IF NOT REPLACED) STATE�/'A_"ZIP: C-COLLAR: (IF NOT REPLACED) v PHOZ.�WORK PHONE: DRY RUN: (AUTHORIZED) ,;4cK EMPLOYER: ___..____—_. OCCUPATION:_.__ OTHER: t,• ADDRESS CITY: STATE: ZIP: COMMF.NTS:.. — ' ---- - - - — CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#" CHECK OR FILL,INAPPROPRIATE SPACES - DATE: PATIENTS NA A ❑ F COMPANY# � ADDRESS AGE— CITY GE CITY STATE ZIP DOB _ ❑ Sn ❑ M ❑ T ❑ W_fh ❑ F ❑.S DRIVER'S LICENSE# __ PHONE _— NATURE OF DISPATCH—S I v . TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) C c TO SCENE- _0. CALL RECEIVED lZ�� TIME 10-8 6-4 L _ PATIENT DESTINATION: �— FROM SCENE"o,1 _ ❑ FIRE TIME 10-97 �••s�.r_ ❑ PSAP TIME 10 49 MILEAC�i ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR I PMD/ER START TIME 10-22 Cl 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. 11 WALKED ❑ GUERNEY ❑ OTHER v ( 1 � I PATIENT CONDITION: DRIVER wy� ✓ C�,s\ ,AT-1A TECHNICIAN 1 v V _ PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RU><CYYES Y❑ NO REASON FOR DRY RUN 1 � G5 AUTHORIZATION FOR DRY RUN(IN USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— ` t`-/IsK F 5�- 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 ❑ 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 ❑ 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) _�oqqv PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) i EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ! _ —_ TOTAL: PATIENT RECEIVED BY: X r: r.r �,•r. w.; (SIGNLTURE) CONTRA COSTA COUNTY AMBULANCE CU 4 PRE-HOSPITAL CARE FORM 1 UNIT14'l AUTHORIZATION } CHECK OR FILL IN APPROPRIATE SPACES )) V DATE: ,1 PATIENTS NAME L (/ U ❑ M ❑ F COMPANY ADDRESS AGF L CITY STATE ZIP -- DOB- ❑ Sn ❑ M O T ❑ W e Th O F O S DRIVER'S LICENSE N _ ___ PHONE-_-....-_ ____ NATURE OF DISPATCH_u'fK- 46- TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LO��C//ATIO RESPONSE CODE: RESTED BY: TIME- (24 HOUR CLOCK) TO SCENE -� S.ns _= CALL RECEIVED ❑ P.U. _ TIME 10-8 PATIENT DESTI ATION: FROM SCENE11FIRE �— TIME 10-97 a7 :� \ �I•fn��_ - - ❑ PSAOTHER/PVT 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 ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ( ❑ PATIENT --❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMP�M (_ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J.LJ RESPONSE ZONE _ ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 2 y EMT-1A TECHNICIAN _ �- L:2W PARAMEDIC Hz: DISPATCHER: �q ( CHIEF COMPLAINT: _ DRY RUN:-,P-YES ❑ NO REASON FOR DRY RUN �I{ UTHORIZATION FOR DRY RUN (EMS USE ONLY). • PATIENT REFUSED SERVICES: (SIGNATURE) �1�-]Y > C-N, 5�- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: J S.S. N PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN- (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN:. (AUTHORIZED) �d•�/v _. EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -- _ TOTAL: IIATILNT HLCEIVED BY X RvuiAor rntaic Whf to jij (SIGNATURE) ois : I.,! ( i CONTRA COSTA COUNTY AMBULANCE b 3 PRE-H SPITAL CARE F RMI UNIT AUTHORIZATIO # /((U t � ��ic , iivdsEy Gl �; CHECK OR FILL IN ROPRIATE SPACES DATE: Q PATIEN'T S NAME ❑ M O F COMPANY III l 63 ADDRESS AGE,L i CITY STATE ZIP — DOB—_—_ O Sn O M OT O W O Th O F O S DRIVER'S LICENSE 0 __ _ PHONE __.___— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: I RESPONSE CODE: REAUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE S O. CALL RECEIVED p / �j 5i• Ci- 2— ❑ P.U. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 OTHER/PVT .R'• 1 Y V� MILEAGE: ❑ OTHER/PVT TIME 10-7 —DOCTOR' 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 {3,• ❑ YES ❑ NO ❑ WAL`<ED ❑ GUERNEY ❑ OTHER j t PATIENT CONDITION: DRIVERV CG'S 6.5 v "�'UEMT-1A TECHNICIAN _ J _ PARAMEDIC Hx: DISPATCHER: 219 CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN TH 1ZATION FO DRY 9U (EMS USE ONLY) '( PATIENT REFUSED SERVICES: (SIGNATURE) X / L'Ny MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: q5 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: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 11 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) 5.111 / EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 0 0 3 9 PATIENT RECEIVED BY X.._ 4• r. ..a — 1S,MN411IRF) 1\ • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION OV-0 � 0 'Q 111 � CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME- f- �__l_.-y. ��_ e M ❑ F COMPANY# / dr ADDR S5 .tUU �{� 1 �+—�'?� ,A`GE^� — 4 CO) ILA � S � M ` ❑ Sn ❑ M ❑ T ❑IN Th ❑ F (3S CITY_. _ � [r���__ STATE-- ZIP— DOB � ` ) DRIVER'S LICENSE _.__. _ PHONE _n_ P------—__ NATURE OF DISPATCH cp TYPE OF TRANSPORT: AMBULANCE 1 11 OTHER❑ INCIDENT LOCATION- RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR K), TO SCENE- S.O.- CALL RECEIVED P.U. TIME 10-8 zuIT ,) PATIENT DESTINATION: FROM SCENE- 2 ❑ FIRE TIME 10-97 / n ❑ PSAP TIME 10-49 �]3 MILEAG ❑ OTHER/PVT TIME 10.7 �1= �j- END_ _ _ TIME 10-98 5 DOCTOR {t�,��� _ - PMD/6) START_ TIME 10-22 HOW CHOSEN: TOTAL - _ STANDBY TIME ❑ NEAREST , ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER =�> ) CALL BACK it: AMBUL,,AgCE COMPANY: PT AMBULATORY') PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE�)� ❑ YES NO ❑ WAL",ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER- __�4 /' r 0 EMT-tA TECHNICIAN— P- �� PARAMEDIC r ; r Hx: _. --- --- ----- - DISPATCHER: i' CHIEF COMPLAINT: __._Lp_-__. __,_________--_ DRY RUN: ❑ YES �KNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4 PATIENT REFUSED SERVICES. (SIGNATURE) X MEDICAL COVERAGE INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 6n4P S.S. a _5_2— 1.377_9) 6q PRIVATE INS. CO.:_--_--__ BASE RATE: l KAISER#: ____-___ MULTIPLE PTS. BASE RATE // BLUE CROSS TOTAL MILES: X J . . MEDICARE#: -_ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19 00-07:00) `-:/"y OS CCHP;PPHP#: EMERGENCY RUN: help MEDI-CAL It: _ CODE 2/3 f OTHER: Q(Zl�_� OXYGEN: (PER TANK) _ IP.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�(iI 1 _ RLATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS1 �45 � t�f�Y ORAL AIRWAY: (IF NOT REPLACED) CITY: 1; -' (- tG!ld'D .__ �_/____ -_ STAT ZIP: C-COLLAR: (IF NOT REPLACED) J PHONE: (} -`_U 7�. WORK PHONE'_- __— DRY RUN: (AUTHORIZED) l EMPLOYER C.b-�tf--__..__-_. OCCUPATIONJ�YLJfjt i _ OTHER: ADDRESS: / CITY: - ___-- STATE:_-ZIP: COMMENTS:- _--_-_-_- TOTAL:_r_'�p _.— -----------.--__-_-. __--- -----_--__.--- _-- PATIENT RECEIVED BY:X S�- , ..,. . . Ll: (SIGNATURE) •'/o.• p�j..� i1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT [jjAUTHORIZATION# �j CHECK OR FILL INAPPROPRIATE SPACES DATE: I -`� 3 PATIENT'S NAME— ,_-1 a�C M ❑ F COMPANY# (� , ADDREW—M _ _`,L.Qr AGE- /q- tCITY- l� STATE l/.� ZI 3-�Z2 ❑ Sn D M D T ❑ W Th O F ❑ S f- . _ F .. 2 - DRIVER'S LICENSE# _. ___ ___. ON .3-.0 NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME - (24 HOUR CLOCK) „„ Sj TO SCENE - so. _______. CALL RECEIVED P.D. _---- TIME 10-8 •' : I PATIENT DESTINATION: FROM SCENE - 11FIRE TIME 10-97 ❑ PSAP TIME 10-49 J MILEAGE. ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _ I PMD/� START y + 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 YES ❑ NO ❑ WAL`:ED ❑ GUERNEY OTHER/ ---- PATIENT CONDITION: DRIVER_ '____ EMT-1A_ `� TECHNICIAN_ � -- _1._____-- PARAMEDIC Hx `-Q // DISPATCHER: CHIEF COMPLAINT: f.-f 11de DRY RUN: D YES ❑ NO REASON FOR DRY RUN J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X _— ,LA) j 3 MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: SS. # 4 _ If 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) nJ CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: _ A OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL-(INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I E.K.G.: (PER EPISODE) I n NE R ATIV tPONSIBLERTY: I.V,: (PER ADMIN)_ X DRUGS: (PER ADMIN)___._._:__-_X N E:---� > �� ELATIONSHIP: E.O.A.. (IF NOT REPLACED) —� ADD ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP:-^ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:.'' S� 20 • 0 DRY RUN. (AUTHORIZED) EMPLOYER: .1 k. OCCUPATIONC/L. OTHE -. T{ 1 _,ADDRE - ---- ��---------- ----Y CITY:_ STATE:---ZIP:__.— COMMENTS: , ` OTS ----.- --------- -. TOTAL00.341 _1 0ATIENT RLCEIVVI) BY X --.-- !? IS0r�NAT1 PFI CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION 0 CHECK OR FILL INAPPROPRIATE SPACES - .DATE: PATIENTS NAME.-.. T f 4 n ❑ M ❑ F COMPANY o P9 ADDRESS AGE CITY STATE ZIP DOB— _ ❑ Sn ❑ M ❑ T ❑ W O Th Aff F O S DRIVER'S LICENSE k _ PHONE------- NATURE OF DISPATCH m-blegAe, . TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: ; C, RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CL9,CK) r TO SCENE- S.O. _ CALL RECEIVED ILL ❑ P.D._ TIME 10-8 PATIENT DESTINATION: FROM S ENE- ❑ 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 CHOSENTOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK t1: AMBULANCF–QOMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �� RESPONSE ZONE 04•� ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 9 () �--- EMT-1A l TECHNICIAN 3 t S PARAMEDIC Hx: DISPATCHER: V Al. % U v IAobo VUo CHIEF COMPLAINT: DRY RUN: Q YES ❑ NO REASON FOR DRY RUN qq,/ AUTHORIZATION FOR DRY.RUN(EMS USE ONLY) ``�/ PATIENT REFUSED SERVICES: (SIGNATURE) X— J� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 �� S.S.N /1 PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE _ BLUE CROSS M: 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 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: IP:COMMENTS: _ TOTAL:___v_ l� 0342 PATIENT RECEIVED BY: X____—�— _._.___. "," f-IGNAT(ME) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I (��(l� UNIT ��7 AUTHORIZATIONM -;-��nhz L•- t CHECK OR FILL INAPPROPRIATE SPACES - DATE: O 2-/b/ OQ z PATIENT'S NAME Alt, L r- ALC ❑ M O F COMPANY N i c• n _ ADDRESS _�114,.ZGls/ AGE 6 Z U /y3 o 8 CIT��E/�>��n�� STATE[`r ZIP DOB ❑ Sn ❑ M ❑T ❑W O Th GIF O S DRIVER'S LICENSE# PHONE `_ NATURE OF DISPATCH /N�DirAl _ TYPE OF TRANSPORT: AMBULANCE Ll OTHER❑ — _ STATION 1(A)_2(B)_3(CI_4(D)_5(E)_• INCIDENT LOCATION RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR LOCK), _ TO SCENE- AN S.O. CALL RECEIVED ❑ P.D. TIME 108 0 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10.97 ❑ PSAP TIME 10.49 MIL b1 E: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 T DOCTOR PMD/ER START It T 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'<EO ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER /<7 ( ) 1A TECHNICIAN -sl�lE,(�E/ y PA -DIC I. Hx: DISPATCHER: r dvAn- CHIEF COMPLAINT: DRY RUN:' � © YES ❑ NO REASON FOR DRY RUN 'T-LeL,lt=�!�� 44 H IZA-TION FOR/URY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE ` v BLUE CROSS C TOTAL MILES: X , \. MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO j ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: 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) 7 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X SIGNATURE Pmvidrr rrtei.. Vhitr ,-r1 Tic= vTp trt�r~ Te'!,v ti,p t• !V' vhen hit ;,w (SIGNATURE) aS-1 1r .� Wj CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# �3 "�C' 19 F' 5 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME /ZA/ES 7- ■ M `❑�F-- COMPANY# ADDRESS ? �oY, 3.7 AGE s �z- C• CITY ��1�C�` STATE_C�� ZIP—_. __ .__ DOB! r� L7 0 $n ❑ M ❑ T ❑W 13Th qF ❑ S i DRIVER'S LICENSE # __ ._-.-,- PHONEC�S X1.35 NATURE OF DfSPATCH7_/Zefo�, 55=t?-c TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) , L TO SCENE ❑ S.O. CALL RECEIVED (2e � , 1 11 " L' P.U. -__ TIME 10-8 C' PATIENT DESTINATION: CliSr LIQ VFROM SCENE - ❑ FIRE _—_ TIME 10-97 09 - Z� ' _ �r❑t PSAP TIME 10-49 15r. f���1E s CO� -y MILEAG OTHER/PVT TIME 10-7 ', 1 END- 3' TIME 10-98 I DOCTOR _!'! 1' A/ PMD/ER STARTQS__V__ C C<<� TIME 10-22 1 HOW CHOSEN: I TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER JC CALL BACK#: AMBULANCE COMPANY: CA S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: r t (/ (f RESPONSE ZONE ❑ YES K NO ❑ WAL`:ED 01 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 6a LIr-5 / EMT-1A ►X TECHNICIAN _► 12 4 C 4,67 PARAMEDIC Hx:C7D1i f�GU S a6S !-i!t'V/t-7- DISPATCHER: �"() ! , - ( J ' CHIEF COMPLAINT:'r RA 4SF��-'FQ IL DRY RUN: ❑ YES 8 NO REASON FOR DRY RUN x.r • c e C' AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES It NO NO, OF PATIENTS: .._-L_-_._--__ S.S. # S-S-/ - ,d- Gyds_ PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE v \ T B ROSS#: TOTAL MILES: X C) � MEDIC(4RE 5 'S-� - D C'S� S E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) <z3DPPHP#: ���ZtZ7 EMERGENCY RUN: MEDI-C #:0-7-1-0 ?5-5-6-20r, CODE 2/3 OTHER: _ OXYGEN: (PER TANK) P.O. . STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) AjES BILLED: STANDBY: (OVER 15 MIN.) L/U o / 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: -- -- ---------- — -- TOTAI 2fS.DD ----- 0 I . _ .. PAI ILNT NECFIVI U BY X /L" l L•r rr•i c:. i I I 1';IGtIA 11f7f) u CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES _ v DATE:._�?- PATIENT'S NAME L '^ P Ll yy ` ❑ M ❑ F COMPANY ADDRESS AGE ` CITY STATE ZIP DOB_�__ - ❑ Sn OM O T ❑ W ❑ Th ArF ❑ S DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH JL' Ffv►K It iAc4C�L, TYPE OF TRANSPORT:, AMBULANCE OTHER❑ / VO. ( CC(A_ .,.t , - INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME•- (24 HOUR CLOCK) Ll� �J� TO SCENE- �.O. — CALL RECEIVED13- !v_ J U l 1 f ��t �j.0 l ❑ P.D. TIME 10-8 .13 �L PA ENT 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 L3 :- 2 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK q AMBUL E PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZO170 _ ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY 11 OTHER /Z PATIENT CONDITION: DRIVER�ld N `'' 0EMT-1A TECHNICIANpLOPARAMEDIC Hx: DISPATCHER:-- I � CHIEF COMPLAINT: DRY RUN: l-GES ❑ NO REASON FOR DRY RUNI-6-z ZZ �)O r SO qqI I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X q99 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: J S.S. 11 PRIVATE INS.CO.: BASE RATE: KAISER 8: 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 M: EMERGENCY RUN: Q� MEDI-CAL q: CODE 2/3 OTHER: OXYGEN: (PER TANK) P,O.E. STICKE ❑ YES ❑ NO NEONATAL (INCUBATOR) DATES BILL STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST REL IVE/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: O CUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: --_ - TOTAL:..._PL-510.U PATIENT RECEIVED BY- X , ISIf:N4fURE) CONTRA COSTA COUNTY AMBULANCE -r PRE-HOSPITAL CARE FORM I Cf�� UNIT r_j=_7__j AUTHORIZATION# r _ CHECK OR FILL IN APPROPRIATE SPACES DATE: .- 7 _—�_C z ps-, PATIENTS NAME �_ � �M ❑ F COMPANY ADDRESS U�� OVE' ��t.{ L( AGE - c" CITYSC,VI FIGu1CSGp STATE ZIP-____-_._- DOBI 1 5 ❑ Sn ❑ M ❑ T ❑ W O Th l/i3�F ❑ S DRIVER'S LICENSE# ___-_._:_ _ PHONE OVY_' _ .. NATURE OF DISPATCH ..... .2 -L-__ TYPE OF TRANSPORT: AMBULANCE FOTHER❑ _. ..._..___. ._ INCIDENT LOCATIO ` RESPONSE CODE: REOIJFSTED BY. TIME- (24 HOUR CLOCK) TO SCENE rS.O. ____...-____. CALL RECEIVED yam_ ❑ P.D. --- TIME 10-8 / PATIENT DESTINA ION: �- FROM SCENE�2 ❑ FIRE -- TIME 10-97 ❑ PSAP TIME 10-49 - MILEAGE: C' ❑ OTHER/PVT TIME 10 7 ,�, Z,•�. END V _.- TIME 10-98 DOCTOR - - PMD R / START— HOW TART� -- TIME 10-22 HOW CHOSEN: _" TOTAL - r ! + STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 13 PATIENT ❑ DIRECT ,, OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TA EN TO AMBULANCE: RESPONSE ZONE ❑ YES NO Cl WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER— �!,� –'EMfi-1A \ TECHNICIAN /��1��i,JJ R�iPARAMEDIC V�- Hx: 1J ( `� DISPATCHER: - ii = CHIE COMPLAINT < ) ' DRY RUN: ❑ YES M-NO REASON FOR DRY RUN _ ~� AUTHORIZATION FOR DRY RUN (EMS USE ONLY) 15 , PATIENT REFUSED SERVICES: (SIGNATURE) X_ �J MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: 1S29. KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X IlL_.L MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) --ee'' CCHP/PPHP#: EMERGENCY RUN: 50 �C/ / v MEDI-CAL#: CODE 2 A 3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 111 DATES BILLED: STANDBY: (OVER 15 MIN.) ct --�J E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I V.: (PER ADMIN.) X / DRUGS: (PER ADMIN.)_ X NAME:�o v C`k e i-1 � n RELATIONSHIP: !"� E.O.A.: (IF NOT REPLACED) ADDRESS: 6 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:_. _ !_>�✓----------- - - /.jCJJ COMMENTS: _ --i_- ..L.� cG ra�. a r TOTAL ✓rZ•�� -- --- - �_7 7i lJ no . Fv✓'The ( lh►.(c, PATIENT FIECFIVI D Dy +'. :.j+.r• rolar•' t7::+•. i +•'.1 ,..I+. +.. (SIGNA'URC) L I CONTRA COSTA COUNTY AMBULANCE R� PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION A CHECK OR FILL IH APPROPRIATE SPACES u DATE:V 7•P'ATIENT'S NAME ❑ M ❑ F COMPANY AgDRESSAGE C U A u CITY m STATE ZIP DOB - ❑ Sn ❑ M ❑ T ❑W ❑ThXF ❑ S DRIVER'$LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)— INCIDENT,LOCATION RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 3y L4 TO SCEN - ❑ S.O. CALL RECEIVED ❑ P.D. TIME 10-8 L:— �° PATIENT DESTINATION:•__. FROM S E- ❑ FIRE TIME 10-97 P'l ❑ PSAP TIME 10-49 7 " LEAGE: ❑ OTHER/PVT TIME 10-7 ENDS_ TIME 10-98 QOCTOR` -y PMD/ER START TIME 10-22 HOW CHOSEN: _ " TOTAL STANDBY TIME �y �;p;NEAREST,.L. 13-/F LY E3 TRANSFER WAIT TIME —_ ❑ PATIENT' ❑ IRECT ❑ OTHER CALL BACK R: AMBULCE I;OCMPANY: ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ �� RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER .q= PATIENT CONDITION. — DRIVER -J L) EMT-tA TECHNICIAN_� G14-o4v�,� yl PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN f l AUTHORIZATION FOR DRY RUN(EMS USE ONLY) AAJ is PATIENT REFU ED SERVICES: (SIGNATURE)'Xi q MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.N PRIVATE INS. CO.: BASE RATE:. KAISER 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) CCH P/PPHPN:I I EMERGENCY RUN: MEDI-CAL N: ` " CODE 2/3 OTHER: OXYGEN:, (PER TANK) P.O.E. STICKER O YES ❑ tio NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) --NEAREST RELATIVE/RESPO 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) t [ EMPLOYER: OCCUPATIONm OTHER: ADDRESS: CITY: STATE: ZIP: ---COMMENTS: -�_ TOTA►• �- 0037 PATIENT RECEIVED BY:X—_ ISIGNATORE) , CONTRA COSTA COUNTY l AMBULANCE -2 PRE-HOSPITAL CARE FORM I '/ UNIT AUTHORIZATION d ' CHECK Oil FILL IN AP qIA TE SPACES DATE:—.4 PATIENTS NAME ❑ M ❑ F COMPANY# ADDRESS AGE` CITY STATE ZIP--- DOB— - ❑ Sn ❑ M ❑ T O W ❑ Th )flF O S DRIVER'S LICENSE# _ _ PHONE---__.—._— NATURE OF DISPATCH. TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INQE+N T LOC ION: RESPONSE CODE: RE TED BY: TIME— (24 HOUR CLOCK) TO SCEN - S.O. _— CALL RECEIVED ❑ P.U.- TIME 10-8 ATIENT DES INATI N: L� ) ; FROM SCEN ❑ FIRE -- TIME 10-97 w.� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ^.. , END TIME 10-98 DOCTOR -* PMD/ER START TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME 1�. ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a AMBULANCE COMPANY:/, � PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE CC ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER _ •;�;j• PATIENT CONDITION: DRIVER_- C �7 '?.�I ;, 'EfAT-1A TECHNICIAN ARAMEDIC Hx: DISPATC R: lir / CHIEF COMPLAINT: DRY RUN: S ❑ NO REASON FOR DRY RUN �06 1, (o AUTHORIZATION FOR DRY RUN (EMS USE ONLY) [' PATIENT REFUSED SERVICES: (SIGNATURE) X 95-2- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# PRIVATE INS. CO.: X 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) ��•�f� EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: -� -- _ 0 ( 3 411 __. PATIENT RECEIVED BY X — - -- — IsIrNA I I inF) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i �` UNIT AUTHORIZATION#IY3 - /&Opt/ CHECK OR FILL IN APPROPRIATE SPACES - DATE: ._9-/1, - 9 3 PATIENTS NAMEOlc�n/i �Q/�'l �I M Cl F COMPANY# ADDR�ESS��� /�C 7✓/S C— �i'Iye,' _ AGE_ C__ 1) CITY-�• / C;r3 CIO STATE C�— ZIP��� L'_ DOB?1/___:Pk S O Sn ❑ M ❑ T. O W ❑ Th IM F ❑ S DRIVER'S LICENSE# ___.__—_:_.________—_ PHONE-0 2- _-�_L�7lNATURE OF DISPATCH_ y2L•'i�'���''1 TYPE OF TRANSPORT: AMBULANCE OTHER O ._._---_____. } INCIDENT LOCATION: SPS RESPONSE CODE: REQUESTED BY. TIME — (24 HOUR CLOCK) !O (�LLMC C TO SCENE- S O. ____—.- CALL RECEIVED ,J`S� — --- O P U.----- TIME 10-8 �f PATIENT DESTINATION: FROM SCENE- O FIRE —_.-- TIME 10-97 ::S--a ❑ PSAP TIME 10-49 - 7�1 MILEAGE: O OTHER/PVT TIME 10-7 END / r _. TIME 10-98 :rT— DOCTOR PM 01 ER START - — — TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER _ _ _____—. WAIT TIME —_ ❑ PATIENT Cl DIRECT O OTHER CALL BACK#: AMBU A COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: `•, ) RESPONSE ZONE _7_ 01.YES Cl NOWAL':ED WGUERNEY-*OTHER / — _— PATIENT CONDITION: DRIVER_R L!:!;;�_�47—L--- — EMT-lA D� TECHNICIAN PARAMEDIC—. �1 DISPATCHER: -1 CHIEF COMPLAINT: DRY RUN: O YES G1 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) _ PATIENT REFUSED SERVICES: (SIGNATURE) X —_ - 1 MEDICAL COVERAGE INDUSTRIAL ❑ YES A_NO NO. OF PATIENTS s.s.# --- PRIVATE INS. CO.: BASE RATE: KAISER#: — MULTIPLE PTS. BASE RATE / BLUE CROSS#: — TOTAL MILES:--- `f X ) J� MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES Cl NO ( O YES ❑ NO NIGHT (19:00-0700) CCHP/PPRP#: ` EMERGENCY RUN' MEDT-CAL#: __— CODF� 2/3 OTHER: OXYGEN: (PER TANK) O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) TES BILLED: —. STANDBY: (OVER 15 MIN.) _ E.K G.: (PER EPISODE) NE EST LFRI.EATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X Dot'vJDRUGS: (PER ADMIN)__ X NAME: i^��r r'HIR�r RELATIONSHIP: SSS EO.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 LZG 00349 PAI IFNT RFr.F IVFn BY X -....... CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 3 I t, CHECK OR FILL IN APPROPRIAtE SPACES{{ DATE- PATIENTS NAME V" ❑ M ❑ F COMPANY K ADDRESS AGE R CITY STATE ZIP DOB— ❑ Sn ❑ M ❑ T ❑ W ❑ Th F ❑ S DRIVER'S LICENSE M PHONE _ NATURE OF DISPATCH C- . TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK). {� ZI O rL S t` `C TO SCENE-3/0 S.O. CALL RECEIVED -\ - ❑ P.U. TIME 10-8 _ PATIENT DESTINATION: FROM,SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 r �c MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 EF- DOCTOR PMD/ER START TIME 10-22 `- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: L & S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j" RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 5 hCG T%' l�•�� EMT-tA TECHNICIAN LIJ ( ` PARAMEDIC —kt'- Hx: DISPATCHER: �)..E� cl - �� _ .\\ 'qV I CHIEF COMPLAINT: DRY RUN: P(YES ❑ NO REASON FOR DRY RUNy 2 IR (>. 1 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) j q y PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �`• j S.S. k PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP A: EMERGENCY RUN: MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) C5 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/R 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS. CITY: STATE-- TATE: ZIP: COMMENTS: TOTAL: - -- - 0 0 PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBULANCES PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION//N CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME �� OM OF COMPANY N ADDRESS , �' AGE k I ` CITY— -- - STATE ZIP DOB ❑ Sn ❑ M O T O W 13 Th.ocF OS DRIVER'S LICENSE N ° PHONE NATURE OF DISPATCH c ala c k n TYPE OF TRANSPORT: AMBULANCE OTHER❑ — STATION 1(A)_._.2(B)_3(C 4(D)_5(E)_ INCIDENT,LOCATION:�� + RESPONSE CODE. QUESTED BY: TIME— (24 HOUR CLOCK) , JJf� ,,)) �f p TO SCENE- 3 S.O. CALL RECEIVED r' \C�� 23 0Y V C�,T 1 .}�. ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �) 1 O PSAP TIME 10-49 D ky ?1%1" C - : i � �f\ MILEAGE: OTHER/PVT TIME 10.7 :_L END TIME 10-98 l S?DOCTOh` PMD/ER START TIME 10-22 �* :T HOW CHOSEN: TOTAL STANDBY TIME O NEAREST,,-,) O FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE`COMP PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ( RESPONSE ZONE � � ❑ YES. O.NO ❑ WALKED ❑ GUERNEY ❑ OTHER IQ ul PATIENT CONDITION:. DRIVER 3'4I? TECHNICIAN 424 l!L�, � <<� PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: k9ES ❑ NO REASON FOR DRY RUN ZO.2Sa—eD 1 1,I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) q q 7. PATIENT PATIENT REFUSED SERVICES:(SIGNATURE) X q.57 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 ( L 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 ❑ 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 ❑ NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RES 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: COMMEN S: . U TOTAL: 0035 . PATIENT RECEIVED BY: X r•,..,, , ,. , ;. (SIGNATIIRE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT h AUTHORIZATION# CHECK OR EIYL IN APPI+O1R1Arf.SPALLS DATE:� / PATIENT'S NA .�� �/_��� " 7 �' !rr__ M ❑ F COMPANY# ADDnSS/S/ ' `—.C��L1 ._ r — AGE Iq C DI CITY.L_L�1�.�rL� �� STATE.._ �L— ZIP—__ DOB a _� ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ _ _._. ,hi23 �E ._. ___.. __._. . NATURE OF DISPATCH DRIVER'S LICENSE q _._. .._ Lf TYPE OF TRANSPORT. AMBULANCE IV OTHER❑ INCIDENT I_ CATION: 6" RESPONSE CODE: PlEgUESTED BY: TIME— (24 HOUR CLO K) -� TO SCENE- A'S.0. CALL RECEIVED Cl / ❑ P.L). TIME 10-8 PATIENT DE IN N: FROM SCENE ❑ FIRE TIME 10-97 �> ❑ PSAP TIME 10-49 . r MILEAGE: ll j ❑ OTHER/PVT TIME 10-7 - //� yam]✓ END. _ ( TIME 10-98 DOCTOR _ I/=l.L� PM !ER) START_ _ TIME 10-22 HOW CHOSEN TOTAL _ r'Ij STANDBY TIME 13 NEAREST 13 FAMILY 41 TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER I ) CALL BACK#: AMBULANCE COM ... PT. AMBULORY? PATIENT TAKEN AMBULANCE: RESPONSE ZONE c'�'}{ � S ❑ YES NO O WAL':ED GUERNEY ❑ OTHER —__— PATIENT CONDITION: DRIVER_ 1:5 �l EMT-1A TECHNICIAN ��! PARAMEDIC �VI Hx: Gf J LI DISPATCHER: "> `• CHI.F C MPLAI�'�T: DRY RUN; 0 YES '�NO REASON FOR DRY RUN - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ,:�• PATIENT REFUSED SERVICES: (SIGNATURE) X—VNO — 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 S�✓'� LaC:�.; MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO Cl YES kNO NIGHT: (19:00-07:00) s. .L (/ HPr'PPHP#;_L"I S G�� 1 ' EMERGENCY RUN: CODE 2/3 1 t� OTHER: OXYGEN. (PER TANK) P.O.E. STICKER ❑ YES Z"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: -------_ --- -- _ LULLED CO. CITY: _ _.___— STATE: ZIP: _ 41 �/ �•:' .�.n .,..L-' •' it I;):' , —��� _ COMNTS: �.� C_L r � t: �3 M r' 1 �✓ 7 "'Y TqL:� �0 352 ___-- -----. -- --. - --- ----.-_.._._-- --. -- PATIENT RECEIVED BY X r•.. ;r.:. ..... .•• fkr.WATUREI r� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION# �-�1 -r---, ' CHECK OR FILL IN APPROPRIATE SPACES DATE: � � •------- 17 PATIENT'S NAME��-_�w� K 7� Q M ❑ F COMPANY# O I ADDRESS � _ �T / AGE CITY 1 �� STATE C' ZIP��i n 0OB7744 (p❑ Sn ❑ M ❑To W O Th .jCfF ff -f DRIVER'S LICENSE# ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE ESTED BY: TIME—(24 HOUR CLO K) �• G C ` �f TO SCENE- W, S.O. CALL RECEIVED ^- -- �— --. -- ❑ P.D. TIME 10-9 �('�, ' PATIENT,DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 SQL ,.0 ❑ PSAP TIME 10-49''1• :: I MILEAGE: D OTHER/PVT TIME ID-7 END TIME 10.99 DOCTOR PMD(ER ) START TIME 10-22 HOW CHOSEN: �' TOTAL STANDBY TIME ,,__L:__V_�� ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULA COMPANY• co� 1 PT,�MBULATORY? PATENT TAKEN TO AMBULANCE: RESPONSE ZON LT YES ❑ NO WAL`<ED ❑ GUERNEY ❑ OTHER p PATIENT CONDITION: DRIVER /& r d IL_ -V O ( !~�A I�yL�j--fir-� _� EMT-1A TECHNICIAN PARAMEDIC Hx: _ DISPATCHER: / ll CHIEF COMPLAINT: 1 DRY RUN: ❑ YES W REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1PATIENT REFUSED SERVICES: (SIGNATURE) X_ - 5. (MEDICAL COV RAGE: INDUS RIAL 11 YES ❑ NO NO. OF PATIENTS: S.S. # - PRIVATE INS. CO, BASE RATE: �'Sy KAISER#: b MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: 2 X • ' SU ^is FA .--- " MEDICARE#: �. ROUND TRIP: D YES D NO ' 2 li• ] /�L( 'A/C' ❑ YES ❑ NO NIGHT: (19:00-07:00) . at .5PI/PPRP k: J D ���14-1 of (f LD S� ' EMERGENCY (; T_X22104 1 M�1-CAC 1t: S' !7 i f `� 3 CODE 2/73) OfiHER: / i , ,. c �� /Q R /9 OXYGEN: PENK C, I r :r f ( ) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) . E.K.G.: (PER EPISODE) NEAREST RELATIV ESPONSIBLE PARTY: I.V.: (PER ADMIN.) X l DRUGS: (PER ADMIN.) X_ NAME- �5�.� � 11 RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRE 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: TOTAL. yy� J `5 3 PATIENT RECEIVED BY:X Provider retaic White rrd Piny Bopp Return Yo'Icw .ropy t- ERC when bii'ina (SIGNATURE) OIB-1 V CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT G AUTHORIZATION 0 $3 I G 39 CHECK OR FILL IM APPROPRIATE SPACES DATE: ' PATIENT'S NAME kc)S 1 u 2i �1 ❑ M KF COMPANY M ADDRESS l / � �'2) N L ��Cf AGE ( l 2 CITY 0 Y 11 h�\� STATE � ZIP �S � �— DOB —'�b �v ❑ Sn ❑ M ❑ T ❑ W ❑ Th ,O FXS' `l DRIVER'S LICENSE M PHONE 25�� i JNATURE OF DISPATCH D ' I TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 11A1_2(8)_3(C) 4(0)_51E1_ r +=1•l INCIDENT LOCATION: RESPONSE CODE: PEOUESTED BY: TIME— (24 HOUR CLOK) i I r 12 1ti1 TO SCENE Q S.O._—_ CALL RECEIVED v �--- • �� ❑ P.U. TIME 10-8 PATIENT OESTINATIO FROM SCENE - ❑ FIRE TIME 10=97 NO - CL ❑ PSAP TIME 10-49 l� 11/��� MILEAGE: ❑ OTHER/PVT TIME 10-7 r:v --� END-1 �'9 TIME 10-98 DOCTOR I tj PMD ER STARTr`f f 9 • ( TIME 10-22 :_,�..-•.-- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER. WAIT TIME ❑ PATIENT ❑ DIRECT J7 OTHER I ,�, CALL BACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TARGUERNEY TO AMBULANCE: �1 RESPONSE ZONE__ ❑ YES NO ❑ WAL'<ED ❑ OTHER PATIENT CONDITION: DRIVER Q 5 �/r� E T-lA lTM ^� n�(} t, • TECHNICIAN Yly L� 0�!221(PARAMEDIC Hx: Lo` `' t S DISPATCHER: CHIEF COMPLAINT: V(`-t.k U ON _Q� DRY RUN: ❑ YESNO REASON FOR DRY RUN .7/ `4 AUTHORIZATION FORDRY RUN (EMS USE ONLY) r PATIENT REFUSED SERVICES (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: SS. >� a - - PRIVATE INS. C C�«5 H L "3-0 BASE RATE: cu KAISER n: _� t �S r UN�' MULTIPLE PTS.BASE RATE _ "I BLUE CROSS 4: TOTAL MILES: X «'' L) MEDICARE#: E.0 B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19 00-07.00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL K: CODE 2 f 3 I•---� I r OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'l4 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ��:.�•l'(/✓3 DRUGS: (PER ADMIN.) / X 30 NAME: V ►TIL RELATIONSHIP: -A 5(3 -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-. 41 Z. PATIENT RECEIVED BY. X l7SIGNAT RE vvidrr rlra;r, Vhi ry .��f /'r•: r.q.� �rhm Y�';.L• , ,�,•, I• nl' uhva f•i l mg ) ►h--1 CONTRA COSTA COUNTY AMBULANCE/ PRE-HOSPITAL CARE FORM 1 UNIT (—,.,� AUTHORIZATION N T 2 ; CHECK OR flll INAPPROPRIATE SPACES / � DATE: f -Z)7 - PATIENTS NAME �U �Z �vu /L S v ❑I M ❑ F COMPANY N r C/ o -42, / I ADDRESS O AGE ku;J CITY STATE LIP DOB I ❑ Sn ❑ M OT O W O ThQ❑ FS - DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH Au�V �,« U��11,`r TYPE OF TRANSPORT: AMBULANCEP OTHER — STATION l(A)_2(B)_3(C)W-4(D)_5(E) INCIDENT LOCATIOWO �I - RESPONSE CODE: R QUESTED BY: TIME–(24 HOUR CLO K) 1 IJP �C ( : C�L C Y,7 lam'Sr �2S g4�!�x S��. TO SCENE- r�.O. CALL RECEIVED / V O p.D. TIME 10-8 PATIENT DESTINATION: 0� FROM SCEN - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 9'DOCTOR 1 PMD/ER START TIME 10-22 7 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST,-, ❑ FAMILY ❑ TRANSFER WAIT TIME ' ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULAN E OMPANY: S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 137 ❑ YES E3 NO, ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: j DRIVER ' /15 rr T- ��I� TECHNICIAN /�Iy�, y ; C% EDIC Hx- DISPATCHER: CHIEF COMPLAINT: DRY RUN.)(YES ❑ NO REASON FOR DRY RUN I V p AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 5�- 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 17 NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: 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:— TOTAL:- 00355 IP: TOTAL• OQ355 PATIENT RECEIVED BY X n, (SIONATI JNFI I. ' ►�lJt-c- �I�� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 3 r _ � A.I t-• CHECK OR FILL INAPPROPRIATE SPACES - DATE: C� / •�, )[PATIENT'S NAME ❑ M ❑ F COMPANY# ADDRESS AGE ApracU W CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# PHONE _— _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ : . INCIDENT LOCATION: P/A/ L 6- RESPONSECODE: REpUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- CR S.O. CALL RECEIVED >17 3 f Y7 u f-g= E R, �/n/� O P.D. TIME 10-8 4 PATIEN DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ` END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERZ A* ��C LLQ e !, 2 EMT-tA TECHNICIAN Z G`N S r; 0 PARAMEDIC // Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: AYES ❑ NO REASON FOR DRY RUN S q6� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 95� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) � vV_ PHONE: WORK PHONE: 9 DRY RUN: (AUTHORIZED) aj1_ _ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: .. TOTAL: 0 0 3 ti 6 PATIENT RECEIVED BY:X ... Prnidr� rrl,.: �.�� • _ n:.. ri. sr .. .. .i. (SIGNATURE) CM`.-} CONTRA COSTA COUNTY AMBULA E /6— 7y' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N l CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME -- ` r 13 ❑ F COMPANY N ADDRESS. , I - - AGES• CITY STATE_ _ ZIP DOB ' ❑ Sn OM OT O W ❑ Th O F, DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER 0 _ — STATION INCIDENT LOCATION: i " RESPONSE CODE! REQUESTED BY: TIME— (24 HOUR CLOCK) y � r7 TO SCENE- S.O. CALL RECEIVED f rp.D. TIME 10-8 PATIENT DESTINATI .-.) 9 FROM SCENE ❑ FIRE TIME 10-97 ! (�� ❑ PSAP TIME 10-49• � � 2"s1 -'.` 't'�•� i MILEAGE: ❑ OTHER/PVT TIME 10-7 ! - END TIME 10-98. t•� I ii DOCTOR _ PMD/ER START!/ TIME 10-22 HOW CHOSEN: TOTA STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER ' WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCECOMPANY: 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 70 RESPONSE ZONE O YES ❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER—6 / EMT-1A Rcc,,./ e✓5 TECHNICIAN �f PARAMEDIC Hx: DISPATCH CHIS COMPLAINT: DRY RUN. YE ❑ NO REASON FOR DRY RUN qqq AUTHORIZA N FOR DRY RUN(EMS USE ONLY) q l !;,I., PATIENT REFUSED SERVICES: (SIGNATURE)X q_lylr MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: KAISER It: MULTIPLE PTS.BASE RATE BLUE CROSS N: M. S MILEKR1 MEDICARE N: TRIPO ONO (19: CCHP/PPRP N:;_-i CY MEDI-CAL M: i' ODE OTHER: ! ! N: (P P.O.E. STICKER O YES ❑ NOTAL: ) DATES BILLED: Y: ( .) E.K.G.: (PER EPISODE) —NEAREST RELATIVE/RESPONSIBLE 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) '--EMPLOYER! OCCUPATION: OTHER: - ADDRESS: CITY: STATE• ZIP: '^COMMENTS: -- TOTAL• ✓— ' PATIENT RECEIVED BY: X_ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE:.__` _ ,y a � ATIENTS NAME" ►L' � 1-�` -m ❑ F COMPANY M I 1 ISI4fJ ) � . ADDRESS AGE _ I j CITYyc [� STATE e 'a zip DOB�IV y 5 13 S ❑ M ❑ T ❑ W '❑ Th ❑ F` (9 S i DRIVER'S LICENSE M — _ — PHONE _ - -- NATURE OF DISPATCH_`)r S�/ T!? (L)F C TYPE OF TRANSPORT: AMBULANCE0 OTHER 11 (STATION 1(A) L2(B)-3(C)._4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) ` T}� TO SCENE- ❑ S.O. ___. CALL RECEIVED t f c.. ❑ P.U. - TIME 1(-B PATIENT DESTINATION: Q�1C�- FROM SCENE- ❑ FIRE __ TIME 10-97 tiLL t/ k, , - 1 TIME 10 49 I '� I ' MILEAGE: OTHER/PVT_ TIME 10-7 - END TIME 10-98 DOCTOR } �T .��'�' _ PMD/ER START � TIME 10-22 . HOW CHOSEN: TAL STANDBY TIME O NEAREST ❑ FAMILYtI TRANSFER I+ , , r WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ( CALL BACK N: AMBULANCE COMPANY: BULATORY? PAT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ NO WAL'<ED'❑ GUERNEY ❑ OTHER + PATIENT CONDITION: DRIVER tA / �_` EMT-1A X , TECHNICIAN PARAMEDIC i Hx: DISPATCHER + CHIEF COMPLAINT: No f C DRY RUN: ❑ YES NO REASON FOR DRY RUN / P N u C"::C�\ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES(m NO IVO. OF PATIENTS: I� ' S.S. I► �---- PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE �BLU SS W TOTAL MILES: X (� ,14 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO } ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: 1 dtE -t>TFALit� C�7` C�3 " M � �Sr CODE'2/3 \O OXYGEN: (PER TANK) Q.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) j ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) i CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN. (AUTHORIZED) j EMPLOYER: OCCUPATION: OTHER: "ADDRESS: CITY- STATE: ZIP: COMMENTS: - - - 58 TOTAL:__-c_._._-!----- -_• -- -- - -------- PATIENT RECEIVED BY: X !r. !r• ;a. (SII3NATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION (p C CHECK OR FILL IN AP OPHIAIE SPACES DATE: 'F'ATIENTS NAME ❑ M ❑ F COMPANY ADDRESS AGE— CITY GE CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F 11 S DRIVER'S LICENSE N _ PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION 1(A)_j't'I(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: 1 C, RESPONSE CODE: 201ESTED BY. TIME-(24 HOUR CLOCK) TO SCENE ��S.O. CALL RECEIVED C V 3Cl_/lam ❑ P.D. TIME 10-8 :(�— PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 T- ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10.98 DOCTOR PMD/ER STARTTIME 10-22 r / HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5(,) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER b S UEMT-1A TECHNICIAN I7P� Di1 ihE'r^© PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: 8�4ES ❑ NO REASON FOR DRY RUN PeC urt 1 yI AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X !� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # 1 PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X } MEDICARE K: E.O.B.ATT. ROUND TRIP: 0 YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER ❑ 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.___. ry...•1,.. (SfONATURF) it I CONT;t COSTA COUNTY AMBULANCE p� ?RE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 33 66j9 CHECK OR FIL, IN APPROPRIA*E SPACES DATE: PATIENT'SNAP.IL < { ►1E�_____._.-','_____- 0M ❑ F COMPANY# ADDRESS _ jID.----�e5r7� -,(JcZ — �D—_. - - (AGE — ( I CITY 2o---------_ STATE .__� _— ZIP-3`-�� _ DOB-L ���5_ 11Sn 11M 1:1T ❑ W ❑ Th ❑ F'/'p�S DRIVER'S LICENSE# SC- J- _ PHONE . _.._.,..- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE �S] OTHER❑ INCIDENT l_OCATIO( RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CJ,OCK) r I TO SCENE- ? S.O. _ CALL RECEIVED G1 f _�_ _ -t��.tfU'�---���17.._-��CF4 ------✓ P.D. _ TIME 10-8 PATIENT DES`rINATION: FROM SCENE- ❑ FIRE TIME 10-97 425 .: 27 1 Z ❑ PSAP TIME 10-49 9 MILEAGE: ❑ OTHER/PVT TIME 10-7 / 1 1 END . /7L TIME 10-98 DOCTOR __—kl ��z,___ PM START_LZ__7__ TIME 10-22 HOW CHOSEN: ----�� TOjAL. _Z STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �1/ CALL BACK#: AMBULANCE COMPANx PT AMBULATORY') PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1 ❑ YES ❑ NO ❑ Vd i :ED xGUERNEY ❑ OTHER PATIENT CONDITION. DRIVER_ -'� C) E - TECHNICIAN ARAM Hx: cam' ?tS� DISPATCHER: � - -- - � L CHIEF COMPLAINT: t _ RUN: ❑ YES NO REASON.FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) I ; MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. # -- ------- -- /� PRIVATE INS. CO. .- _ BASE RATE: 30•� KAISER #: _. MULTIPLE PTS. BASE RATE E� BLUE CROSS.#:- - TOTAL MILES: �� X '50 MEDICARE#: __.- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO \ ❑ YES ❑ NO NIGHT: (19:00-07:00) l ) CCHP;PPHP#:�. _-_ - EMERGENCY RUN: Q� \ MEDI-CAL'++:__. _ CODE 2�3 OTHER )Ul, �/� OXYGEN: (PERTANK) P.O.E. STICKER G YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_._ __ _"-__-____ _ ._ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIEl:.E PARTY: I.V- (PER ADMIN.) X �/ DRUGS: (PER ADMIN.) X NAME JN C.V-VALt/l. RELATIONSHIP:51�?'11.._. E.O.A.: (IF NOT REPLACED) ADDRESS: ._- ORAL AIRWAY: (IF NOT REPLACED) CITY_ _._._ �,_ _ STATE____ZIP:___- GCOLLAR: (If NOT REPLACED) PHONE ._. -__ WORK PHONE—— _ DRY RUN: (AUTHORIZED) EMPLOYER.' ---.- OCCUPATION: _.-_- OTHER: ADDRESS: CITY:-------- STATE: ZIP:_-_ COMMENTS: __ _ -- ---- - -"- d ----- ---- --- ---. TOTAL: y T U0360 PATIENT RF.CFIVF7 RV X �>~- CON A COSTA COUNTY AMBULANCE 6 PRE-HO PITAL CARE FORM I UNIT ((�_� AUTHORIZATION#1 7z 6w CHECK OR FILL IN WROPRIArE spApEs PATE: ` PATIENTS NAME: ' O M O F COMPANY 0 ADDRESS., - AGE C Q X _,C U .° CITY STATEZIP DOB P(Sn ❑ M O T ❑ W -13 3 Th O F ❑ S- DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH I_T� TYPE OF TRANSPORT: AMBULANCE 0 /OTHER - STATION 1(A)._.2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: --- I CJI RESPONSE CODE: REQUESTED BY:_ TIME- (24 HOUR CLOCK) r) Nod TO SCENE- KS.O. CALL RECEIVEDP.D. TIME 10-8 U ; ATIENT DESTINATION. FROM SCENE ❑ FIRE TIME 10-97 L'r Q� , f) 1 ,( ❑ PSAP TIME 10-49 -•r •. MILEAGE: 13OTHER/PVT TIME 10.7 1 — END TIME 10-98 R'DOCTOii I ) PMD/ER START TIME 10-22 < < HOW CHOSEN: TOTAL STANDBY TIME . a",l j O NEAREST, O FAMILY ❑ TRANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK F: AMBULANCE QOM PANY: L IN PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER L''u EMT-IA TECHNICIAN r PARAMEDIC Hx: DISPATCHER: I- nn(,, CHIEF COMPLAINT: DRY RUN: YES •P NO REASON FOR DRY RUN DC-r. Cldif AUTHORI TION FOR DRY RUN(EMS USE ONLY) j PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N I PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE r BLUE CROSS#: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 OTHER: ' OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '-NEAREST RELATIVE/RESPONSIBLE ARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: R �ATIONSHIP: 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: COM NTS:__nn / r C e ) t7- 1 TOTAL: '�J- 0036 PATIENT RECEIVED BY: X I.. CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM 1 UNIT P ) AUTHORIZATIONr# _1b2Z 7 CHECK OR FILL M APPROPRIATE SPACES DATE: ( / J/ PATIENTS NAME X11�/ R U/ �' ❑ M ❑ F COMPANY A y� • ADDRESS AGE� L�� CITY STATE ZIP DOB Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCHAvn COL L OV FQ - �fl TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ c..�P T 'J/-o IB INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME•-- (24 HOUR CLOCK) TO SCENE- 3S.O. CALL RECEIVED ' MAc U olvAcy n f` KAN1P P.D. TIME toe PATIENT DESTINATION: P90M SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 V MILEA ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10.22 L HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK A: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE- ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER WILLIAMr t��r EMT-1A TECHNICIAN LfFN62#4 41 a` Pa nic Hz: DISPATCHER / CHIEF COMPLAINT: DRY RUN: YE ❑ NO REASON FOR DRY RUN pr- C •U. A. i /rj V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ) / PATIENT REFUSED SERVICES: (SIGNATURE) X q 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS. S.S. a I 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 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY. X . ' rl,.., r,•.. r rr r:.: .... ---- -- ` (SIGNATURE) Z CONTRA COSTA COUNTY AMBULANCE �''� PRE-HOSPITAL CARE FORM I UNIT (7-1 AUTHORIZATION N U v m2 CHECK OR FILL IN APPROPRIATE SPACES DATE; III PATI.ENT'S NAME1Jd7c1ir--_�� q) ❑ W1 F COMPANY N ! 7 ADDRESS —f] �- C �_�Qc'�^k AGE CITY_ ,•if L4 STATE `_ ZIP/�L�7 �` _ DOB/- >ia-Sn ❑ M ❑ T /❑W O TA ❑ F Cl S- DRIVER'S LICENSE K ___ _ PHON&`L_L�___._�_ NATURE OF DISPATCH— TYPEOF TRANSPORT: AMBULANCE-1 OTHER❑ _ STATION 1(A)_2(8)_3(CI 4(D)_5(E)�-.- . I (DENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) �) TO SCENE- NO S.O. CALL RECEIVED + W l- � ��' f _.••/1�� r/'. 1. . c/ ❑ P.D. TIME 10-8 / :;2 v PATIENT DESTINATION- FROM SCENE -� n- FIRETIME 10-97 - rr c r� O PSAP TIME 10-49 MILEAGt:, r OTHER/PVT TIME 10-7 � • END TW1E 10-98 DOCTORPMD STAR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER i WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ] CALL BACK N: AMBULANCEOMPANY: -- , PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: r �' RESPONSE ZONE�T_ ❑ YES NO ❑ WAL"ED ❑ GUERNEY,-O OTHER PATIENT CONDITION: DRIVER f n^ EMT-1A TECHNICIC PARAMEDIC��' Hx: DISPATCHER: ? �' ' 0 CHIEF COMPLAINT: M 0 T� - /O( � DRY RUN: ❑ YES tir NO REASON FOR DRY RUN /))^7�`!'►Sr ii+s ?^i 0,Fr17 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X___ " MEDICAL COY �Gf, / � DUSTRIAL ❑ YES NO NO. OF PATIENTSr�-FF ?� S.S. K `> _ i lIJ 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 UU ❑ YES ❑ NO NIGHT: 119:00-07:00) ,�r?•.�D ,+ T-r CCHP/PPHP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 ,?• TCJ,, `� -- - OTHER: OXYGEN: (PER TANK) /0(o ..?T P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBA a3 a 7,j DATES BILLED: STANDBY: (OVER 15 IN. A-v. � E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �. r�� , DRUGS: (PER ADMIN.) X NAME:L~u, � 1✓/�1'�j / -'� RELATIONSHIP 6P'E 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: .�ice/ '�/� I S.Da �c CITY: STATE: ZIP: COMMENTS: TOTAL: �� n�" PATIENT RECEIVED BY: X P.r•^Vidrr Into' VIc r.? r.. •.. r... .. ., - ,. (SIGNATURE) [MS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM"I UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: �s 83 PATIENT'S NAME�_L�IL�w��C?��/, �d�Z i� RM ❑ F COMPANY k ADDRESS �IU<E./©e_A AGE Q ly q- CITY_RLQd STATE I CA ZIP�7 .7 DOB_1 �L8 g S� ❑ M ❑ T ❑`W ❑ Th 0 F O S DRIVER'S LICENSE q __ PHONE ��� 7O NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE®. OTHER❑ __ -- STATION 1(A)_2(B)_3(C)_4(D)_51E)_ - INCIDENT LOCATION: 1 RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLrOCK) ��/ TO SCENE- 18S.O. CALL RECEIVED � o ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 17 7 r� ❑ PSAP TIME 10-49 � -1 P E c MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR __)(aT_jW-�EE SZ- PMD/ER START '_Z TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME EI PATIENT ❑ DIRECT. ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1d YES ❑ NO 9 WAL"ED ❑ GUERNEY ❑ OTHER P t0-1k1s�� PATIENT CONDITION: DRIVER �Q>My /(7 [MT-IA TECHNICIAN ��k-�d PARAMEDIC Hx: Efell A&AiWTDISPATCHER: CHIEF COMPLAINT: 'L!n(FQAI rD A-)fi O DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE:_ INDUSTRIAL ❑ YES ANO NO. OF PATIENTS: (7 �L1•.� -� ,.,)MEDICAL k S5 5 07 125057 PRIVATE INS. CO.: BASE RATE: lQ,� KAISER k: MULTIPLE PTS. BASE RATE -' I BLUE CROSS k: TOTAL MILES: X 0 MEDICARE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP k; EMERGENCY RUN`: �� .. 1 MEDI-CAL k: CODE 2 31 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,t0! k-) n�L'' C��� RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: /72-Cf r//A^- LpP- AJ' ORAL AIRWAY: (IF NOT REPLACED) CITY: 111C1 _ STATE M ZIP:9 �� C-COLLAR: (IF NOT REPLACED) PHONE: a'3�' �)3 WORK PHONE: DRY RUN:.(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ` ADDRESS: CITY: STATE:—ZIP:- COMMENTS: TATE: ZIP:COMMENTS: 4 TOTAL: S O ------ PATIENT -----PATIENT RECEIVED BY: yl/ PYbvidrr rrt� Lhdtr tJ: �'Ir: ,•�I•L .SErYIr 7r [.L• ^.9FY (SIGNATURE) r EHE when biI'ir(' DIS-1 CONTRA COSTA COUNTY AMBULANCE {� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N S? 16 J�S_ CHECK OF FILL INAPPROPRIATE SPACES , ! DATE: / PAT IENT'S NAME 0I.L �Ja IL t.�. -__,-.___ O M jF COMPANY k 1/ 3 ADDRESS --!� 5--- r►�1 �15� N ------. - AGE-1-'L--- XSn CITY--WC..____ —.__ STATE__C.A.__— ZIP—____-.—.—_—. DOBL_� 1-� n ❑ M ❑ T OW O Th OF OS DRIVER'S LICENSE q _._ _- _-___. PHON U�rcNJ ..— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE THER❑ _ . ___ .___- .. INCIDENT LOCATION: 8A SS RESPONSE CODE: R VESTED BY:, TIME— (24 HOUR CLACK) TO SCENE - ? O. — CALL RECEIVED L� {�� _SL,a (__r��orJ N�`�- ❑ P.U. TIME 10-8 lQ_ PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 : O ❑ PSAP TIME 10-49 : Z MILEAGE ❑ OTHER/PVT TIME 10-7 'Q END_- -7 TIME 10-98 1_L DOCTOR - U�1rJS_� PMD ER START W- S TIME 10-22 HOW CHOSEN: TOTAL _-L`t STANDBY TIME ❑ NEAREST ❑ FAMILY Cl TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT Cl OTHER I 7._ CALL BACK M: ArULF+ANCE COMPANY: _ PT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE , YES Cl NO ❑ W,CL':ED GUERNEY ❑ OTHER PATIENT CONDITION: _ l 1 DRIVER1 �2 EMT-11A lSu,<X-C Bo o'JL`N TECHNICIANPARAMEDIC J Hx: - _ .Y._N_j. - ._ _ ..-- - -- .QIDc �C - DISPATCHER: U CHIEF COMPLAINTDRY RUN: ❑ YES REASON FOR DRY RUN l ; AUTHORIZATION OR DRY RUN (EMS USE ONLY) O PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES Ir NO. OF PATIENTS: -�. IC S.S. -- PRIVATE INS. CO.:— H-aSbr rro S BASE RATE: KAISER n: 1`1 , -CQ CS MULTIPLE PTS. BASE RATE LUE CROSS a _$��t - S 1' 1 �A O TOTAL MILES: 2 X .—soHT IJ•(Ja MEDICARE 7^-z-1=�1 i 7 —_ JE O.B. ATT. ROUND TRIP: ❑ YES ❑ NO bit CA20 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP s; _ _ EMERGENCY RUN: 3O UbOC' MEDI-CAL u: -- CODE 2/3 LSI nit^ OTHER: - OXYGEN: (PER-TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) /� DATES BILLED:_ _-- _- STANDBY: (OVER 15 MIN.) M, /� ,O/ l E.K.G: (PER EPISODE) (n) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ^n D DRUGS: (PER ADMIN.) X NAME FLt.t-Y_J.'.`dt"K RELATIONSHI P! E.O.A.: (IF NOT REPLACED) - ADDRESS: a_ RGG1V�l.tl.� �.__- ____ ORAL AIRWAY: (IF NOT REPLACED) CITY: -- M••��UO-A�rfi` STATE.- ____.ZIP:_.. C-COLLAR: (IF NOT REPLACED) PHONE __.J.�b=�_lE. WORK PHONE _ _.__ __ DRY RUN. (AUTHORIZED) EMPLOYER �. ___.. __..- OCCUPATION _._ _ OTHER: ADDRESS: --- -- --------- -- - ,���/D�C2 /S•UD&r CITY:-_----.- -- STATE:___---ZIP:- - -- COMMENTS:_-; ----- -- ------ - -- ---- ------- --- TOTAL'4mg! PATIENT RECEIVED BY:X ty .I;,+. • rr1: _ (SIGNATURE) • •.w.._ I:1':,.: DIS-1 CONTRA COSTA COUNTY AM13U CE 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATEIL: PATIENT'l NA �11 Lt i`� l ,_� ' {�S- � ❑ M a+ COMPANY N � 2, � :3� .. .I ADDRESS -% tl _' r-_, AGE�— y �.1 CITY_*, - STATE'n ZIP _ DOB_L–)`�__ Sn ❑ M OT ❑ W ❑ Th ❑ F ❑S` ' DRIVER'S LICENSE N ___.._-.. ____.__ _.F_ __.-� PHONE7_:5":5 lq 7 NATURE OF DISPATCHS `■M L1,7�',U.�S- TYPE OF TRANSPORT: AMBULANCE 1p'OTHER❑ __ _ STATION l(A)_21B)_3(C)_j,_/4(D)_51E)_' INCIDENT LOCATION: RESPONSE CODE: REOKSTED BY: TIME- (24 HOUR C CK) r _j TO SCENE Q S.O.— CALL RECEIVED i l.. ( 1:;1–��(J 1:5 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 n - ❑ PSAP TIME 10-49 O !) MILEAG ❑ OTHER/PVT TIME 10-7 : '^ � i � END__L�.'�5.�� TIME 16-98 . DOCTOR"- ' – , P M D% START39 '1_ TIME 10-22 HOW CHOSEN: TOTAL -3 STANDBY TIME g--NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AM ULANCE COMPANY: PT. AMBULATDAY? PATIENT TAKEN TP?�MBULANCE: �'7 RESPONSE ZONES ❑ YES U.1440 O WAL':ED p GUERNEY ❑ OTHER PATIENT gONDITION: DRIVER_ L EMT-1A } L TECHNICIAN , PARAMEDIC 1 HX. 1 ' n( 1 DISPATCHER: ,) ] CHIEF COMPLAINT: ���1 DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN J Cl / I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) iATIENT REFUSED SERVICES: (SIGNATURE) X— ( ' MEDICAL COVERAGE: INDUSTRIAL 11 YES NO NO. OF PATIENTS: ,�•��C S.S N I ._... PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE c BLUE CROSS N: TOTAL MILES: t X •-C� �2� CZ MEDICAR N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES [IN 0 NIGHT: (19:00-07:00) CCHP/PP P N: EMERGENCY RU © - 0,6 MEDT-CA N: CODE 2/I 4 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILI LED: STANDBY: (OVER 15 MIN.) ( , E.K.G.: (PER EPISODE) NEAREST:PELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X J DRUGS: (PER ADMIN.) X NAME: ` 1�'_L�L,]�� EL T.ImNSHI� E.O.A.: (IF NOT REPLACED) ADDRESS: t.�'� )` ORAL AIRWAY: (IF NOT REPLACED) CITY: �- _ STAT •ZIP'. '' ( C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHON y DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: - OTHER: ADDRESS: CITY: STATE:—.ZIP:— COMMENTS: TATE: .ZIP:COMMENTS: TOTAL •10 PATIENT RECEIVED BY:X Ptrvidr� »r r.'- Ftir•r _ran - n irr,T !'. R•^ ..Lr� t:, :n.7 (SIGNATURE) QIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N n 3' IG 2GG Q CHECK OR FILL IN APPROPRIATE SPACES DATE:- -1 -1 k--a -) PATIENT'S NAME_._C a.:�Crl:�.-� % C" �.C_'hc_r-_( �M ❑ F COMPANY p ADDRESS —tL�.���---) -1___._----- -- AGE. 3-7 D I ' CITY-__/•'_�L_/_LSTATE ZIP___ DOB..,faL7-14 'O Sn ❑ M ❑ T ❑ W ❑ Th ❑ F O I DRIVER'S LICENSE u PHONE,.. -� '...'.i__. -�_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCES OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOURC OCK)� TO SCENE- H S.O. — CALL RECEIVED ---- �- -- ---r-- -- -- - ❑ P.U. TIME 10-8 L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 21 ❑ PSAP TIME 10-49 t :QLZ MILEAGE: Cl OTHER/PVT TIME 10-7 Q END_- .�I _s_. TIME 10-98 DOCTOR _-1_<s �.�.�r_--- PMD/,C START—_<LCY TIME 10-22 HOW CHOSEN: TOTAL _ _ STANDBY TIME E NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. RESPONSE ZONE $ YES ❑ NO 0 WAL',ED ;ZGUERNEY ❑ OTHER J PATIENT CONDITION: DRIVER___..0 -�J�at �•r1•'� -� �? EMT-1A TECHNICIAN 00 PARAMEDIC �Tl Hx: _____� 1� DISPATCHER: '!'.� (" n_ S j CHIEF COMPLAINT: _.S-�_� v-_�' ___ 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 of -- PRIVATE INS. CO. ___ BASE RATE: _L�Q—_m_ , KAISER 4: MULTIPLE PTS. BASE RATE I BLUE CROSS q —._—-_ _____- __`__— TOTAL MILES: X (o.d0 /9•�� MEDICARE a: ____. E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO I 1 ! ❑ YES ❑ NO NIGHT: (19.00-07:00) �� 05 CCHP/PPHP C `-- EMERGENCY RUN: 2lo6 / MEDI-CAL#: CODE 2/3�) L OTHER - OXYGEN: (PEi TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) DATES BI(LED:-_--.___ STANDBY: (OVER 15 MIN.) \ E.K.G.: (PER EPISODE) NEARESTIELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r 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:} �-c�i:.sei�=fo r �.�1 Ao.B -- ------------- -----— TOTAL:1i _ PATIENT RECEIVED BY:X 0 0 36.7/= (SIGNATURE)EI y .. (. 1 U as-1 CONTRA COSTA COUNTY AMBULANCE x PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION# > CHECK ON FILL INAPPROPRIATE SPACES DATE: > 1PATIENTS NAME-E u— J I T 1AQ nQ ❑ M RF COMPANY K ADDRESS IST`�1 AGE 2- ( t 1 = Lr J CITY 1 Ll 94 2 )V-� -�iZ c O ❑ ❑ ❑ ❑ O . STATE � ZIP DOB Sn M T W Th F S 4) DRIVER'S LICENSE# _ PHONE `l 3 C NATURE QF DISPATCH t TYPE OF TRANSPORT: AMBULANCEA'_OTHER O �� STATION 1(A)_2(8)_3(C),�r4(D)_5(E)_. RR INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR C pCK) c TO SCENE- 7S.O. CALL RECEIVED � � t` )`Zil Loi /4271210 P M O PD TIME 10-8 I {� PATIENT DESTINATION: FROM SCENE--7 ❑ FIRE TIME 10-97 f _ !� ❑ PSAP TIME 10.491 _ : 3�5I' MILEAGE: 13OTHER/PVT TIME 10-7 1 C : `'C END -s TIME 10-98 ;:"DOCTOR.._ U�� PMDER STARTlLC, TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME I `•?> ❑ NEAREST PCFAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER K CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j ( RESPONSE ZONE ❑ YES b NO ❑ WALKED [�)1-6UERNEY ❑OTHER PATIENT CONDITION: DRIVER CEMT-1A TECHNICIAN— T Z PARAMEDIC i Hx: L DISPATCHER: Li , CHIEF COMPLAINT: -t J 141I DRY RUN: ❑ YES ;�JO REASON FOR DRY RUN lit V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) t PATIENT REFUSED SERVICES: (SIGNATURE) X r.' i MEDICAL COVERAGE: INDUSTRIAL OYES NO NO. OF PATIENTS: S.S.# SS-2 PRIVATE INS. CO.: BASE RATE: lt_ ! KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X �• } •0� �. 1 MEDICARE#: ��Z—O c/-(]SSD A E.O.B. ATT. ROUND TRIP: ❑ YES 9,NO i 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) I' �J CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/( OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES '(NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) " �•- E.K.G.: (PER EPISODE) }v W --NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ,1T C L1 DRUGS: (PER ADMIN.) X -- NAME: (AKA (-, RELATIONSHIP: '• E.O.A.: (IF NOT REPLACED) ADDRESS: ,r l ORAL AIRWAY: (IF NOT REPLACED) -CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) --EMPLOYER: �22A,Col) OCCUPATION: OTHER: ADDRESS:— _,l; i LSO CITY:_ STATF; 7 D: ' `•00 COMMENTS: TOTAL D —_ PATIENT RECEIVED BY. X Providir Ivtai� 1'hitu end 1inA ropy koturn N'1�61 •,,,.y t • W': when bit ink (SIGNATURE) _..r__1w_-_. . . . . ... 003 1 `lam- CONTRA COSTA COUNTY �1 AMBULANCE ..� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR F/LL IH APPROPRUTE SPACES DATE: PATIENT'S NAME /a _� t eM .❑ F COMPANY#r ADDRESS YnA�� AGE �� l ( I CITY W•` STATE — ZIP -L�_ D'OB!VI-�_l ❑ Sn ❑ T 13W�,,P Th ❑LIF EI S DRIVER'S LICENSE# ____._-_ _ _ PHONE RW O IDI- NATURE OF DISPATCH NCS i.tr ca—yr e� TYPE OF TRANSPORT: AMBULANCE OTHER❑ _- STATION 1(A)_2(B)_.3(C) (D)_5(E)_ . INCIDENT LOCATION: I ' RESPONSE CODE: RRE906TED BY: TIME- (24 HOURLACK) TO SCENE - G S.O. CALL RECEIVED (� �O O P.D. TIME 10 PATIENT DESTINATION: FROM SCENE- -� ❑ FIRE TIME 10-97 Q2 =_=k r _ ❑ PSAP TIME 10-49 MILEAGE- .� ❑ OTHER/PVT TIME 10-7 ` n END-- TIME 10-98 0 J : �" i DOCTOR,c PM E3) START�<_ TIME 10-22 HOW Cp6SEN: TOTAL STANDBY TIME ^ (P NEAREST O FAMILY O TRANSFER ` WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: A�BULAANCE COMPANY: — PT. AMBULATORY? PATIENT TAKEN Sf7 AMBULANCE: ,> RESPONSE ZONE -� ❑ YES NO ❑ WAL'<ED ¢1 GUERNEY ❑ OTHER (J /^ PATIENT CONDITION: DRIVER k3 v }2 EMT-1A TECHNICIAN PARAMEDIC Hx:c n^, DISPATCHER: ? CHIEF COMPLMNT�.A�; vnz_ DRY RUN: ❑ YES 1D<_o REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X - MEDICAL COVERAGE: INDUSTRIAL ❑ YES ® NO NO, OF PATIENTS: -h. S.S �w,^ �'' j PRIVATE INS. GO�k),Q� ' `7 BASE RATE: KAISER #: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X �¢ �U M DICARE#: E.O.B. ATT, ROUND TRIP: ❑ YES ❑ NO c ❑ YES ❑ NO NIGHT: (19:00-07:00) �•�D�" CCHP/PPRP k: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 n OTHER: OXYGEN: (PER TANK) 0.7 P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) y� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 0•6v 33 DRUGS: (PER ADMIN.) X _/,56Z) 45 GSD 30 NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) �9 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: 511COMMENTS: v TOTAL:�r "V TENT -IECEI\ED%X CONTRA COSTA COUNTY AMBULANCE 831 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATI N M CHECK OR FILL INAPPROPRIATE SPACES DATE: j PATIENT'S NAME ❑ M O F COMPANY M 1 ADDRESS AGE� CITY STATE ZIP DOB.— ❑ Sn ❑ T 13 W 13Th O F ❑ S I DRIVER'S LICENSE M _ PHONE __�— _ NATURE OF ISPATCH Q TYPE OF TRANSPORT: AMBULANCE❑ OTHER INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME— (24 HOUR CLOCK) t, TO SCENE- CALL RECEIVED /�(110-8 CCCr�1 C-T ❑ P.U. TIME 10 8 LCL_ PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 lo"1.Z IN G IS"rJA 0 •h MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 (� DOCTOR PMO/ER STAR TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COMPANY: CA5 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER p PATIENT CONDITION: DRIVER ) EMT j -1A TECHNICIAN___.4�Y NG �Q PARAMEDIC Hx: b � DISPATCH R. U ��J CHIEF COMPLAINT: _- DRY RUN: 0 NO REASON FOR DRY RUN l �1 AUTHORI TION FOR DRY RUN (EMS USE ONLY) Qqq PATIENT REFUSED SERVICES: (SIGNATURE) X- 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ` l S.S.>r PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE P S. BASE RATE BLUE CROSS M: TOTAL M ES: X MEDICARE#: E.O.B. ATT ROUN RIP: ❑ YES ❑ NO ❑ YES ❑ NO NIG : (19:00-07:00) CCHP/PPRP C E RGENCY RUN: MEDT-CAL k: CODE2/3/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑.YES 13 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: AL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C- LLAR: (IF NOT REPLACED) _ PHONE: WORK PHONE: DRY N: (AUTHORIZED) EMPLOYER: OCCUPATIO OTHER: ADDRESS: -. CITY: STAT ZIP:— COMMENTS: IP:COMMENTS -- - _------._._ TOTAL: , L1 __..._. PATIENT RFC;FIVFD BY X r���,LM T11RFl CONTRA COSTA COUNTY AMBULANCE /'I t� PRE-HOSPITAL CARE FORM I UNIT I AUTHORIZATION N (Oy r CHECK OR FILL IN APPROPRIATE SPACES - DATE: 1 -- •_ yPAT1ENT'S•N'AAE ( ❑ M ❑ F COMPANY n /1DDRESS.. _ ' AGE-L` CITY STATE----. ZIP DOB_ ____ ❑ Sn !(M O T ❑ W ❑ Th ❑ F Os DRIVER'S LICENSE M PHONE ----.---T NATURE OF DISPATCH O" Dnoir r TYPE OF TRANSPORT:, AMBULANCE QTHERO _ . STATION 1(A)_2(B)_-3(C)Y4(D)_5(E)_ INCIDENT.LOCATION ~� I r'' j RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) , TO SCENE- W S.O. CALL RECEIVED '/_u ❑ P.D. TIME 10-8 _'L/ i . . PATIENT DESTINATION: -- FROM SCENE O FIRE TIME 10-97 �j O PSAP TIME 10-49 - C. MILEAGE: ❑ OTHER/PVT TIME 10-7 v l END TIME 10-96 1 PMD/ER, START' TIME 10-22 r f L . HOW CHOSEN: ,_. ... TOTAL STANDBY TIME 0 NEAREST, O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT 0 DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY �S t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE s O. YES.,,O NO 4 '❑ WALKED ❑ GUERNEY ❑,OTHER / ? {� PATIENT CONDITION: DRIVER LIf.�T.41 U EMT-1A 'U.Tau7• r. - i _L;,,. f___ TECHNICIAN PARAMEDIC Hx: ---- DISPATCHER: S���� J (10 �f CHIEF COMPLAINT: if G L �� P DRYRUN: (�cYES 13 NO REASON FOR DRY RUN /D " AUTHORIZATION FOR DRY RUN(EMS USE ONLY) tJi;� PATIENT REFUSED SERVICES:(SIGNATURE) X 5;L- MEDICAL COVERAGE: .__ INDUSTRIAL 0 YES MAO NO.OF PATIENTS: ley- ) _. S.S. ,► PRIVATE INS.CO.: BASE RATE: I KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS 0 TOTAL MILES: X MEDICARE M: r E.O.B. ATT. ROUND TRIP: O YES Yl�IN0 O YES .0 NO NIGHT: (19:00-07:00) - CCHP/PPRP M.^ 7 r EMERGENCY RUN: MEDT-CAL 0: - I. .. CODE 2/(g> -I OTHER: OXYGEN; (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) `-NEAREST RELATIVE/RESPONSI E 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--CITY:• - STATE-_ZIP: C-COLLAR; (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: ADDRESS: —CITY:---- STATE• ZIP: COMMENT - - - TOTAL: PATIENT RECEIVED BY: X v " CONTRA COSTA COUNTY AMBULANCE f(� 2 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION a U 1 CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N I 'ADDRESS ' AGE _ CITY STATE ZIP DOB--_ .❑ Sn ❑ T OW ❑ Th ❑ F ❑ S DRIVER'S LICENSEN _ PHONE __—_.�-- NATURE OF DISPATCH MLS 1 G 14 L_ TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE TED BY: TIME— (24 HOUR CLOCK) I�\ TO SCENE� WL - S.O CALL RECEIVED l) T iL ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 A ti. 2 �,rt (fib ❑ PSAP TIME 10-49 -r - -}n - MILER 2 11OTNER/PVT TIME 10-7 s;� END TIME 10-987 DOCTOR PMD/ER START TIME 10-22 f y� HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBUUokNCE`COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALItED ❑ GUERNEY ❑ OTHER — — ie1 Z ;PATIENT CONDITION: DRIVER 1 \� '1 �T_1-Ql •�� EMT-lA w� ��b TECHNICIAN _�YNC � l U PARAMEDIC Hx: ,h Z_Z _ DISPATCHER: �� f U L'q q CHIEF COMPLAINT: RY RUN:)q YES ❑ NO REASON FOR DRY RUN 1 ! UTH ZATION FO RUN E ONLY) J �f PATIENT REFUSED SERVICES: (SIGNATURE) X f 1101 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. O 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. VRN IP: ❑ YES O ❑ YES ❑ NO :00-07:00) CCHP/PPRP C CY RUN MEDT-CAL N: E 2/OTHER: ( R TANK)P.O.E. STICKER ❑ YES ❑ NO (INCUBATOR)DATES BILLED: (OVER 15 MIN.)R EPISODE)NEAREST RELATIVE/RESPONSIBLE P\RELATI ADMIN.) X DRUGS: (PER ADMIN.) X NAME: HIP: E.O.A.: (IF NOT REPLACED) _ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ~ CITY:`- STATE— P: C-COLLAR: (IF NOT REPLACED) _PHONE: WORK PHON DRY RUN: (AUTHORIZED) EMPLOYER: OCC ATION: OTHER: ADDRESS: CITY: STATE:—ZIP:— COMMENTS: TATE: ZIP:COMMENTS: , •— ------- TOTAL:-.�- �'..__.._......... .____—. _ t" PATIENT RECEIVED BY: X ICIr.tiA��InFI l COtdTRA COSTA COUNTY I AMBULANCE F,`SE-HOSPITAL CARE FORM I UNIT / AUTHORIZATIGNM�`3� �7-3c�� CHECK OR FILL IN APPROPRIATE SPACES DATE; PATIENT'S NAt`^E ❑ M ❑ F COMPANY ADDRESS _ AGE ` v PJ CITY_ _ STATE_ ZIP DOB _ ❑ Sn D T 0 W –0 Th Cl F D S DRIVER'S LICENSE # —_ PHpNE_ _.— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCECI OTHER C;1/ _ STATION 1(A)_2(B)_3(C)4e�'4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: REgUtSTED BY: TIME– (24 HOUR CLOCK)d Com` TO SCENE- mls.O. CALL RECEIVED _ C3P.U. TIME 10-8 :0 - PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ : 1 r� ❑ PSAP TIME 10-49 ._1 vL +Z= _ MILEAGE\ ❑ OTHER/PVT TIME 10-7 1 END TIME 10-98 DOCTOR _ _� PMD/ER START---r� TIME 10-22 HOW CHOSEN: � TOTAL STANDBY TIME ❑ NEAREST ❑ t(ILY ❑ TRANSFER \ WAIT TIME ❑ PATIENT IRECT 13 OTHER CALL BACK#: A74LANCE COMPANY: PT. AMBUj AT SORY? PATIENT TA EfU�1J AMBULANCE: -� RESPONSE ZONE !.aS ❑ Y O ❑ WAL'(EDUERNEY ❑ OTHER PA IENT CONDITION: DRIVER 'ham ]'� �,� �'� EMT-1A TECHNICIAN\, o-��}� PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN (1} "AUTHORJZATION FOR DRY RUN(E;;--M��S-USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES q,N� 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/PPRP#: EMERGENCY RUN: MEDI-CAL#: 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/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: STA\TE: ZIP: COMMENTS: ,i TOTAL: PATIENT RECEIVED BY:X 00373- 1'r• r ret :'F,i t� ,• 'SIC NATURE) :va ..-�. 'r': ..:p EIS ' 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: ..__ i PATIENTS NAME J�` ❑ M OF COMPANY# `I 1 ADDRESS AGE CITY STATE ZIP DOB O Sn OT OW ❑ h Of OS. DRIVER'S LICENSE# __ PHONE ----- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ __. ! . INCIDENT LOCATION: RESPONSE CODE: UESTED BY: TIME= (24 HOUR CLOCK) . TO SCENE S.O. CALL RECEIVED 1 I _ ❑ P.D. TIME 10-6 PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBU ANJCE O ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER AIR �T ONDITION: DRIVER ()C MT-1A / ��/,�p.. TECHNICIAN PARAMEDIC Hx: '�' 1� —/u�/1/ DISPATCHE CHIEF COMPLAINT: DRY RU YES NO REASON FOR DRY RUN AUTHOR OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— ,J qcq MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. # ' PRIVATE INS: CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES O 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 O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) -� E:K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) —�8 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) Sp EMPLOYER: OCCUPATION: OTHER: "ADDRESS: CITY: STATE: ZIP: COMMENTS: _ TOTAL L00374 PATIENT RECEIVED BY: X (SIr:NATI IpF) CONTRA COSTA COUNTY �. AMBULANCE Q PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N S CHECK OR FILL IN"APPROPRIATE SPACES \ DATE: r PATIENT'S NAME WKM ❑ F COMPANY N f t AGE -� CITY Of- ADDRESS ``r_ STATE ` ZIP 2 YR-0 DOBA;!!C6_ �/ ❑ Sn ,M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N q� tIL—L" / PHONE ------ NATURE OF DISPATCH %4X t P1 V4.L [ - TYPE OFTRANSPORT: AMBUL.ANCEC) OTHER — — _-- STATION 1(A)_Lj(8)_3(C)_4(D)_5(E)_ -C_.., INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) �t / TO SCENE- - S.O. CALL RECEIVED 7 J G I ❑ P,a_____ TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �� (� / • ❑ PSAP TIME 14.49 T ) MILEAGE: ❑ OTHER/PVT TIME 10-7 END— ��' TIME 10-98 DOCTOR W I PMD R START. TIME 10-22 HOW CHOSEN: TOTAL , STANDBY TIME ❑ t4EAREST 13FAMILY 13TRANSFER WAIT TIME —_ ATIENT 13DIRECT ❑ OTHER CALL BACK p: AMBULANT C PfNY: �► 7 I KT.,T MBULATORY? PATIENT TAK O AMBULANCE: ) RESPONSE ZONE YES ❑ NO ❑ WAL'SED GUERNEY ❑ OTHER MNssc c,r i PATIENT CONDITION: DRIVER �--� � EMT-tA (� (� 5 �ctTECHNICIAN S Ir,i_p fe PARAMEDIC Hx. ucC�_14 O� DISPATCHER: CHIEF CO PLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVE E: INDUSTRIAL 11 YES NO NO. OF PATIENTS: �f s.S. N 4'' `1 _ !G 35 5 "PRIVATE INS.CO.: BASE RATE: KAISER C 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 A b� EMERGENCY RUN: -�)•��- MEDI-CAL N: CODE 2�3 _ I OTHER: OXYGEN: (PE TANK) -%'•'•`- 1J r P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) Jl E.K.G.: (PER EPISODE) 4AAEST RELATIVE/RESPONSIBLE PARTY: I.V.: (PEO 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- = may WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:—ZIP:— COMMENT TATE: ZIP:COMMENT TOTAL. - --- 00375 PATIENT RECEIVED BY. X.—. (SIGNATURE) tt• rr`•�^� i CONTRA COSTA COUNTY \ AMBULANCE `- PRE-HOSPITAL CARE FORM 1 UNIT (� AUTHORIZATION# 3 KJ U CHECK OR flt!INAPPROPRIATE SPACES DATE. IF PATIENT'S NAME � � _ COMPANY# AQ 1 tADDREyS �1r � 1� AGE I / 'Y CITY.._�L_l11l-�.!__ _�_�-I, STATE.— ❑ Sn M ❑ T qW ❑ Th OF n❑ S DRIVER'S LICENSE # _ .. ._ _. ....____._.__ PHONE__ 1_.- . ------ NATURE OF DISPATCH ^ TYPE OF TRANSPORT AMBULANCE OTHER❑ c INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- lr�s.a. CALL RECEIVED S "2 ❑ P.D. TIME 10-8 P� 7 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �.t — ❑ PSAP TIME 10-49 Y; _LL — MILEAGE: ❑ OTHER/PVT TIME 10•-7 L p _ J_ II ( ----- - END —� __��j TIME 10.98 :1 DOCTOR _ 1 1� -- PMD4R-) START_ va •spTIME 10-22 HOW CHOSEN: TOTAL - � I Q STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER f WAIT TIME _ PATIENT ❑ DIRECT ❑ OTHER ( '� % CALL BACK#: AMBULANCE COMPANY: n Lw AMBULATORY') PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL',ED GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER x ('� -ET1�A` _ `1 TECHNICIANS { _ PARAMEDIC Hx I`)l•�_ --- - DISPATCHER: _ L;^ h /y n =� q�IP INT { (��_ -- tDRY RUN: ❑ YES ANO REASON FOR DRY RUN ��• AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /PATIENT REFUSED SERVICES: (SIGNATURE).X MEDICAL COVERAGE: INDUSTRIAL ❑ YES,*NO NO. OF PATIENTS: S.S. PRIVATE INS. CO.: _ BASE RATE: KAISER #: MULTIPLE PTS. BASE RATE BLUE CROSS# __ TOTAL MILES:_ X 4—so / /•.5 MEDICARE #: __ _ E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �— CCHP/PPHP#: ,T EMERGENCY RUN: y511d1 �. r i MEDT-CAL#: V { CODE 2/;3 I OTHER:_.. —_-- OXYGEN: (PER TANK) p,.O.E STICKER ❑ YES NO NEONATAL: (INCUBATOR) DINES BILLED: _—_, STANDBY: (OVER 15 MIN.) E K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V: (PER ADMIN.) X DRUGS: (PER ADMIN.) X .NAME.__---__ _________.__-.— RELATIONSHIP: E O.A: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) .T. CITY. _ __ ____-.. - __. .. .__ STATE_..___ZIP:—_-._—. C-COLLAR: (IF NOT REPLACED) PHONE: -..___ ..___-_._ WORK PHONE __—__ __— DRY RUN: (AUTHORIZED) EMPLOYER: ._-.__. . _.-._..___.__ _.. OCCUPATION.------- OTHER: ADDRESS: CITY: ___ —_ STATE: ZIP: COMMENTS:—__ __- —.---- --__-- TOTAL:!_ [ �� PATIENT RECEIVED BY: X , IG A RE) /'nmi i. r.•t r• Ln:i(. .>'i . . . re r•n^ ��" ^n;ro ",' Ghon tit"ina i i 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ` UNIT 1-6 AUTHORIZATION N CHECK OR flLl IN APPROPRIA SPACES � DATE: '4TIENT'S NAME N O M O F COMPAN N o� 3 I ADDRE1 ., SS 1` � ' AGE lki CITY STATE j ZIP DOB O Sn '? M O T OW O ThO F OS DRIVER'S LICENSE N PHONE NATURE OF DISPATCH Rd/J'AA--e Lf TYPE OF TRANSPORT: AMBULANCE Q OTHER 0 STATION I(A)w218)_31C), 4(D),5(E)_ INCIDENT LOCATIOW: i f RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR COCK) I TO SCENE- O. CALL RECEIVED l, e ( 1/ �` 6P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENT . ❑ FIRE TIME 10.97 O PSAP TIME 10.49 `�` '� ( !`' `• I ( MILEAGE: O OTHER/PVT TIME 10-7 _r ENO TIME 10-98 OCTOR ' ) + PMD/ER START TIME 10.22 : HOW CHOSEN: TOTAL STANDBY TIME L>1'; ❑ NEAREST_'7 O FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANqf COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: I S� RESPONSE ZO , ❑ YES ❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER �''L QEMT-1A Irl 't1 ' L..;...__} TECHNICIAN �' ) PARAMEDIC Hx: DISPATCHER: _ CHIEF COMPLAINT: DRY RUN: YES' ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 2A PATIENT REFUSED SERVICES: (SIGNATURE) X ' [5Z MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: •`j _ S,S.N I I I PRIVATE INS. CO.: BASE RATE: KAISER N: t MULTIPLE PTS. BASE RATE ! BLUE CROSS C TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C �T EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN% (PER TANK) \J P.O.E. STICKER O YE ❑.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: W K PHONE* DRY RUN: (AUTHORIZED) ! -EMPLOYER: ' OCCUPATION: OTHER: ADDRESS: CITY: STATE• ZIP: COMMENTS: Y TOTAL• PATIENT RECEIVED BY: X. rSlRNA 11 mr) CONTRA COSTA COUNTY AMBULANCE $311 G 333 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 V t7 Dp Aj G - � CHECK OR TILL IN APPROPRIATE SPACES - DATE: w. GG 'PATIENTS NAME t ❑I M ❑ F COMPANY ADDRESS: AGE ' CITY STATE_��ZIP --DOB ❑ Sn KM O T O O Th 13 F O S r' r 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)_ INCI ENT LOVI �! RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED LJ CSU ww i ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE--;:)- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 , AH MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98CTORPMD/ER START TIME 10-22W CHOSEN: TOTAL ___J_ STANDBY TIME c.'!l: :❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME .. ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N; AMBULAN C MPANY: ; PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Lag❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER t ll PATIENT CONDITION: DRIVER �� V EMT-tA 1►Szf' J ± TECHNICIAN PARAMEDIC Hx: DISPATCHER: _ R j� CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUNlO z/wt C E V u - AUTHORIZ TION FOR DRY RUN(EMS USE ONLY) � y�I ` C�C Vii.:..:'. - PATIENT REFUSED SERVICES:(SIGNATURE) X l ✓ Z 77-7 MEDICAL COVERAGE: _ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N �C - � ' i PRIVATE INS.CO.: BASE RATE: KAISER N: 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 N:" EMERGENCY RUN: MEDI-CAL N: CODE 2/3 G� OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 13 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,. STATE ZIP: C-COLLAR; (IF NOT REPLACED) PHONE: WOR PHONE: DRY RUN: (AUTHORIZED) —EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: - - - TOTAL: - 7 8 PATIENT RECEIVED BY: X , f'r.midtrt• rvtnjc Vhita •r.l hi•:: •. f•� 4•r .- ,„ ',. (SIGNATURE) .. I CONTRA COSTA COUNTY AMBUL CE t� 2 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N J CHECK OR FILL IN APPROPAIATE SPACES DATE: Qom/ PATIENTS NAME _ ❑ M O F COMPANY Mj1 ADDRESS AGE U ,` CITY STATE ZIP DOB ❑ Sn,><M ❑ T O W O Th ❑ F O S DRIVER'S LICENSt N _ PHONE _ NATURE OF DISPATCH ImE. TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ STATION 1(A)._ (B)_3(C)_4(D)_5(E)_ ( i INCIDENT LOCATION:~ /\>L' RESPONSE CODE: QUESTED BY: TIME— (24.HOURc CLOCK) TO SC E - � .0. CALL RECEIVED O P.D. TIME 1 0-8 ' I •� � , / PATIENT DEST TION. FROM ❑ FIRE TIME 10-97 111 11 10N./ TIME 10-49 �' )V (J ( MILEAGE: 13OTHER/PVT TIME 10-7 , — END TIME 10.98 \ ) DOCTOR ' PMD/ER STARTTIME 10-22 I I OW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK k: AMBUL/ C COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C,,iJ ) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER-- PATIENT THER`PATIENT CONDITION: DRIVER EMT-tA TECHNICIAN (-/= PARAMEDIC Hx: DISPATCHER: tl I I LI q CHIEF COMPLAINT: DRY RUN: 'YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 9q PATIENT RE SED 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/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/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) -tom PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X 00379 ,. ... ,.. (SIGNATURE) r CONTRA COSTA COUNTY AMBULANCE p1 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION ���� CHECK OR FILL IN APPROPRIATE SPACES vDATE; I ,Ab PATIENTS NAME 1yL - ❑ M ❑ F COMPANY ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M KT ❑ W ❑ Th ❑ F ❑S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH DI fE Q/1CAPI,v(, TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ — STATION 1(A�X2(8)_3(CI_4(DI_5(El— INCIDENT LOCATION: j RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- 3 S.O. CALL RECEIVED C'`� ( /J �V ( �E R b _ /)��� ; t ❑ P.D. TIME 10-8 "'--f— PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 Q�! ti () ❑ PSAP TIME 10.49 �'`1 ` I ` `' v MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 T- -=DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP NY: A S�' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S� RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LeAIV6AAM 5-1.0 EMT-tA Cry Z L' o T S TECHNICIAN lAl'1ttlAMf Z4 05 RA Hx: DISPATCHER: I n n 1`(? CHIEF COMPLAINT: DRY RU ❑ YE ❑ O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �y PATIENT REFUSED SERVICES: (SIGNATURE) X ` MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �1 S.S.N PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X A MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO /! ❑ YES ❑ NO NIGHT: (19:00-07:00) .CC HP/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 RELAT E/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: TATE: ZIP:COMMENTS: TOTAL: 0030 PATIENT RECEIVED BY: X IsIrMAT11nF� CONTRA COSTA COUNTY AMBULANCE 9'3 fl' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 9/ 3 �/ v 3 CHECK ON FILL IN APPgOPR ArE SPACES DATE: PATIENTS NAME- V N OM ❑ F COMPANY N Az ADDRESS AGE n \- CITY STATE ZIP DOB 0 Sn O M T^^OW 0 Th OF OS DRIVER'S LICENSE N ' PHONE NATURE OF DISPATCH Y OJ-r- O- ;V TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ -- STATION 1(A) 2(B)_3(C)-4(D)-5(E)._ INCIDENT-LOCATION:r I f RESPONSE C BY: TIME-(24 HOURC;LBCK)Z�� . D TO SCENE- S.O. CALL RECEIVED L� C, OA RSAw I -- FOUESTED P.D. TIME 10-8 .. EEG-G PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME 10-97 ^ I / ❑ PSAP TIME 10-49 MILEAGE: 0 OTHER/PVT TIME 10-7 i END TIME 10-98 DOCTOR ` PMD/ER START TIME 10-22 L :L _ HOW CHOSEN: TOTAL STANDBY TIME 0 NEAREST ❑ FAMILY O TRANSFER �a WAIT TIME 0 PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE y 0 YES 0 NO O WALKED 0 GUERNEY 0 OTHER PATIENT CONDITION: DRIVER L M 5 (r% EMT-lA TECHNICIAN /L f) RAA BIG Hx: 0 5 DISPATCHER: t CHIEF COMPLAINT: DRY RUN Y d.NO REASON FOR DRY RUN i'1 `I - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r, PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: " r S.S.N ,PRIME INS.CO.: BASE RATE: / KAISER N: MULTIPLE PTS.BASE RATE BLUE CROS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: 0 YES 0 NO O YES 0 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) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "NEAREST RELATI E/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) ^aa PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: \ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ TOTAL: ��✓ 00 38. 1 PATIENT RECEIVED BY: X r. ,,, +,• (9frNATURF) i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT -7V AUTHORIZATION kIL 3 �6syi CHECK OR FILL INAPPROPRIATE SPACES DATE: c% I WA f •G 3 PATIENT'S NAME L_Sru.0-C�. ❑ M &`F COMPANYtt C-YJS ADDRESS L\ L 10 S�_ AGE Ll C 0 1 H 44 , .5 ( !I 7 CITY �� - STATE ZIP DOB -X25"3� 13S ❑ M C240 w'❑ `Th '�O IF g DRIVER'S LICENSE tt ____.__.._._ —_. PHONE NATURE OF DISPATCH ^�k`� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) RESC t ` u TO SCENE- I9 S.O. CALL RECEIVED �� �...\OL�[)u�LJ ` " ❑ P.D. TIME 10-8 PATIENT DESTINATION FROM SCENE- I ❑ FIRE TIME 10-97 1 ,1 1 •, 7. ❑ PSAP TIME 10-49 MILEAGE ❑ OTHER/PVT TIME 10-7 _(L� t END I TIME 10-98%4 '.O1 R DOCTOR PMD/ER START_ TIME 10-22 HOW CHOSEN: TOTAL i STANDBY TIME 17 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CO PANY: k . PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: /0 RESPONSE ZONE YES 1:1 NO ❑ WAL'CED yroUERNEY ❑ OTHER + SrZ - I PATIENT CONDITION: DRIVER ' �1SS0� UUO j EMT-1A f I / _`O �n TECHNICIAN u A{� 48�ARAMEDIC Hx: _.S ` `� -_ l J DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN - AUTHORIZATION FOR DRY RUN(EMS USE ONLY)-; PATIENT REFUSED SERVICES: (SIGNATURE) X_ (j MEDICAL COV RAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 'S„" PRIVATE INS. CO.: BASE RATE: KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: 7 X 'L_ ti MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO )' : .,.q " ?'l.'��7 f ❑ YES ❑ NO NIGHT: (19:00-07:00) --7 CCHP/PPHP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) _ I DATES BILLED: STANDBY: •(OVER 15 MIN.) I, E.K.G-: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r T DRUGS: (PER ADMIN.) NAME:- F RELATIONSHIP: / E.O.A.: (IF NOT REPLACED) j ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: p�, WORK PHONE: DRY RUN:, (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: �`- 4� S I ADDRESS: CITY: STATE: ZIP:- COMMENTS: IP:COMMENTS: r TOTAL: �- Cl' 13 I. DD .�_.... PATIENT RECEIVED BY:X Q G3 8-2 s� Provider retuir, Vhitr crd Pin: ropg Aeturn Ye;Iow mpy t WS when biVing (SIGNATURE) DIS-I /1"10 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I 1(! UNIT AUTHORIZATION N a��- CHECK OR FILL INAPPROPRIATE SPACES DATE: Z/c>10/e3 •.��� t1 PATIENTS NAME t` _12e 1� 1 )CLQ-A�— O MDQ` COMPANY N r ADD S �I Vit t AG&,L Z 1•�_..., CITY w,Q�STATE�4=' ZIP C� (,)0,8��,Qj�?-❑ Sn O M T Ow ❑ Th .O F ❑8--, DRIVER'S LICENSE N Lc.t 1 �L-Z iZ PHONE v`0 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ - STATION 1(A)._2(B)_3(CI 4(D)-_5(E)_,.._.. .� INCIDENT LOCATION: RESPONSE CODE: REqZESTED BY: TIME- (24 HOUR CLO K) r�w_� Q ' TO SCENE- urS.O. CALL RECEIVED � e• ' �I II A � 1 ❑ P.O. TIME 10 8 i:� � p ?: fid PATIENT ESTIN ION: FROM SCENE- 11 FIRE FIRE TIME 10-97 : ���`� [3PSAP TIME 10-49 •.• : 1 ,:�.,�' V MILEAGE. �� 13OTHERIPVT TIME 10-7 v END.�s 9� TIME 10-98 DOCTOR PM /ER STARTS 1 _ TIME 10-22 �. HOW CHOSEN: TOTAL 1:3 -Q STANDBY TIME ❑ NE REST O FAMILY 11 TRANSFER WAIT TIME ATIENT ❑ DIRECT 13 OTHER n CAIS BACK N: AMBJ{LAACE COMPANY: 'w PT. BULATORY? PATIENT TAKEN TO AMBULANC . ^� �5 J^ RESPONSE ZONE �� ~� ES ❑ NO 13 WALKED ❑ GUERNEY ER `- , 1` Jt) PATIENT CONDITION: DRIVER_ , u1y��'� ) EMT-1A --I -� TECHNICIAN 1 '� -�? PARAMEDIC Hz: DISPATCHER: l ^ ^ CHIEF COMPLAINT: - DRY RUN: 13 YES NO REASON FOR DRY RUN �I �( y-4 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - PATIENT REFUSED SERVICES: (SIGNATURE) X - MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO.OF PATIENTS: �r�G S.s. N MVV Y2 W/la PRIVATE INS, CO.: BASE RATE: ZKAL)E ISE MULTIPLE PTS.BASE RATE CA DS TOTAL MILES:: - X � : RE N: E.O.B.ATT. ROUND TRIP: ❑ YES O-NNO `-�•"I ❑ YES ❑ NO NIGHT:(19:00-07:00 i�0 CCHP/PPRP N: EMERGENCY RUN: 3t7,t'Jv - - MEDI-CAL N: CODE 2/3 �y/• L OTHER: OXYGEN: (PER TANI -9 F- 75- P:O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOAh "'9S 2zr 1 DATES BELLED: STANDBY: (OVER 15 MIN. iyyG3J E.K.G.: (PER EPISODE) _ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: AMRv' e- RELATIONSHIP E.O.A.: IIF NOT REPLACED) ADDRESS: Q 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: QQ PATIENT RECEIVED BY:X - Provider t•et '. ISIGNI�lUAF) -+ ut. vtiit. ,rt r:-, PF •rr...• r.... .. .., ,., I .., Iw.E PATIENT'S NAHL•': Cristina Cerda ADDRESS: ry5p 1Rt_h_ct_ Richmond , Ca_ • :S DATE OF SERVICE: 09-20-83 }•�•. 4, AUTHORIZATION NUMBER:83-16386 AMOUNT DUE: $193.00 INCIDENT LOCATION: 558 18th st. Richmond PATIENT DESTINATION: Brookside Hospital t 'r . t r 00384 rte. t2�)2 3 r 1 ! �� ` f; ' �'1 35 r"I �,3 �'EP Z0 6 36 N 183 cn SO NUMBEF3/62j(z CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 -rnp w r CALLED BY- - --- -- -' - - PATIENT INFORMATION D o NAME: 3 — ------- -- — a2 23/bZ c Q? AGENCY: ,� CUSTOMF� p(PT. 1): ( D08: c- AGENCY: DEPT/FLOOR/ROOM #: _ NAME: t'.0 c-LCl )lL T t S+l n6 n O m a CALLBACK a _ INS. TYPE:QjD MCAR MCAT KHP PHP VA IND CHAMPUS ? `b ` s uj INCIDENT IOC: POLICY f MCAL p: 1 CI t3f 1 ��I n m r^f MCAR p: m W m CROSS STREET: LY_ 1- _ _ VERBAL PRIOR: o 14 a 1URIS: _ ity: - DOCTOR: ---- DESTINATI�_ _ Yom" _ PT. #2 NAME: DOB: NATURE: _�.!' CUST. R ; m _ PT. #3 NAME: DOB: c hl o Z G d TYPE OF CALL: G TRANS TIME UNIT#, CUST. a z n m w CREW: --SC==��- - � - - WAIT TIME: YES NO REASON: m !E 0Z UNIT TYPE:(o BIS WC RESPONSE CODE: 0 1 2 4 REASON FOR 10-22: p 3 a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0QQ1 3 4 CANCELLED BY: v BY: END MILEAGE: COMMENTS: p z CA a TIME: BEG MILEAGE: �l. g -1 W DISPATCHE 1a 9n, n{R spy > w a TOTAL MI V V 3 V V 4 p XZ-01 NOIIVIS IV 3JNv1f18Wv 61.01 ONINdnl38 3DNvinowv 86-01 31OVIlVAV 3JNV1f18Wv L-01 1V11dSOH 1V 3JNVlf18Wd L CZ d3s 3 CONTRA COSTA COUNTY AMBU CE / Q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION po, .,... . . a CNECK OR ALL INAPPROPRIATE SPACES ( DATE: ''PATIENTS f IR ❑ ki ❑ F COMPANY N _ ADDRESS, /'AGE` 1 `-'-O& ) CITY ST TE�Y.._ ZIP DOB O Sn OM ow Th F O-S l DRIVER'S LICENSE N - ! PHONE NATURE OF DISPATCH TYPEOF TRANSPORT:i AMBULANC OTHER❑ STATION 1(A)_2(8)_3(C)_.4(D)�51E__1,�i��j C`-p> IN DE T LOCATION: - RESPONSE CODE! REOUESTED BY: TIME- (24 HOUR CLOCK) nn TO SCENE- O. CALL RECEIVED :±- G ❑ P.D. TIME 10-8 3/7 PATIENT DESTINATION: - FROM SCENE- ❑ FIRE TIME 10-97 p ❑ OTHER/PVT TIME 10-49 R� yG.'.1� i 1 M LEAG ." ❑ OTHER/PVT TIME 10-7 D TIME 10-98 ^. DOC R P ER START TIME 10-22 ) HOW CHOSE TOTAL STANDBY TIME 13 NEAREST, FAMILY ❑ TRANSFER WAIT TIME 13 PATIENT E3 DIRECT 13 OTHER �/ . CALL BACK M: AMBULANCE C PA Y• PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5,/o RESPONSE ZONE . OYES "❑ NOj 13 WALKED ❑ GUERNEY ❑ OTHER' /� PATIENT CONDITION: DRIVER [C' EMT-1A TECHNICIAN Z�' ) ... . .. PARAMEDIC Hx: DISPATCHER: 7c i yp� . CHIEF COMPLAINT: ' DRY RUES 13NO REASON FOR DRY RUN " AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `S(7 ► ' �Nv i;.?.PATIENT R ERVICES: (SIGNATURE) X j MEDICAL COVERAGE: .__ ._ INDUSTRI O YES ❑ NO NO. OF PATIENTS: S.S.N i PRIVATE INS.CO.: BASE RATE: KAISER R; MULTIPLE PTS. BASE R BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: OYES ❑ NO _ O YES ❑ NO NIGHT: (19:00-07:00) i CCHP/PPRP#:,-, ' + EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: F' 1 OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPON BLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X --NAME: ' RELATIONSHIP: E.O.A.: (IF NOT REPLACED. ADDRESS: ORAL AIRWAY: (IF NOT EPLACED) "-"CITY: ,- STATE_ ZIP: C-COLLAR: (1F NOT REPLACED) PHONE: RNE: DRY RUN: (AUTHORIZED) -EMPLOYER: - �KPUHPO TION: OTHER: ADDRESS: CITY: STATE-.\-,, ZIP: , COMMENTS: - TOTAL: �Sd. fes-- PATIENT RECEIVEn fly x... -.- _ . CONTRA COSTA COUNTY AMBULANCE ., PRE-HOSPITAL CARE FORM IUNIT ' %- AUTHORIZACTION N ,(� ' �!d CHECK OR FILL M APPROPRIATE SPACES �V DATE: + c 0 -pD l ,OATIENrS NAME t,& Om YY F COMPANY M ADDR`E,�SS, `�V �.-f"1S 1 -`-�.'/Z� y� t� Q AGE YL_Z /j ' l� �� O O CITY "v 1 STATE CA ZIP 34x92 1_ DOB((����2V❑ S. O M X(T O W ❑ Th OF OS DRIVER'S LICENSE M - PHONE93'57 1�!�1 NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE MOTHER❑ - STATION 1(A)._,2(B).-3(C) 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: O STEO BY: CALL RECEIVED R CLOCK) RES 5 I/_,rte` l n STLE��K TO SCENE ❑ P.D. TIME 10-8 fel PATIENT DDEESTIIN-AATTION: G FROM SCENE- ❑ FIRE TIME 10-97 ` 1 Kl II 1_1 i 2- ❑ PSAP TIME 10-49 c3. Q�al t"1 1 ' ` MIL EAG ❑ OTHER/PVT TIME 10-7 1 END i TIME 1.0-98 DOCTOR ZEN NZ\AS PM R START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME �•=-- � NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— IVPATIENT ❑ DIRECT ❑ OTHER �J CALL BACK N: AMBULANCE COMPANY: -- C� PT. AMBU TORY? PATIENT TAKen O AMBULANCE: �� :I- RESPONSE ZONE 13 YES 91NO D WAIL<EOERNEY ❑ OTHER PATIENT CONDITION: DRIVER - tJ (/ ' EfdT-1A I��J1fS10 TECHNICIAN_ n RAMED P �— HK: DISPATCHER: /j CHIEF COMPLAINT: S. 01�. DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I�. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COV RAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N VA I L, PRIVATE INS. CO.: L F 6 0 02 BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r ❑ YES O NO NIGHT` (19:00-07:00) � ��� J CCHP/PPRP N: EMERGENCY RUN: 30-w MEDI-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) 00`'7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) Z E.K.G.: (PER EPISODE) U•GD i' NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �•v0 3 1 DRUGS: (PER ADMIN.) X NAME: '` RELATIONSHIP: V 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: OCCUPATION: OTHER: ADDRESS: �� �'d� •' CITY: STATE: ZIP: COMMENTS: _ 0 C? 3 1 — ------ -- TOTAL. /•�Q .�.._._... ._.,----- - _.. _. PATIENT RErEIVFD BY.X./. ` '-.. �. ' ( 'IA---- -`-- —_._I_.. lr r.•r. �ti_.�_.. •_-. -(51(�NAi(INfI T.�-__.__-• CONTRA COSTA COUNTY AMBULANCE Z.� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR PILL IM APPAOMATE 3PACE3 DATE: 3 'PATIENTS NAME .S.H, IFA r r3 -I O W7Z F COMPANY N ADORE S^;j� ,;2da - M�C �an o )C.�_ ► AGE _ CITY R STATEe-14... ZIP DOB t/.. ❑ Sn ❑ M-�T ❑W O Th OF OS -, -----* DRIVER'S LICENSE N PHONE_AH NATURE OF DISPATCH Z 4 2- It 1" If• TYPE OF TRANSPORT:'AMBULANCEA OTHER 0r — STATION 1(A)__Z1(B)_3(C)_4(D)_5(E)_ f / INCIDENT LOCATION:; I % RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK).. //�p 1 G h ,/ TO SCENE- Q'S.O. CALL RECEIVED 62 1 ID (, c'il r-,,� Gz C a a-M(2--;')j 3 O P.D. TIME 10-8 O �— FROM SCENE- FIRE TIME 10.97 - —L t� ' ell PATIENT DESTINATION: (�IC H M tl 4 �03 nalt.i 1 O PSAP TIME 10-49:r '-I3S��H _ MILEAGE:oZ 3, ❑ OTHER/PVT TIME 10-7 �= L _ END TIME 10.98 2, .L� $766dTOR t ':Srpa<^ _-+ PMD START 2Q.9 TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ("NEAREST; O FAMILY ❑ TRANSFER t / WAIT TIME O PATIENT O DIRECT ❑ OTHER i CALL BACK C AMBULANCE'CqM ANY: t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 ' RESPONSE ZONE� �rt, YES• ❑ NO. , ❑ WALKED k-;k13 OTHER I a�PATIENT CONDITION DRIVER .SG r t"P_ 1( e r �f 77 EMT-IA TECHNICIAN JE C, V 1 r PARAMEDIC'_ Hz: oz 'G + DISPATCHER: clo �5 CHIEF COMPLAINT: Q G k PC M' DRY RUN: O YES ANO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 80 3 : '•.•1 PATIENT REFUSED SERVICES:(SIGNATURE) X SYG MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: �'�_-y� S.S. N 't PRIVATE INS.CO.: BASE RATE: — KAISER K: + MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: N MEDICARE N" ! ' - E.O.B. ATT. ROUND TRIP: O YES O NO / , f O YES ❑ NO NIGHT: (19:00-07:00) !>7 CCHP/PPHP N? r r i EMERGENCY RUN: d' ad OG MEDI-CAL N: Pa. 5,1 '>u 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 1 L DRUGS: (PER ADMIN.) X ­NAME: TC 1%A- S M �7 "t RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) `- CITY: 11'r rc d-f S i&CSTATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 1226- 6 7 7 WORK PHONE: DRY RUN: (AUTHORIZED) —.EMPLOYER: OCCUPATION- OTHER: ADDRESS: --CITY: STATE: ZIP: -"COMMENTS:• - c3 8,o TOTAL: a-a4� UJ PATIENT RECEIVED BY: X J Pn+vfrl�r rvtaf: Vhrt• •rd nr.: ,� tSfONI1TURp) CONTRA COSTA COUNTY t AMBULANCE PRE-HOSPITAL CARE FORM I t i UNITAUTHORIZATION M � W 14 ou Q ` /-> , i _ oI ... CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 M 111 PATIENT'S NAME'�:/��.C,,�I .->>.1, -�C'�lC,-���k � ❑ F COMPANY ADDRESS AGE /�4 S.'�llf / �'.��r'��^��-' l f SCS— ll ` 35 CITYc. (►y�1� STATE `\ ` ZIP DOBC'2.( , a O Sn OM O T O W ❑ Th .I7 F 0 S DRIVER'S LICENSE q PHONE L_i/� NATURE OF DISPATCH S �� TYPE OF TRANSPORT: AMBULANCE VIOTHERO _ STATION 1(A)-_2(B)_3(CL..ZC4(0)_5(E)_�.. •. INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) 1 ) /". _ TO SCENE- 7 S.O. CALL RECEIVED _ 1�� :_5 . O P.D. TIME 10 B UO 7•� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �� / O PSAP TIME 10-49 e L I ( c` MILEAGE: O OTHER/PVT TIME 10-7 /11/ _ '!, END � TIME 10-98 -�.:-�`-L DOCTOR ( 430-C PMD(ER START TIME 10-22 - HOW CHOSEN: TOTAL / STANDBY TIME . O NEAREST O FAMILY . O TRANSFER WAIT TIME D PATIENT DIRECT ❑ OTHER -( rr� CALL BACK M: AMBULANCE COMPI Y,:� PT AMBULATORY? ATIENT TAKEN TO AMBULANCE: 5 RESPONSE ZONE YES ONO WAL'tED O GUERNEY ❑ OTHER - 1 PATIENT CONDITION: DRIVER C_ C �� �E?i�A.IMLTECHNICIAN ; '� rEDIC i + Hx: _ Sf•� DISPATCHER: r CHIEF COMPLAINT: ,tG+ic I--- 0t #-,j:U V'-C DRY RUN: ❑ YES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - PATIENT REFUSED SERVICES: (SIGNATURE) X I MEDICAL COV//ERAG� INDUSTRIAL O YES O NO NO. OF PATIENTS: f �." � S.S. k PRIVATE INS. CO.: L_ 7? �'� BASE RATE: o KAISER a: MULTIPLE PTS.BASE RATE BLUE CROSS s: TOTAL MILES: �� X 11'7.0-. MEDICARE k: E.O.B.ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) 0 '�_ CCHP/PPHP N: EMERGENCY'RUN: SZL � MEDI-CAL k: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) 1Y I n C,t( DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME L RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: 5-) ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE__ZIP' C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN:, (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ` TOTAL. - PATIENT RECEIVED BY:XqA 1 Pmvidrr reto:*. Whity ,-rI r•.r; (SIGNATURE) • C .-.�/`� Frt:.r Yv" ',-:1 '• rvr uhr� Ti 1'ino 0151 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION II O / ' r ML• ' CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME' �r x f �1 n , - ❑ !A ❑ F COMPANY 0 ADDRESS.• ^ T t ( AGE, 1 t.... ._ CITY STATE ZIP DOB E3Sn ❑ M ❑T eW 13Th 13F O S i DRIVER'S LICENSE N - - PHONE NATURE OF DISPATCH A '.•� TYPE OF TRANSPORT:11 AMBULANCEW OTHER❑ STATION I(A)_2(8)_3(C)-4(D)_5(E)_ r' INCIDENT LOCATION. 1 R:' RESPONSE CODE`. REE ESTED BY: TIME-(24 HOUR CLOCK) (� L TO SCENE- (5S.O. CALL RECEIVED G uZcP C Y. & US''1 V:m NN o0m. ❑ P.D. TIME 10-8 jLt� L- PATIENT DESTINATIO • ..-� FROM SCENE-„f O FIRE TIME 10-97 Z ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 TOOCTORly;T t' �` PMD/ER START TIME 10-22 cto HOW CHOSEN: TOTAL STANDBY TIME •:. O NEARESTI ,1 O FAMILY ❑ TRANSFER WAIT TIME E3 PATIENT 13 DIRECT O OTHER CALL BACK M: AMBULANCE_COMPANY: .. .! PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: LI RESPONSE ZONE ❑ YES. 0,NO r_. ❑ WALKED ❑ GUERNEY ❑ OTHER. PATIENT CONDITION. DRIVER �- 1 (� EM.T_-JAj TECHNICIAN f tN a ,`L RAMED i 9 Hx: DISPATCHER: ' 8�1CHIEF COMPLAINT: DRY RUN: ❑ YES leNO REASON FOR DRY RUN ' -- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) q7 ! 3.y.i .e PATIENT REFUSED SERVICES:(SIGNATURE) X i MEDICAL COVERAGE:._ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: +:t S.S. PRIVATE INS.CO.: t BASE RATE: KAISER K: ( MULTIPLE PTS. BASE RATE t• , BLUE CROSS M: ' TOTAL MILES: X .. MEDICARE 0. { E.O.B.ATT. ROUND TRIP: 13 YES 13NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:` ! EMERGENCY RUN: t MEDI-CAL N: 1 t' CODE 2/3 ii .•OTHER: ''t' t OXYGEN: (PER TANK) '�. P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) y=""-NEAREST-RELATIVE/RESPONSIBLE PARTY: - I.V.-. (PER ADMIN.) X - �• 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) i r'r•`.!^"EMPLOYER: - OCCUPATION: OTHER: ADDRESS: --CITY:• STATE: ZIP: --COMMENTS:- -- ......._ _... TOTAL: w- PATIENT RECEIVED BY:X ProVidil' Ntofa Vhit• .rd Pig:: .--rR�h,r• i." .. t (SIONAfURE) tM`-t t y PATIENT'S NAME: Marcus Suess ADDRESS: 1710 First st. Richmond, Ca. DATE OF SERVICE: 09-21-83 , AUTHORIZATION NUMBER:8316415 AMOUNT DUE: $189.50 INCIDENT LOCATION: 1710 First st. Richmond PATIENT DESTINATION: Brookside Hospital i ; CO 31 P 3 ;,- 50 NUMBED. r: ((� �,�,� CALL RECEIVED—— _ AMBULANCE DISPATCHED — AMBULANCE ENROUTE 10.8 r CALLED BY- PATIENT INFORMATION rn ' r > •� o NAME: ; J�� ^I AGENCY: / CUSTOMER a(Pi. 1): DOB:C Zoo c > DEPT/FLOOR/ROOM a: NAME: ('�-�1 Y311MC1L)$ n m a CALLBACK a - INS. TYPEC& MCAR MCAL KHP PHP VA IND CHAMPUS, w y CC n INCIDENT LOC: ) (J S I ✓ZPOLICY/MCAL 8: t'i CJ -A T v Q MCAR#: m m CROSS STREET: _ VERBAL PRIOR: o �j JURIS: Cil �� 111 m w a +� t' DOCTOR: —- DESTINATION: t ?1 I PT. a2 NAME: DOS: NATURE: 'l)I P�•�!� CUST. a 3 �n - c rn PT. $13 NAME: DOB:. > N d TYPE OF.CALL:gMCC� TRANS TIME UNIT a ( � CUST. $1 m w CREW: C�2 C d 1l d 2- L WAIT TIME: YES NO REASON: m O UNIT TYPE: ALS CL� WC RESPONSE CODE: 0 ](-72_)3 4 REASON FOR 10.12: p0 xc a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1( ��3 4 CANCELLED BY: . BY: END MILEAGE: C7U�U-} COMMENTS: py. 3 a TIM BEG MILEAGE: GD ,a DIS TC ER: TOTAL MILES: 00392 r 1' 3 ' XL•01 I1V1S 1V 3JNVlflBwv 61-01 0NINaf1138 3DNv1f19wM 86:01 319VIIVAV 3DNb1DgWV L-01 1V1IdSOH 1V 37NVV19WV P�'�, CONTRA COSTA COUNTY AMBULANCE PRE'HOSPITAL CARE FORM I UNIT ® AUTHORIZATION LL INAPPROPRIATE SPACES DATE: E Om O F COMPANY N d, X`Ia 4 A ' AGE�i " 13 Th OF E3 STATE ZIP OOB �418n ❑ M O T ❑ W ❑ Th ❑ F ❑S ISE# ` PHONE NATURE OF DISPATCH— PORT:, ISPATCH PORT:: AMBULANCE 10 OTHER❑ — STATION 1(A)_2(8)_3(C1=4l6l___�5(E)_ + r IR CLOCK) �TION:t 1 `s RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) TO SONE,- �• 3 t j ..� S.O. CALL RECEIVED {G�p I"�)t 1- 3I At ❑ P.D. TIME 10-8 FROM SC IN - ❑ FIRE TIME ID-97 NATION; / �.� ❑ PSAP TIME 10-49 V MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 L (_ 1 PMD/ER START TIME 10-22 I`—. ! TOTAL STANDBY TIME ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ DIRECT ❑ OTHER _ CALL BACK M: AMBULANCE MPANY: RY7 PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE - I O WALKED ❑ GUERNEY ❑ OTHER I 1 TION: `r DRIVER rv p— EMT-IA rIEDiC ! _ TECHNICIAN ` /,- PARAMEDIC DISPATCHER: NT: DRY RUN: O Yr S ❑ NO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) IT REFUSE SERVICES:(SIGNATURE) X IAGE: .- INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: BASE RATE: MULTIPLE PTS.BASE RATE TOTAL MILES: X , E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN: CODE 2/3 1 OXYGEN: (PER TANK) C) YES ❑ NO 1 NEONATAL: (INCUBATOR) ' STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) !E/RESPO ISIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ORAL AIRWAY: (IF NOT REPLACED) . STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) WORK PHONE: DRY RUN: (AUTHORIZED) �� OCCUPATION. OTHER: STATE: ZIP** a TOTAL: '5c _ PATIENT RECEIVED BY: X_ I 4E1 rM�-t (SIGNAl URE) CONTRA COSTA COUNTY AMBULANCE n 1 PRE-HOSPITAL CARE FORM I UNIT r� AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: 71PAT1ENT'S NAME I J W c �'� O M O F COMPANYJI ADDRESS I AGE L t` r "IQ CITY- - STATE_�.�_,ZIP DOB - 6n ❑ M ❑ T W ❑ TA O F ❑S ' DRIVER'S LICENSE N _ PHONE _ NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCEO OTHER _ STATION I(A)_2(8)_3(C_4(D)_5(E), r INCIDENT.LOCATION:I_ _ 1 RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- IPS.O. CALL RECEIVED L• 3 V ` �.��lP ��{�(•, �� '. . 7 O P.D. TIME 10-8 .3 T PATIENT DESTINATION:-_._..J FROM S E- ❑ FIRE TIME 10-97 �I 1 1_3 PSAP TIME 10-49 ��lc'; T'v ' ` [� I MILEAGE: ❑ OTHER/PVT TIME 10.7 ••� yli END TIME 10-98 (yOCTOf� `�•►"� PMD/ER START TIME 10-22 HOW CHOSEN: r ___._ TOTAL STANDBY TIME 'yr O NEAREST---:, FAMILY O TRANSFER WAIT TIME c...�.. 13 PATIENT DIRECT ❑ OTHER CALL BACK N: AMBULANCE P NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J r • RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER' PATIENT CONDITION: DRIVER a'ti— EMT-1A TECHNICIAN 1 I PARAMEDIC '/t/n� Hx: DISPATCHER: l.� CHIEF COMPLAINT: DRY RUN: ❑ OFO NO REASON FOR DRY RUN qqq U 10DRYA (EMS USf ONLY) PATIENT REFUSE SERVICES: (SIGNATURE) X_ '� MEDICAL COVERAGE: . . . INDUSTRIAL ❑ YES ❑ NO NO. PATIENTS: S.S.0 ' PRIVATE INS.CO.: BASE RATE: I KAISER N: I MULTIPLE PTS. BASE RATE BLUE CROSS N: 't ` TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: '❑ YES ❑ NO ❑ YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: ( EMERGENCY RUN: 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/RESPONSIBLE PARTYr- I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ' NAME: - RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) �- CITY: — STATE, ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) --EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: -COMMENTS: r -1 iltz Ito, TOTAL: .60-CIV PATIENT RECEIVED BY:X H--rr.lnr rvr•ri. ►^.r.. 11i.; .,.• anr.,•_ ,. ISIGNArURE) CONTRA COSTA COUNTY AMBULANCE 666 PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N �1. CNECK 011 FILL IN APPROPRIATE SPACES DATE: x Q f 1.• PATIENTS NAME f ❑f M ❑ F COMPANY N ` ADDRESS 1 AGE CITY STATE—.ZIP -- — DOB n O M OT Ow O1t CIF F O S i 777771 DRIVER'S LICENSE N PHONE NATURE OF DISPATCH ?el \A- TYPE ATYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 -- STATION 11A)_2(B)._3(C)_4(D)_51E1, INCIDENT LOCATION:- - - RESPONSE CODE: RkOUESTED BY: TIME— (24 HOUR CLOCK) TO CENE- S.O- CALL RECEIVED j 1J t_�� . 1�eSe1/YCTY••+ OP.D. TIME 10-8 PATIENT DESTINATION: ._._ .� FROM—SCENE O FIRE TIME 10-97 1 3 4 V ❑ PSAP TIME 10-49 Dxt_ ~ '-+ i MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 ,,(DOCTOR? �' ` PMD/ER START TIME 10-22' HOW CHOSEN: TOTAL STANDBY TIME �;• O NEAREST, EI O FAMILY O TRANSFER WAIT TIME ❑ PATIENTJJ ❑ DIRECT 11 OTHER CALL BACK C AMBULA,�qE COMPANY: PT. AMBULATOf1Y7 PATIENT TAKEN TO AMBULANCE: )�) RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER r'nUT AI&A'A �-J_ EMT,tA TECHNICIAN L-A� «"►'1�� �/ ` PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: t -� DRY RUN: ❑ YES '❑ NO REASON FOR DRY RUN Rec� AUTHOR TION F DRY U S USE ONLY) `1 1 1 }'•,•;. '.:. PATIENT REFUSED S VICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES .O NO NO. OF PATIENTS: ��s✓y S.S. N r I PRIVATE INS. CO.: BASE RATE: KAISER N: ( MULTIPLE PTS.'BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C I E.O.B. ATT. ROUND TRIP: ❑ YES O NO c: O YES .O 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 aNEONATAL: (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: _ Q02��r TOTAL;—w/"D - PATIENT RECEIVED BY. X pf-vidir retafn Nhft� ,nf Pfni (SIGNATURE) 1 •'t�� MIt1T1 Y. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT j AUTHORIZATION# 3 CHECK OR Flll IN APPROPRIATE SPACES DATE: / (� I PATIENTS NAME Om OF COMPANY# ADDRESSAGS I_ f CITY STATE ZIP DOB - ❑ Sn OM OT OW O Th OF O S DRIVER'S LICENSE# PHONE NATURE OF DISPATCH Mltzd-Lk c"a TYPE OF TRANSPORT: AM.B LANCE❑ OTHER O _ INCIDENT LOCATION: U RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- � ©�S.00. -.P CALL RECEIVED ❑ P.D. TIME 10-8 :�_ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 lz_aVI /J / ❑ PSAP TIME 10-49 �Y. z _ MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: _ . TOTAL STANDBY TIME "n ❑ NEAREST-' O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALLI BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE f ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER N� :� I EMT-IA I TECHNICIAN 6��-iL���>��+ r'I' PARAMEDIC Hx: DISPATCHER: I doR CHIEF COMPLAINT: DRY RUN: 0"YES ❑ NO REASON FOR DRY RUN i AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qqq PATIENT REFUSED SERVICES: (SIGNATURE) X I MEDICAL COVERAGE: INDUSTRIAL OYES ❑ NO N0. OF PATIENTS: � 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 ONO ❑ YES ONO NIGHT: (19:00-07:00) i CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER;TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) i 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 NOTIREPLACED) ADDRESS: ORAL AIRWAY:! (IF NOT REPLACED) CITY: STATE-_ZIP: C-COLLAR: 0.NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY; STATE ZIP: COMMENTS: i TOTAL: • PATIENT RECEIVED BY: X_ 00396 h-eider retain "i to ..m4 Itin6 N,pp !return Yc'!••u I (SIGNATURE) A—.' •„I.N t.• !Pl:' i•h.•.t I illi•ir LMS-I• _ >r CONTRA COSTA COUNTY AMBULANCE c c) PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION n X3 //` Z > 1 CHECK OR FILL INAPPROPRIATE SPACES DA TE i _J73 — PATIENT'S NAME!-_!L.Jv�v �L/�3`R .T --- - - %` �__-_. -_ _ .._ �3-fi1 ❑ F COMPANY p ADDRESS�fAF?t'�E2- �1�T��- ------ AGE.�L�P.- I •. C T)Y_-OQK---- ATE _ ZIP-.J_ ._ DOB-I- - Srt M El ❑ W 13Th 13F ❑ S DRIVER S LI EN E N _ _. _. ...._ HONE _.._ .. _-.._ NATURE OF DISPATCH.. (Z r TYPE OF TRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE. REOUESTED BY TIME - (24 HOUR CLOCK), TO SCENE - )d-S O ___. ._ .... CALL RECEIVED Y �• 7 n C ` ------...-_---..-_.__ ❑ P.D. _. __-.. TIME 10-8 / c PATIENT DESTINATION: FROM SCENE- ❑ FIRE ___.____ TIME 10-97 /_ l e S` ❑ PSAP TIME 10-49 IA03 3 J ti MILEAGIEj ❑ OTHER,PVT TIME 1D-7 END. �' � --_— TIME 10-98 r DOCTOR �r,, -_- PMD.>® START_bXY_- --_._ TIME 10-22 HOW CHOSEN- TOTAL _ � STANDBY TIME XNEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -_ KPATIENT ❑ DIRECT ❑ OTHER �� CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE P(YES ❑ NO ❑ WAL:ED D(GUERNEY ❑ OTHER L PATIENT CONDITION: DRIVER_ 5d�! ._r EMT-IA— _ TECHNICIAN PARAMEDIC )c l la►� Z_ G Hx: _�743� � &�`__._-�..Q_ � DISPATCHER: UGI/ CHIEF COMPLAINT: f Crn._�rr _ DRY RUN: ❑ YES .,OLNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE UNL Y) 1�✓ PATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL CO yERAGE: INDUSTRIAL ❑ YES k ND NO OF PATIENTS: I i . i S.S. x Ci -------- �� PRIVATE INS. CO.: _ BASE RATE: /_ua� 1 KAISER n: MULTIPLE PTS. BASE RATE � �,✓� /Q� � BLUE CROSS#: TOTAL MILES: - X 1 MEDICARE a: E.O.B. ATT. ROUND TRIP ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) FESrICK EMERGENCY RUN:CODE2/3 __ -__ OXYGEN: (PER TANK)ER ❑ 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 Suiv V e "'d iv 544) • NAME'_ ELATIONSHIP E O.A.: IF NOT REPLACED) -- ADDRESS: -_-____-_.___.__...____.-__._..___._.__._._ ORAL AIRWAY: (IF NOT REPLACED) _ CITY:14!�a�S U�1-__..__-._ STATE r4AZIP: _____ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE.._-.. _._ ..______._ DRY RUN (AUTHORIZED) EMPLOYER: .1 OCCUPATION_-_____......__. OTHER: ADDRESS: r CITY: STATE---ZIP:.-- - ---- - .._.. ---- - - COMMENTS: _—.._-_-._----._---- . TOTAL �/ f 0039'7 .n. . ntrl i CONTRA COSTA COUNTY , AMBULANCE PREHOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION If CNECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME � — `" t ADDRESS AGE CITY STATE ZIP DOB O Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S j DRIVER'S LICENSE N PHONE NATURE OF DISPATCH & ;r n ux T ed - TYPE OF TRANSPORT: AMBULANCE12T OTHER❑ INCIDENT LOCATION: RESPONSE CODE: ROUESTED BY: TIME- (24 HOURCK), TO SCENE- S.O. CALL RECEIVED •7 l Y �S L i�-� i ✓t S� ❑ P.U. TIME 10.8 :% ;J-T t PATIENT DESTINATION: J FROM SCENE- ❑ FIRE - TIME 10.97 2 ry :CA2 ❑ PSAP TIME 10-49 ) MILEAGE: ❑ OTHER/PVT TIME 10-7 ENDTIME 10-98 DOCTOR -PMD/ER START�K TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATI ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: r Al s i L PT. AMBU Y7 PATIENT TAKEN TO BULANCE: S RESPONSE ZONE I ❑ YE NO ❑ WALKED ❑ ERNEY ❑ OTHER . PATIENT CONDITION: DRIVER �C1.-�1) J EMT-1A ` i TECHNICIAN 00 PARAMEDIC Hx: DISPATCHER: �� � �A, 0 120 CHIEF COMPLAINT: DRY RUN:-0 YES ❑ NO REASON FOR DRY RUN , r4rLF�I Ed t- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) G LZ L� PATIENT REF ED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N r PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E. B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ Y S ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: MEOI-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 PART I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X _ NAME: ELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT R LACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REP ACED) PHONE: ORK PHONE: DRY RUN: (AUTH IF ) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: f TOTAL: v 157 i 09398 PATIENT RECEIVED BY: X Providor mta•'n Ai tor.r.d Piny cnfa Aotum Yr1• i.' t: nr' ,,•• (SIGNATURE) t u5,.: �.r f End-i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N C,r CHECK ON/ILL IN APPROPRIATE SPACES \/� DATE: PATIENT'S NAM N�G ANy Nl A AY arm ❑ FCOMPANY M ADDRESS n,�t 1r ' AGE�2 (1 ISI ' 3-7 AGE ( -�AIJl44XGCnSTATEC.42S ZIP 0-2- )DOB�4��%"(r� ❑ M ❑ T ❑ W O Th OF ❑ S DRIVER'IS LICENSE M _ __�. _ PHONE NATURE OF DISPATCH r r - TYPE OF TRANSPORT: AMBULANCE OTHER — -- STATION 1(A)__.-2(B)_3(C)_41D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQYJESTED BY: TIME- (24 HOUR CLOCK) Ap TO SCENE- 2 (�/S.O. _ CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 : j M' 1 I 2 ❑ PSAP TIME 10-49 i y 1 1 i� MILEAGE: ❑ OTHER/PVT TIME 10-7 -T END--__- TIME 10-98T i f DOCTOR PMD/ER START "d I�� TIME 10-22 HOW)ZHOSEN: TOTAL STANDBY TIME pQ NEAREST O FAMILY O TRANSFER WAIT TIME i ❑ PATIENT ❑ DIRECT ❑ OTHER I I ) CALL BACK k: AMBULANC�Cf>?YANY: PTT MBULATORY? PATIENT TAKE�O AMBULANCE: C RESPONSE ZO��N--}}EJJ 1A YES ❑ NO ❑ WALKED I�GUERNEY O OTHER PATIENT CONDITION: DRIVER �-IL- 1 '`" EMT-1A 6MUlONA>✓ v'o's TECHNICIAN M(_C()PQL DD'jLLF q , PARAMEDIC r.7 Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES lifNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YE !�N NO. OF PATIENTS: ! 5.S. # Nor PRIVATE INS.CO.:` 1 oaNV\moz IC BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE / �^ BLUE CROSS M: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO I ❑ YES ❑ NO NIGHT: (19:00-07:00) �� ;J OS o'&CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 J OTHER: OXYGEN: (PER TANK) � p P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) fl l_- !/ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E,O:A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: jIF NOT REPLACED) PHONE: ,P(HONE: r/k` --) c-1' DRY RUN: (AUTHORIZED) EMPLOYER: v1E1iL CDPATION: OTHER: ADDRESS: N1�� CITY: STATE: ZIP: COMMENTS: TOTAL: _ _ __-- -- PATIENT RECEIVED BY: X r•..... . . (SIGNAIUPE) CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION ORS CHECK OA PILL IN APPAOPAIATE SPACES DATE: PATIENTS NAM nom- O M OF COMPANY# ADDRESS v j AGE Col. r_% � S ' CITY NATE S. ZIP ID DO ( 6y ❑ Sn O T O w 0 Th O F O S e ' , ►�- DRIVER'S LICENSE# _ _. _ PHON�. .��:_—.,___ NATURE OF DISPATCIi,�_ TYPE OF TRANSPORT: AMBULANCE qKOTHER❑ _— —_ STATION 1(A)_2(B)-3(C) 4(D)_5(E)_. f� INCIDENT LOCATION: RESPONSE CODE; REQfdESTED BY: TIME—(24 HOUR CLOCK) TO SCENE\� R//S.O. CALL RECEIVED l�� 1�_� ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 f MILEAGE. D OTHER/PVT TIME 10-7 =.. END TIME 10-98 DOCTOR — Md ER START TIME 10-22 HOW CHOSEN: � TOTAL �2t� STANDBY TIME D N REST �fAMILY ❑ TRANSFER WAIT TIME 4ATIENT ❑ DIRECT ❑ OTHER �. CALL BACK#: AMELANCE COMPANY: [POT AMBULAT0 PATIENT TAKEN O AMBULANCE: RESPONSE ZONE YES 1 NO ❑ WALKED �iUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J EMT-1A TECHNICIAN PARAMEDIC �1 Hx:0ANpe-4 ` U� ( 1 J ISPATCHER: CHIEF COMPLAINT: ORY RUN: ❑ YES O REASON FOR DRY RUN l j AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COV AGE: I USTRIAL DYES O NO.OF PATIENTS: !. G &S.#J,� � V�2 (� 9 PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE TOTAL MILES: 4- X E.O.B.ATT. ROUND TRIP: D YES D NO DYES ❑ NO NIGHT:(19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: UlJ MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER-TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) -�--- DATES BELLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) Lo Liv L// NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -NAME: SAF 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: ,R ADDRESS: CITY: STATE: ZIP: COMMENTS: C• �� i - =i1L1�t� , TOTAL:-----'- -- — -- ----- 00400 PATIENT RECEIVED BY: X Pn)vid*r retain whit. ,.•! �' n% I•� 4 t.- � (SIQNAM14F) /M'. � �FF i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M 575 3" S 30 n CHECK OR FILL IN APPROPRIATE SPACES DATE: ` 03 - _ PATIENTS NAME - r ❑ M ❑ F COMPANY N 4 ADDRESS ` AGE o/ CITY STATE ZIP _ DOB- _ ❑ Sn QO T ❑W ❑ Th ❑ F ❑.S DRIVER'S LICENSE M _ PHONE -- NATURE OF DISPATCH 6-A L, i I TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE TIME- (24 HOUR CLOCK) _ . G TO SCENE- ® S.O.SS_ CALL RECEIVED s g£K 1 '-' TIME 10-8 1L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �- ❑ PSAP TIME 10-49 L �Y MILEA ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 DOCTOR PMD/ER START TIME 10-2222 HOW CHOSEN:CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: 1 --c A S 1 15 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: f 4 DRIVEREMT-1A Hx: TE CHNICIAN � � � AMEDIC PT ?/ �^ CHIEF COMPLAINT: CAL��2 REASON FOR DRY RUN A C7 L� I Ll RUN(EMS USE ONLY) , PATIENT REFUSED SERVICES: (SIGNATURE) X L�5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO 0. OF PATIENTS: 6� i S.S. a PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE f BLUE CROSS a: TOTAL MILES: X t MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ® NO ❑ YES ❑ NO NIGHT: (19:00-07:00) f CCHP/PPRP 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: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X E NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 1 I ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) . i PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: 1 ADDRESS: CITY: STATE: ZIP: COMMENTS: --- TOTAL: .. -- - - ---- Q 1. _ ..... PATIFNT RrrFIVFI7 RY X -_. _ -- . _. - 1 ^0 CONTRA COSTA COUNTY. AMBULANCE - PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N - �`- `1�5 CNlCK OR FILL IN APPpOPRlATE SPACES DATE: A> ,PATIENTS NAME ❑ M ❑ F COMPANY N ( `, , l ADDRESS.' ` * I AGE K� C U ' CITY_ STATE ZIP DOB I O Sn -13'M ❑ T ❑W ❑ Th ❑ F DS DRIVER'S LICENSE ` ` PHONE NATURE OF DISPATCH ( 1-7 11 - TYPE OF TRANSPORT:'AMBULANCE OTHER O — STATION 1(A)_2(B)_3(C).be4(D)_.5(E)_ INCIDENT LOCATION: +i RESPONSE CODE' REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE S.O. CALL RECEIVED r C U( s 2q na CQ 11Tr'a 1 - 1 LA i ❑ P.U. TIME 11}8 PATIENT DESTINATION:• MNP FROM SCENE - ❑ FIRE TIME 1x97 � T ^ ❑ PSAP TIME 10-49 _. _ V`� -(w''1'� A� Y MILEAGE: ❑ OTHER/PVT TIME 10-7 'T— END TIME 10-98 l T- KaOCTOR1 LL�_'' I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME G^'j"1; ❑ NEAREST.:� ❑ FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION.* DRIVER 1,(CATA ' /! EMT-1A �l TECHNICIAN i' PARAMEDIC t �Q Hz: DISPATCHER: . v•I;l (, CHIEF COMPLAINT: ) DRY RUN:J0 YES ❑ NO REASON FOR DRY RUN •'l& 7�c• LtaC AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `1 ✓� RA-L PATIENT REFUSED SERVICES: (SIGNATURE) X f_ , MEDICAL COVERAGE: .. . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.0 l I PRIVATE INS. CO:: BASE RATE:- KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE N:•_ E.O.B.ATT. ROUND TRIP: ❑ YES 100 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C I EMERGENCY RUN: MEDI-CAL N: " CODE 2/ OTHER: OXYGEN: (PER"(ANK) 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: 0gni ally i PATIENT RECEIVED BY:X CONTRA COSTA COUNTY AMBULANCE 1� 2 PR€-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE _. 'y�p.ATiENTS NAME_ 11G l �n __—._..._.____...._ ❑ M ' COMPANY R e, -DDRES / •`J ` �' `J %� i' _ AGE �. CITY STATE— <<- ZIP DOBI� ❑ Sn .O M ❑ T ❑ W O Th ❑ F ❑ S r - PHONE a--3L/ 6C,ryATURE OF DISPATCH ' DRIVER'S LICENSE K TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: , RESPONSE CODE: REQUESTED BY. TIME - (24 HOURCOCK)r TO SCENE .0's-0. ______ CALL RECEIVED ❑ P.D. ___— TIME 10-8 PATIENT DESTINATION: FROM SCENE - , ❑ FIRE —_. TIME 10-97 / ❑ PSAP TIME 10-49 MILEAGE:�/ ❑ OTHER7PVT TIME 10-7 _ END 7�' TIME 10-98 14— L DOCTOR -i=� f+ -� PM ,ER START—Il _ TIME 10-22 HOW CHOSEN: TOTAL {— STANDBY TIME ❑ NEAREST FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHERCALL BACK a: AMBULANCE COMPANY- EoT AMBULATORY? PATIENT TAKEN TO AMBULANCE. 7_77 RESPONSE ZONE_ YES Nb ❑ WAL',ED GUERNEY ❑ OTHER 7/ PATIENT CONDITION. DRIVER _.Y�J. �—��:��'^1�) ��.� EMT-1A_ TECHNICIAN1\'Nr' " �`_-'�j PARAMEDIC V Hx: -7� 15�— �J) DISPATCHER: 1 CHIEF COMP AINT: y1 K DRY RUN: ❑ YES W NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (• PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS. S.S. R ------ PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: 7 TOTAL MILES: _ X MEDICARE#: yy 1 �'1 3�1'Z�� E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NQ O YES ❑ NO NIGHT: (19:00-07.00) C HP/ PHP p: —... EMERGENCY RUN: f EDI- L K: 'n CODE 2 3 THEFi: SUGAR LE06 OXYGEN: (PEA TANK) T.E STICKER / YEE 07609564084477 NEONATAL: (INCUBATOR) D TES BILLED: ✓� 20783P I LF STANDBY: (OVER 15 MIN.) E K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.)_ X DRUGS: (PER ADMIN.),___ X NAME: U• RELATIONSHIP .h.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:._ _ T 111 A L _-_-. I'AIII.NI 111('FIVII) H, x CONTRA COSTA COUNTY AMBULANCE (� P E•HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 lis, 2 CHECK OK FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ` OM OF COMPANY N ADDRESS ;"' l I AGES.", r U CITY - STATES_ ZIP DOB O Sn O M O T O W O Th O F O S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER STATION 1(A)_2181_3(C) 4(D)_5(E)_ INCIDENT LOCATION:.1 RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) Cn n ,,- TO SCENE-• J�S.O. CALL RECEIVED / `.> 'V III GLObVCl_� TC�FLIN'✓f'l �� ❑ P.D. TIME 108 . ,a :� PATIENT DESTINATION: I FROM SCENE- iO FIRE TIME 10-97 ❑ PSAP TIME 10-49 �"t �/��✓ RLj MILEAGE: O OTHER/PVT TIME 10-7 END _ TIME 10-98 —� 'DOCTOR T)r4 I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST.,,, O FAMIIl D TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE MPANY: PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ��,� ❑ YES ONO i ❑ WALKED O GUERNEY O OTHER. ^^ PATIENT CONDITION: DRIVER /"/ EMT-1A i TECHNICIAN �_(A P AMEDIC Hx: DISPATCHER: ��(q IIy CHIEF COMPLAINT: I DRY RUN: YES O NO REASON FOR DRY RUN /D-2- `i i AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qq9 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: S.S.M ' • PRIVATE INS.CO.: BASE RATE: ' KAISER><: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B.ATT. ROUND TRIP: O YES O NO DYES ONO NIGHT: (19:00-07:00) CCHP/PPRP 0: I EMERGENCY RUN: o MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) _ NEAREST RELATIVE/RESPONSIBLE PARTY: - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ - ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: "CITY: STATE: ZIP: COMMENTS: fn-f7 /N o2O(J7zE-• ,6y _ . 0,40A)CA4 FhE. TOTAL:__ 00404 PATIENT RECEIVED BY: X L,...,:r.. r.r, - ��.;,_ ..1 r•:. ., , . (SIGNATURE) rr•.-� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION N A T CHECK OR TILL IM APPROPRIATE SPACES DATE: - �' PATIENTS NAME ❑ M_* ❑ F COMPANY N ADDRESS ' AGES CITY STATE ZIP DOB " ❑ Sn 9/m O T O W O Th' O F O S DRIVER'S LICENSE N _ PHONE _ )NATURE OF DISPATCH - TYPE OF TRANSPORT:. AMBULANCE OTHER 0 - STATION i(A)_2(B)_3(CI 4(0)_5(E)_ INCIDENT LOCATION' ^� I•% RESPONSE CODE: REqJdESTED BY: TIME- (24 HOUR CLOCK) /1 /� ,� n - '], n TO SCENE- S.O. CALL RECEIVED �---� V - 1.7EHt�y 1�5�T � K�-" . ❑ P.D. TIME 10-8 ��i 7, PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 .� t , ❑ PSAP TIME 10-49 �- �� v MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 Sr.DOCTOR PMD/ER START TIME 10-22 C? HOW CHOSEN: I TOTAL STANDBY TIME ?;'•. 13NEAREST O FAMILY O TRANSFER WAIT TIME D PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: CAAMBULANCJEC(PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: - RESPONSE ZONE ❑ YES ❑ NO ..., ❑ WALKED ❑ GUERNEY ❑ OTHER i j PATIENT CONDITION: DRIVER _CQ LLO 1-4 E ) TECHNICIAN PARAMED Hz: DISPATCHER: •� ( '= CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN Z? /,Iv/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qqq `! I'. _ PATIENT REFUSED SERVICES: (SIGNATURE)X 15x 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 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES .D NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: I 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: IN 120 L/1­6 f0,_Iy r j)NAPLfi_:,- 7D C_ncATZ-7r TOTAL: ��• 90405 n4V5 - PATIENT RECEIVED BY:X ISIONAt'11AE1 . 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I Qj I AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: ` r S PATIENTS NAME OM ❑ F COMPANY K C,3f// i ADDRESS AGE CITY STATE ZIP DOB – ❑ Sn M O T ❑ W ❑ Th ❑ F O S I 2 } DRIVER'S LICENSE N __ PHONE _ NATURE OF DISPATCH O 1' TYPE OF TRANSPORT: AMBULANCE❑ OTHnER O INCIDENT LOCATION: I I'/ . RESPONSE CODE: REO ED BY: TIME- (24 HOUR 9OgK)n G Y 2 (1q �� -� ^ TO SCENE - S.O. CALL RECEIVED LLQ ` ' - !�J 3 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- Q O FIRE -- TIME 10-97 O PSAP TIME 10-49 r I�, 1 MILER ❑ OTHER/PVT TIME 10-74: 1111 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY— PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �j0 RESPONSE ZONE C_ I , ❑ YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERO Ef4T-1A TECHNICIAN A."f 12' -'`� PARAMEDIC �0nn Hx: DISPATCHER: + _ 0 CHIEF COMPLAINT: DRY RU YES ❑ NO REASON FOR DRY RUN i1 11 Q r`'Sf�L !0yA AUTHORIZAT N F R,DRY R N MS�jjS.f ONLY PATIENT REFUSED SERVICES: (SIGNATURE) r cl MEDICAL COVERAGE: INDUSTRIAL ❑ 4S NO NO. OF PATIENTS: S.S.a PRIVATE INS. CO.: BASE RATE: KAISER K.. MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X j 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 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) t CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ---- TOTAL: ---- - - - - -- --- -��-0-406 PATIENT RECEIVED BY: X t�..;•;,,.. ..,. •,•�:. . . ISIGNATUREI I CONTRA COSTA COUNTY AMBULANCEO1 '7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY M ADDRESS AGE h OR, U CITY STATE ZIP DOB ❑ Sn ❑ M ❑.T ❑ W O Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE — NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) f 2/� '� n �E � TO SCENE- 0 S.O. CALL RECEIVED "- 3 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 .ZL ❑ 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 t1: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER LU/Lt✓/Alf EMT-1A TECHNICIAN 1NCI`J,V'kl ` PARAMEDIC l Hx: DISPATCHER: >14e r CHIEF COMPLAINT: DRY RUN: O YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) f PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# I PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS st: TOTAL MILES: X MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ) ❑ YES ❑ NO NIGHT: (19:00-07:00) I CCHP/PPHP N: 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) i EMPLOYER: OCCUPATION: OTHER: ADDRESS: j CITY: STATE: ZIP: COMMENTS: TOTAL: — 00407 PATIENT RECEIVED BY X...__ Provider retain lAitc and fink copi, Retur+i Yr.'Iru, '.•14 t.: I!L'{when I i 71in,I (SIGNATURE) Ins t 1 / ) CONTRA COSTA COUNTY r AMBULANCE j PRE-HOSPITAL CARE FORM I UNIT. AUTHORIZATION N J\ CHECK OR FILL IN APPROPRIATE SPACE'S DATE: -� n �-1- PATIENT'S NAME--__ `��. ��+ �-LS_ ❑ M 1)(F COMPANY 11 / , ' ' A D D R E S _LL: ' �11�it,� ��S.n �_1 AGE^! CITY =,t1L!LLe�6TATE_c_�r T ZIPl� T ❑ F ❑S� � .j5 ❑ DRIVER'S LICENSE q __.___.__._. PHONE 7 ZC*.%NATURE OF DISPATCH—__- TYPE OF TRANSPORT. AMBULANCE OTHER❑ STATION 1(A)..—.2(e)._3( 4(D)-51E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) Si y6b ✓ �( TO SCENE S.O. CALL RECEIVED 3L' l te• P.D. TIME 10-8 ^� PATIENT DESTINATION: FROM SCENE - 13FIRE r� TIME 10-97 _ ❑ PSAP TIME 10-49 �- 1►r �! MILEAGE/►? 7 O OTHER/PVT TIME 10-7 END l� c► TIME 10.98 7 ` DOCTOR �� PMD6) START T TIME 10-22 HOW CHOSEN TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER J J CALL BACK N: AMBULANCE COMPANY: ' P AMBULATORY'? P TIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO WAL',ED �UERNEY ❑ OTHER 11� PATIENT CONDI N: DRIVER—_ � �� �l EMT-1A TECHNICIAN r' PARAMEDIC Hx: DISPATCHER: C CHIEF COMPLAINT: _ DRY RUN YES 13 NO REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X i MEDICAL COVERAGE. INDUSTRIAL ❑ YES �KNO NO. OF PATIENTS: I�YI.G� S.S. M -o - PRIVATE INS, CO.. BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS x: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO T �� L�V O YES ❑ NO NIGHT: (19 00-07.00) CCHP;PPHP p EMERGENCY RVN: _ _�z �C^ MEDT-CAL M: CODE 2''3 1 OTHER- thi OXYGEN: (PEPTANK) P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RE PONSIBLE PARTY: IN: fPER ADMIN)- X - DRUGS: (PER ADMIN.) X NAME Ll RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:_ STATE__ IP: C-COLLAR (IF NOT REPLACED) PHONE: 3C2 `1 39 WORK PHONE. - DRY RUN: (AUTHORIZED) EMPLOYER5_ J � r�L OCCUPATION: P OTHER- ADDRESS: ADDRESS:—�-5- _ --1- Oa- ;.v CITY: STATE' ZIP:— COMMENTS IP:COMMENTS TOIAI - - -- --- - - - 00408 PATIENT RECEIVED BY X r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION« CHECK OR FILL IN APPROPRIATE SPACES - - DATE: CL" I PATIENT'S NAME ) ❑ M $ F COMPANY«, ADDRESS AGE4013 F3 L.L CITY- 01'�STATE ��ZIP 2V le' DOB_Z_'!jl_-tJ ❑ Sn .® M ❑ T OW O Th OF OS. DRIVER'S LICENSE« PHONENATURE OF DISPATCH—LSI- SG 14 TYPE OF TRANSPORT: AMBULANCE OTHER D INCIDENT LOCATION:: Q,/{ RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,n TO SCENE- 9"5.0. CALL RECEIVED �� / —�k hi't h e rs T 3 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 t S ! ❑ PSAP TIME 10-49 : _ I MILEAGE—OTHER/PVT TIME 10 7 END l� D TIME 10-98 5D6CTOR 'I &--i =C_ PMD[Efg!> START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME —44—NEAREST: -. ❑ FAMILY O TRANSFER WAIT TIME —_ O PATIENT ❑ DIRECT ❑ OTHER CALL BACK«: AMBULANCE COMPANY: , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1 {LYES ONO ❑ WALKED-5OtUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �L,-�r-LjG✓I!� if h�J EMT-IA _ TECHNICIAN (,C_.. J LIQ PARAMEDIC HK: �Adds.0 ts� e—A'(_ DISPATCHER: V/I/�J!/�l 7 CHIEF COMPLAINT: 51,Q s 13 cnCt DRY RUN: ❑ YESGS'TJO REASON FOR DRY RUN r 5 S c —, 9';/ � '=Idd 7F AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 15 PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES-9rNO 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: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ; CCHP EMERGENCY r3/) �� EDI-CA "' CODE 2 OXYGEN: (PER TANK) E. STICKER ❑ YES ❑ NEONATAL' (INCUBATOR) DATES B STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSISLE 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..Qi_�� _� -- ---- --- �_ 00,409 PATIENT RECEIVED BY X Prouidar rltaiq whit• n.t t'•.t / CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION w _7 I CHECK OR FILL IN APPROPRIATE SPACES ll DATE: PATIENT'S NAME.�1�1 �_ _ _Y } l ❑ M �QQF COMPANY k p� ADDRESS ( � • AGE CITY: ' I STATES — ZIP L/ DOB o .O❑ Sn /S M ❑ T ❑ W ❑ Th ❑ F ❑S I DRIVER'S LICENSE 7� _._ ..__.._._ ..__.___..._ PHONE _ �> _. �__ NATURE OF DISPATCH TYPE OF TRANSPORT. AMBULANCEA OTHER❑ INCIDENT LOCATION: RESPONSE CODE: OUESTED BY: TIME- (24 HOUR CL K) TO SCENE- .S. . CALL P.D. TIME 10 0-8 8 PATIENT DESTINATION: n FROM SCENE 13FIRE TIME 10=97 d� 1 ❑ PSAP TIME 10-49 _ 03 IJ�_ U del � MILEAGE' ❑ OTHER/PVT TIME 10-7 a END O TIME 10-98 Q!Z 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: E AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO E] WAL`<ED GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER D RAT-1A 7 II 1TECHNICIAN PARAMEDIC Hx:+.�.L� �4(,) cv) DISPATCHER: CHIE OMPLAINT _ .�_�} �� DRY RUN. ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (/ PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL CVER E:- INDUSTRIAL ❑ YES*NO NO. OF PATIENTS: s s. p `, b9- - /" PRIVATE INS. CO.: BASE RATE: Io, KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS Ir: TOTAL MILES: `7 X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) /CCC;j4PHP q: -' EMERGENCY RUN: 4D•[-�V K MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: ( ER TANK) -tea Lv 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�1 C:^AlL — REA L•TIONSHIPRLLL E.O.A.: (IF NOT REPLACED) EL ADDRESS. —.� _ _ ORAL AIRWAY. (IF NOT REPLACED) CITY: _ STATc-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATI(5N- OTHER: ADDRESS: IO.C�'. CITY: STATE: ZIP: COMMENTS: w TOTAL: PATIENT RECEIVED BY:X Pr•vidrr rrtcir whit, tzrd Pin: rrpy FetLm YF',L' �.opp •• n/ Lhor, FiI'ino (SIGNATURE) Q15-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N CHECK OR Flll INAPPROPRIATE SPACES DATE: r �7I PATIENTS NAME(�ZI t . �-p S �- M ❑ F COMPANY# a /� t ADDRESS I SIS"ry F O Z(> AGE� CITY • STATE t--1 V' ZIP `4 O ( 1 p DOBI 1��0_1 ` ❑ Sn ❑ M ❑ T t❑ W ❑ Th 0 F O$"n DRIVER'S LICENSE# _ _ PHONE�'Z `rNATURE OF DISPATCH -- .� TYPE OF TRANSPORT: AMBULANCE❑ OTHER _ STATION 1(A)_2(8)-3(C)_4(D)_5(E)_,�.-...�1 r�INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR C QCK),; �nTO SCENE- 3 WS.O. CALL RECEIVED --y l 7 a5N Fo ❑ P.D. TIME 10-8 '.T" PATIENTTINATION: FROM SCENE--L ❑ FIRE. TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 00_� -� - -� 1 END 016 . 1 TIME 10-98 Ll!Q DOCTOR PMD40 START '73 •7 TIME 14.22 �. HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �: ) Iff"PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: C PT AMBULATORY? PATIENT TAKE TO AMBULANCE: i JV RESPONSE ZONE _ YES ❑ NO ❑ WALKED7GUERNEY Cl OTHER PATIENT CONDITION: DRIVER • �R ti `` 5 0 EMT-1A TECHNICIANS}{c[Z o�'D ^ PARAMEDIC— / Hx: DISPATCHER: Li� I/) Pcl 16 CHIEF COMPLAINT: C--, DRY RUN: ❑ YES )�'NO REASON FOR DAY RUN .3 c/f I AUTHORIZATION FOR DRY RUN(EMS USE ONLY)o. -� PATIENT REFUSED SERVICES: (SIGNATURE) X_ J MEDICAL COVERAGE: INDUSTRIAL ❑ YES ®N NO. OF PATIENTS: �� ` ��, -•,.'O I Y S.S. # '2._� • RIVATE/INS. CO.: RATE: '1 r K ISER�#: `t ���' ' '�� ��(� S �N ULTIPLE PTS. BASE RATE BL E� OSS#: -/ �' •� << / -�_R - )OASE TAL MILES: X MEDICA�E#: n ^ �-E.O.B. A.T . ROUND TRIP: ❑ YES ❑ NO )❑ YES ❑ NO NIGHT: (19:00-07:00) -�� CCHP/PPRP M / ��' �t EMERGENCY RUN: 7 ... MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES N NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) a� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �---- __ p DRUGS: (PER ADMIN.) X NAME6R1E?z �- RELATIONSHIP: 1 E.O.A.: (IF NOT REPLACED) -� ADDRESS: 5 A n ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) •- - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIOta= OTHER: ((\\ - ►� ADDRESS: I_�l�-� �_Y'.�s u..C�... f D •Cy CITY: STATE: ZIP: 3= (l I COMMENTS: TOTAL: I ... PATIENT RECEIVED BY:X + O A 4 1 i (/ Provider reta:r, Whit, ,d Pincop, .Return Ye*low ropy r• OfS ulva t•:17i W (SIGNATURE) Ems-1 f CONTRA COSTA COUNTY AMBULA E PRE-HOSPITAL CARE FORM 1 �i) UNIT I V AUTHORIZATION q 1-T5 CHECK OR FILL IN APPROPRIATE SPACES r DATEIy PATIENTS NAME ❑ M ❑ F COMPANY M ADDRESS AGE ,✓, L CITY STATE ZIP DOB--_ ❑ Sn ❑ M �1 T ❑.W/�❑ Th ❑ F ❑ S DRIVER'S LICENSE# — = PHONE _-_ —__ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE9JUESTED BY: TIME- (24 HOUR CLOCK) ' c { TO SCENE- R'S.O. CALL RECEIVED I� Z J O Im �' ) ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �Q N ❑ PSAP TIME 10-49 J-1 MILEAGE: ❑ OTHER/PVT TIME 10-7 I' END TIME 10-98 DOCTOR PMD/ER STAR- TIME 10-22 i HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME r ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 1r: AMBULANCE COMPAN ` { PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Y( c f J 1 ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER b 6✓EMT-1A 1 TECHNICIAN��tt� PARAMEDIC__ ,K - �� Hz: �(r'-a DISPATCHER: t '�L �•-�C_ I�i �i !� CHIEF COMPLAINT: DRY RUNO<YES ❑ NO REASON FOR DRY RUN In 4 ��1,, -`` AUTHORIZATION FOR DRY RUN (EMS USE ONLY) jn,.-e Pei PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: _ SS a_ I PRIVATE INS. BASE RATE: _ f KAISER M. MULTIPLE PTS.BASE RATE E BLUE CROSS K: TOTAL MILES: X i MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO . ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: /1 MEDI-CAL M: CODE 2/3 ( OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ ES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) — 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:— COMMENTS: IP:COMMENTS: I TOTAL: 00412 PATIENT RECEIVED BY: X . I �i CONTRA COSTA COUNTY AMBULANCE 3 ,PRS-HOSPITAL CARE FORM 1 �;. UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT S NAMEi2 ( ❑ M F COMPANY Y ADORES L.7 eJU-)Pt AGE (/ .0 L)7 CITY STATE _ ZIPrr DOBQQ�� �-� -Z) O Sn O M IPT OW ❑ Th O F 0 S DRIVER'S LICENSE N —_�G� _' PHONE 2`?9�.3LINATURE OF DISPATCH—CUP TYPE OF TRANSPORT: AMBULANCE,0 OTHER❑ __ -- STATION 1(A)_2(B)_3(C)A4(D)_5(E)_ INCIDENT LOCATION: RESPONSE C E: REOUESTED BY. TIME— (24 HOUR CLOCK) [_ �j TO SCENE- -- P.D.__ TIME o-8 RECEIVED + l3 S (. II.I.1,� PATIENT DESTI TION FROM SCENE O FIRE TIME 10-97 C / ❑ PSAP TIME 10-49 O D MILEAGE 7 f OTHER/PVT TIME 10-7 a c r f �g END � — TIME 10-98 + DOCTOR `� f�r PMD START ZU _ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 17 PATIENT. ❑ DIRECT ❑ OTHER ! CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY?EPATIENT TAKEN TO AMBULANCE: RESPONSE ZONE r" ❑ YES NO LKED GUERNEY O OTHER k Q t i� UA PATIENT CONDITION: DRIVER 4� EMT-IA $Ca'� TECHNICIAN N PARAMEDIC Hx: DISPATCHER: `Od CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL 13 YES 1�NO NO. OF PATIENTS: 000_ S.S. M I• PRIVATE INS.CO.: BASE RATE: S I KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS W TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES 13 NO QCT OS IJ01"/� Cl YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: Ot, ME CODE 2/3 VOTN R' S{L�{ OXYGEN: (PER TANK) STICKER Cl YES ly NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) � 1 { NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X f DRUGS: (PER ADMIN.) X 1111 NAME: �(' �� Pf' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS- S 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: COMMENTS: -oD' OO. _ 413 PATIENT RECEIVED BY' X 00 Nnii•lur• rvt rig uh/r. .•I ,, (SIGNATI)IIE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M 7 3-/ CHECK OR f!(L IN APPAOiF1A7E SPACES DATE PATIENTS NAME AL i o b.S E' �' _ ❑ M d F COMPANY IF +'o I ADDRESS S 3 S S 1 /I }� _ AGE CITY STATE C_11 ZIP 11-1 DOBE)-1 �7 ❑ Sn ❑ M © T ❑ W O Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE % j G� NATURE OF DISPATCH n='•5 f: TYPE OF TRANSPORT: AMBULANCE Z OTHER❑ __ _-_^-_._ ___ STATION 1(A)_2(B)_3(C)-4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME- (24 HOUR CLOCK) � , f b. nTO SCENE - l ❑ S.O. _- CALL RECEIVED 3-3S 19 ' • I lll` �1 1) > O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ? FIRE —; TIME 10.97 5 �/ ❑ PSAP TIME 10-49 MILEAGE: / ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR L� `4•` PMDttpRl START ft �� Cl TIME 10-22 HOW CHOSEN: ITOTAL 2 STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- -� PATIENT ❑ DIRECT ❑ OTHER CALL BACK p AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �_ I_ L ) RESPONSE ZONE YES ❑ NO ❑ WAL'(ED-0 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �� _' r ���? l,f EMT-1A ) TECHNICIAN F`- PARAMEDIC f 4^q Hx: [:, DISPATCHER:I I ��; U 1 O CHIEF COMPLAINT: 4' Ln s:t 40-1 r*l DRY RUN: ❑ YESd NO REASON FOR DRY RUN 1d0 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1 ' S.S. « LI 3 r-- `z 4-1 PRIVATE INS.CO.: BASE RATE: KAISER N_. ` MULTIPLE PTS. BASE RATE BLUE CROSS N: -7 `� `���� `�' TOTAL MILES: X ��� '9.- J MEDICARE M: `'��' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) C' % CCHP/PPRP N: EMERGENCY RUN. t MEDI-CAL M: CODE 2/3 i / OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 'cf n'1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X DRUGS: (PER ADMIN.) X NAME: ecft ct.`� ' <-'�' RELATIONSHIP: 1f''` ' E O.A.: (IF NOT REPLACED) ADDRESS: 4t�,Zl/f ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: / OCCUPATION: -/ r7 OTHER: ADDRESS:A CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: AA /,/, TOTAL FIAT HLCI.IVI0by X 00414 ------ ._--- - ---.. (SIGNATURE]-. .. . . . . ( F•r wi.(✓r rtr.;`.: 4n. •. • EMS-1 1283UJ F(P G to �'� I'l SEP 6 6 20 Am ! 3 SEP 6 6 21 AN '83 Sp NUMBERf'-;'/•j 3o CAII RECEIVED j AMBULANCE DISPATCHED - AMBULANCE ENROUTE 10.8 � t I CALLED BY- PATIENT INFORMATION o _ NAME' _..- ---- --- - � AGENCY: .__. �^V. _- ____.---_---_-_ ______.__- CUSTOMER a(PT, 11: _-. DOB I Z 1 J D U DEPT/FLOOR/ROOM 9: ..__. _ _ _`__.. NAME: I_11.C^r lr'Ir r� n a CALLBACK a _ ( _ INS. TYPE!.PVT MCAR /MCAL KHP PHP VA IND CHAMPUS > v INCIDENT LOC: --"�' —_ POLICY/MCAL !1: l i�� 5��Q G'G C''� Jj(j T ------- --- - m cx) CROSS STREET: 4 '* —----- - -r-C..� MCAR p: ! Z vo Ciz �7 ------- VERBAL PRIOR: 1/ �110 ' a Jl1RIS: .._ City /C/X -._ DOCTOR: -�V t DESTINATION: /CS`�<T . PT. 112 NAME: DOB: NATURE: ,/ •_--_.-._. __..______..____ __—__ CUST. a ; PT. a3 NAME: DOB: rn TYPE OF CALL -..-._---.. C y• I o : TRa S TIME UNIT a _ CUST. 0 / n i CREW: 1��0 i"s — WAIT TIME: YES NO REASON: Z O UNIT TYPE:GAlS BLS WC RESPONSE CODE: 0 1 2 Ja 4 REASON FOR 10-22: 7O - = O . c a INCREASE/DECREASE CODE:2 3 10-49 CODE: 01 33/ 4 I CANCELLED BY: ,"'„ t»'.- » v x co BY: _--.-. END MILEAGE: . 1 - COMMENTS: TIME BEG MILEAGE: DISPATCHER: 00415 r- , � TOTAL MILES: � � � .. OD i a ''• Q �a,i XL-01 NOIIVIS IV 3JNVinswv 61'01, ONINNF113tl 3DNvNTBW96.01 31EVTIVAV 3DNVlnSWV I-OI TYIIdSOH IV 3:)NVTTTBWV :t II t LS 9 9 d33 1 ' w ey'• 754.-.%1 r is J • ), lt=:: o!_� ' s•. •s,R t�. ., ����! ��_ �:- '�. �� `�����' L.��w� • •� s • ' .7'• .;fir..�•?1IM1 1 .'�kr l i at mg t • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 {�� UNIT , AUTHORIZATION# c-J 't•:J - CHECK ON FILL IN APPROPRIATE SPACES DATE:gr Ll PATIENTS NAME- ❑ M ,❑ F COMPANY# ADDRESS r AGE C L R I 1• CITY STATE ZIP DOB ❑ Sn O M I f T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# PHONE___. ____.—__ NATURE OF DISPATCHTJ_9n� - - TYPE OF TRANSPORT: AMBULANCE19 OTHER❑ INCIDENT LOCATION: ``' RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)_ CA ' ) TO SCENE- ❑ S.O. CALL RECEIVED Ank- l a ❑ P.U. TIME 10-8 PATIENT DESTINATION: I FROM SCENE - ❑ FIRE —_ TIME 10-97 :SLLL yv ❑ PSAP TIME 10-49 \ �-, NPU MILEAGE: EW OTHER/PVT TIME 10-7 END TIME 10-98 T— DOCTOR PMD/ER STARTTIME 10-22 LI !2 HOW CHOSEN: TOTAL '-I. (Ll H STANDBY TIME Y' 1 ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: CAs PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: !�L� RESPONSE ZONE2, ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER .f' �._u EMT-1AY ! �( TECHNICIAN PARAMEDIC ►�" Hx: IC'2 2 DISPATCHER: t 'c C •� 1' ) P CHIEF COMPLAINT: DRY RUN: VYES ❑ NO REASON FOR DRY RUN :t-- C)C DI'1 S(-pRQ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 14 1 I I 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: v MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ ES ❑ NO NEONATAL: (INCUBATOR) 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: 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: 00416 4�_. _ TOTAL:__`-lIv'_._ PATIENT RF(-.FIVFF) Ry X C;If:TIAT1oil f 1_ i i i CONTRA COSTA COUNTY I AMBULANCE / ,Z (r PRE-HOSPITAL CARE FORM I 'V UNIT AUTHORIZATION N ` 3 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY M ADDRESS AGE J R M1 / CITY STATE ZIP DOB_ ❑ Sn ❑ M ��❑qqW ❑ Th ❑ F ❑ S . DRIVER'S LICENSE N PHONE __ NATURE OF DISPATCH-11! TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ 1 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) i G TO SCENE- S.O. (=CALL RECEIVED y 60 �1// - - ❑ P.D. TIME 10-8 c'1 :� PATIENT DESTINATION: FROM SQf NE- - ❑ FIRE TIME 10-97 i ❑ PSAP TIME 10-49 N � MILEAGE: ❑ OTHER/PVT TIME 10-7 �) END TIME 10-98 '�I DOCTOR PMD/ER START TIME 10-22A� HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME __ I ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBUf,A{VCE90 PANY: i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �. ;1 RESPONSE ZOONNE�--(- ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER (-J � PATIENT CONDITION: DRIVER 4� tj - -I U EMT-1A I TECHNICIAN S PARAMEDIC A Hz: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ,f� YES ❑ NO REASON FOR DRY RUN O� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFU ED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # L1 PRIVATE INS. CO.: BASE RATE: 1 KAISER#: MULTIPLE PTS. BASE RATE rt BLUE CROSS#: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 �t CCHP/PPRP#: EMERGENCY RUN: 1. Cn 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) I 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: STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) I EMPLOYER: OCCUPATION: OTHER: ADDRESS: M CITY: STATE: ZIP: COMMENTS: TOTAL: �� f1(�4 1 7 PATIENT RECEIVED BY:X Pr •t'i,frr ,yr., ��•., .,. r,, .., r,, ., . . (SIONATUgE) cr• . CONTRA COSTA COUNTY / AMBULANCE PRE-HOSPITAL CARE FORM 1 -� UNIT AUTHORIZATION N Oo-y CHECK OR fill IN APPROPRIATE SPACES - DATE: ,t —7 PATIENTS NAM ( ❑ M ❑ F COMPANY N ADDRESS ' AGES ( � I� L1 v i CITY $TATE ZIP DOB - ❑ Sn OM ;PT ❑W O Th OF O S DRIVER'S LICENSE 0 PHONE NATURE OF OISPATCHo�/�c�L/.&, TYPE OF TRANSPORT:'AMBULANCE OTHER 0 _ _ STATION 1(A)_2(B)_3(C 4(D)_5(E)_ INCIDENT LOCATION.1 I RESPONSE CODE`. VESTED BY: TIME- (24 HOUR CLOCK) 1 TO SCENE- . CALL RECEIVED 1. 4pl o1,._1P.D. TIME 10-8 ; 1� PATIENT DE TINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 1 � MILEAGE: ❑ OTHER/PVT TIME 10-7 r END TIME 10-98 %•DOCTOR' `-r', 1 PMD/ER START - TIME 10-22 �:� �� HOW CHOSEN: ...... TOTAL STANDBY TIME -0 NEAREST,;; ❑ FAMILY ❑ TRANSFER WAIT TIME __ t ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMB ANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE ZONE—07 ❑ YES ❑ NO . ❑ WALKED ❑ GUERNEY ❑ OTHER X3'1T PATIENT CONDITION.` I DRIVER f EMT-1A 'p�('' TECHNICIAN PARAMEDIC Hx: `' DISPATCHER: I "EF COMPLAINT: DRY RUN: ❑ YES .5Q'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. M PRIVATE INS. CO.: i a BASE RATE: ' I KAISER#: I MULTIPLE PTS.BASE RATE BLUE CROSS M: - TOTAL MILES: X MEDICARE C I E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES :❑ NO NIGHT: (19:00-07:00) . CCHP/PPRP M:" EMERGENCY RUN: MEDI-CAL M: L CODE 2/3 I OTHER: OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) " NEAREST RELATIVE/RESPONSIBLE PARTY:.. `' I.V.: (PER ADMIN.) X 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: 00418 PATIENT RECEIVED BY: X PrOvidfr rftail Vhit• r.nd Nnk (SIGNAIURE) ra1•p hihr.+ Yr', v ..,..;, f. ?Ir -•k:•n fir i.,: rns- I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM IUNIT AUTHORIZATION a CNECK OR FILL IN APPROPRIATE SPACES DATE: 7' Q -- PATIENTS NAME D M OF COMPANY a ADDRESS AGE �• CITYS A ZIP DOB '❑ Sn ❑ M ❑W O Th ❑ F O S DRIVER'S LICENSE a PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O STATION 1(A)_2(B)-31C) 4(D)_5(E)_ INCIDENT LOCATION:I I RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 9 f�//-�l�/�¢ TO SCENE- / O. CALL RECEIVED / /O1^C�� I 1 I �/y O P.D. TIME 10-8 ='� 1 \ PATIENT DESTINATION: _ FROM SCENE- ,x ❑ FIRE TIME 10-97 1 N O PSAP TIME 10-49li MILEAGE: 11OTHER/PVT TIME 10-7 \ END TIME 10-98 "DOCTOR "'"1 r•, ) PMD/ER START TIME 10-22 -` :41 HOW CHOSEN: / I TOTAL STANDBY TIME i" O NEAREST,'... O FAMILY ❑ TRANSFER WAIT TIME _— O PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: EPT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO., ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER /�/� I l J EMT-1A •('� i TECHNICIAN PARAMEDIC Ci`� 14- DISPATCHE ,: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) u 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 C BLUE CROSS a: TOTAL MILES: X MEDICARE a:• E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: MEDI-CAL a: 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: 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) y� PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) -EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE• ZIP: COMMENTS: TOTAL: �•�� PATIENT RECEIVED BY: X 1-g P1r1vi,fir roto/n uhi l• ,.ra Pi.:: .. _ (SIGNATURE) T i' CONTRA COSTA COUNTY / AMBULANCE PRE-HOSPITAL CARE FORM I �/ •� UNIT AUTHORIZATION# I ,'1 ; 1 ,�; •- CHECK OR fill IM AiGROvpIATE 5 ACES DATE: - t% SA ATE:t%fS• ATIENTS NAME ❑ M ❑ F COMPANY :{ �' AOORESS �L AGE U !.3( l spt+' CITY ILt— !� STATE ZIP DOBy-� ❑ Sn ❑ M )WT ❑ W O Th O F O $ DRIVER'S LICENSE N _ ' PHONE . NATURE OF DISPATCH , TYPE.OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION:, RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) c TO SCENE- 'q S.O. CALL RECEIVED .` r`✓Zj I �2:(✓kI-11Gt\� 31 ,P.D. TIME 10-8 PATIENT DESTINATION: FROM SCEt - ❑ FIRE TIME 10-97 p� ❑ PSAP TIME 10-49 MILEAGE:'�` ❑ OTHER/PVT TIME 10-7 END �^' TIME 10-98 POO( TIME 10 -22T HOW CHOSEN: TOTAL STANDBY TIME �Iv,-_ ,❑ NEAREST1' FAMILY ❑ TRANSFER - WAIT TIME PATIENT 11DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY?j PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES 13NO ❑ WALKED r2a UERNEY ❑ OTHER i PATIENT CONDITION: DRIVER EMT-1A P� 146 TECHNICIAN VYNA'n PARAMEDIC Hx: DISPATCHER: V CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN 1Kp®• AUTHORIZATION FOR DRY RUN(EMS USE ONLY) V l A-11.!, PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: +: S.S. N r` PRIVATE INS.CO.: BASE RATE: SO.C.r�j KAISER N: MULTIPLE PTS. BASE RATE 1 TOTAL MILES: X �c • .�.C� J�.SQ y 2 (v a E.O.B. ATT. ROUND TRIP: 13YES ❑ 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 ..II_�_ DRUGS: (PER ADMIN.) X t —NAME: �� LATIONSHIP: 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 t1 20 ISI , 4T1 Provider rttain Vhifr .rd Pi••t enp� Yat�r•n Y.•'.' - ,.y �, ��• pl,,. ►!!ti � . 1 CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I UNIT [7j)&_'j AUTHORIZATION 4 e � CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME 11 ) xNi O F COMPANY M ADDRESS nQ AGE CPC> r U r' ,J CITY 5 STATE ZIP 17 3&5 DOBaL^I ZZ ❑ Sn ❑ M I ❑ W ❑ Th ❑ F OS DRIVER'S LICENSE N _ _ __._-. -.__-._____.. PHONE NATURE OF DISPATCH SBY1) ' TYPE OF TRANSPORT: AMBULANCE OTHER _.—__ ._._._.____._._ STATION I(A)--2(8)_3(C 4(Dl_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-- (24 HOUR-CLOCK) TO SCENE- *( -O. CALL RECEIVED e 7 n ❑ PD. TIME 10-8 L PATIENT DESTINATION: FROM SCEN - ❑ FIRE TIME 10-97 - ❑ PSAP TIME 10-49 / J MILEAGE:. ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR W,�+��� PMD/ER START '! TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER I CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONSE ZONE YES ❑ NO ❑ WALKED kGGUERNEY ❑ OTHER PATIENT CONDITION�!f�rrk Y1 _f DRIVER • / _ EMT-1A v TECHNICIAN 4 Ll i 1 PARAMEDIC Hx: DISPATCHER: ` CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN 1uO AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAG INDUSTRIAL ❑ YES rwNO NO.OF PATIENTS: s.s.« PRIVATE INS. CO.: BASE RATE: ! KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X � TTC U MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHPlPPHP 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: WQjlK- E: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATIO - OTHER: n ADDRESS: ( I CITY: STATE:-ZIP:- COMMENTS: TATE: ZIP:COMMENTS: TOTAL-00ig PATIENT RECEIVED I]Y X • i I CONTRA COSTA COUNTY I AMBULANCE PRE-HOSPITAL CARE FORM I �1 ' UNIT /\ AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME � l/1- ❑ M F COMPANY ADDRES AGE Intlo CITY ���� �`4 !` 1 �f\�•j� �� ZIP y� 1�C�c.� ' STATE arv2 DOB ❑ Sn OM T ❑W OTh OF 0S DRIVER'S LICENSE K _�� _r_ PHONE 23 _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ -- STATION 1(A_ (B)_3(C)_4(D)_5(E)= •-- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR%OCKI I TO SCENE- ❑ S.O. CALL RECEIVED `' —U`-14 1 r_1 L Cl P.D. TIME 10-8 . y Y� t ` PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 1Q`97 � : l f �A Y ❑ PSAP TIME 10-49 r _ MILEAGE:/' 7 ,/ T R/PVT TIME 10 7 r J �� END CSS ' `� TIME 10"98 1_L DOCTOR 1 PMDr� STAR- TIME 10-22 HOW CHOSEN. TOTAL '� � ' J STANDBY TIME &Y'EAREST ❑ FAMILY 'TRANSFER WAIT TIME _.. ❑ PATIENT ❑ DIRECT ❑ OTHER ' S ( CALL BACK N: AMBULANCE C MP --- i PT AMBULATORY? EATIENT TAKEN TO AMBULANCE: I_� I RESPONSE ZONE-0 - NYIES ❑ NO L1 �L"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I �? EMT-1 TECHNICIAN N ` 'U PARAMEDIC i `j Hx: �� \ DISPATCHER: �• f i t �i=Z-( -1 L�11 CHIEF COMPLAINT: � DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) G,'� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL,CDVPAGF7_ IND STRIAL ❑ YES ❑ NO NO.OF PATIENTS: PRIVATE INS. CO.: BASE RATE: - KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS Jt: TOTAL MILES: 2 X 2,'SO 3 ' MEDICARE p: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ,1 ❑ YES ❑ NO NIGHT: (19:00-07:00) �• CCHP/PPHP M: EMERGENCY RUN: ss .J(,ICv1EDI-CAL M: CODE 2/3 -•-= (AOTHER: OXYGEN: (PER TANK) - -, P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) LL_ �0,co o 1q E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X sil)/ f/l �.ij L�J DRUGS: (PER ADMIN.) X NAME: 1 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS. ' Com' 1 ORAL AIRWAY: (IF NOT REPLACED) CITY:-��� U�f-n�J� STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE:'S-J -S QWORK PHONE: DRY RUIN: .(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: 1 �'�_J' n_I � I S .[1U 70 . I CITY: STATE: ZIP: COMMENTS: 2 TOTAL: PATIENT RECEIVED BY: X ` N&tL Pr,vidrr rrtai. Aitr Mrd P:,.. SIG ATU E) 'rF .4etur� Yr';re -nCp ^I." vhr� h:1'inp OIS-I t CONTRA COSTA COUNTY AMBULANCE �i _ j " 7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M 9 '1 � CHECK OR FILL IN APPROPRIATE SPACES DATE: G ? — PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE aq oil / / I CITY STATE ZIP DOB ❑ Sn ❑ M �T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH ��p�S�J ASSC� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ l INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 22-3 n V14 �i Gh' TO SCENE O. CALL RECEIVED L ❑ P.D. TIME 10-8 .2.9- <.J _ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 11 MILEAGE: ❑ OTHER/PVT TIME 10-7 LEND TIME 10-98DOCTOR PMD/ER ART TIME 10-22HOW CHOSEN: TAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME - - ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE C MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZO ❑ YES 13NO 13 WALKED ❑ GUERNEY ❑ OTHER r - i c PATIENT CONDITION: DRIVER �^ n (Z-h �� 0 EMT-1A TECHNICIAN__ o �.SC' ��5-0 PARAMEDIC ^A Hx: l Z Com'. �2 r y &;,q t`' DISPATCHE I " - ` CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN 'Z-74Q r R FD 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: t KAISER C MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: C� 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/RE 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: j ADDRESS: CITY: ST9TE: ZIP: COMMENTS: TOTAL: �� r W0042PATIENT RECEIVED BY: X Prmnidor retain L'hit• a+rd hint- corp Netury Yr•!.+t• ^•'I,y M EPL•' tJherr 1,illina (SIGNATURE) CMS-1 ' 1 II CONTRA COSTA COUNTY AMBULANCE PRE—HOSPITAL CARE FORM I UNIT AUTHORIZATION M Q 9 I CHECK OR FILL INAPPROPRIATE SPACES DATE: �� PATIENT'S NAME.- _V ..•M ❑ F COMPANY M ��'G -� !9 ADDRESS J6 9_-A-_3rd. ..Si-- ---- --- AGE C( _ U / C 0511, ; CITYC�L-_- STATE.-C—Q- ZIP—__n_. DO�_=6�� ❑ Sn ❑ M ❑ T 16W 11Th O F .O S DRIVER'S LICENSE is ___ _..__.. PHONE L -l._�_)_ 6_ NATURE OF DISPATCH i \ TYPE OF TRANSPORT: AMBULANCE iOTHER❑ Elo(- t_�_ INCIDENT LOCATION: �(,�� RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) / � t o h TO SCENE- O.— CALL RECEIVED -- -- '� \t L �ti'K: -- -�— ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ( J v ❑ PSAP TIME 10-49 �� j --_ Lc�tc�-2 t 1�._ _ MILEAGE: ❑ OTHER/PVT TIME 10-7 u END_ �1 TIME 10 98 7 DOCTOR _ ' V L - PM "ER STARTS 1_-1 TIME 10-22 HOW SEN: TOTAL �� STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME Y� ❑ PATIENT ❑ DIRECT D OTHER { CALL BACK#: AMBULAUCE.COO P�PT MBULATORY) PATIENT TAKEN TO AMBULANCE -3 RESPONSE ZO t ES ❑ NO D WAL':ED 'g-GUERNEY ❑ OTHER __L� _rfC;, yLeCA PATIENT CONDITION: DRIVER n P rSa�^ �'S�' EMT-IA 1 TECHNICIAN L C h 1 ](> - PARAMEDIC I Hx: + , laD DISPATCHER: - __ CHIEF COMPLAINT _ _ DRY RUN: ❑ YES NO REASON FOR DRY RUN t27_1aRt �1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__. MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. it_ PRIVATE INS. CO.. —_ — BASE RATE- KAISER ATE KAISER R: --. _ MULTIPLE PTS. BASE RATE 1 l / BLUE CROSS It: --._-__— _ TOTAL MILES: X MEDICARE#: __ E.O.B. ATT ROUND TRIP: ❑ YES 0 NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP q:- _. EMERGENCY RUN: �>✓ MEDT-CAL k: _--_ - CODE 2/3 OTHER __. _-_ __ -. OXYGEN: (PER TANK) 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 DRUGS: (PER ADMIN.) X NAME: tVrn�r RELATIONSHIP:__L"__4�__ E.O.A.: (IF NOT REPLACED) ADDRESS/_1---14-a0.cb.0_vr ORAL AIRWAY: (IF NOT REPLACED) CITY: 1-11�nnhi'��.__.. -__ STATEC:(,--- ZIP:-_.____ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:_-_ _ DRY RUN: (AUTHORIZED) EMPLOYER: - _-_-____ , OCCUPATION:_ __. .__ OTHER: . ADDRESS:-__-_.___ CITY: [�' _ STATEN. c ZZIIP:-- C MMENp( TS:._ .T 1_-x .�T HCl _�L�---- --- 1 004 TOTAL-. --- ---_- ____- - - --- .__ PATIENT RECEIVED BY: X SL r'"vldrr «;ir,• r! r:,.; ,..ry -�•:.rn rr•'L:c -gyp: nr:' ::hon hf1-iro (SIGNATURE) 1715-1 / I 1 1 CONTRA COSTA COUNTY AMBULANCE ��� PRE-HOSPITAL CARE FORM I UNIT 1 L/1 1 AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME �-U F�/���`� r<n n)p ) J EJ_-t� ❑ M/� F COMPANY N / �O ADDRESS -W �C.._(il�� �LC(,� AGE W -. Y CITY_ C � _T�nIe- LL❑Th OF-OS STATE—ek- 41� ! ❑ 4 I DRIVER'S LICENSE if _ _ _... . ___-... _..__._... PHONE ___ _____-___ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ .. __ _.__ __.___... .._ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOCK) , TO SCE �n �� CALL RECEIVED ❑ P.U. - TIME 10-8 I PATIENT DESTINATION: FROM $BENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 f �'�j :Yz i MILEAGE: ❑ OTHER/PVT, TIME 101 L ' ill ����� END__—� TIME 1098 DOCTOR(1��1iC3={ ^"'sti.uua- PM 'ER START - TIME 10-22 HOW CHOSEN TOTAL -. !!X STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULAN?EgOfAPANY: PT. AM U TORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_sr - '� lJ ❑ YES 0,NO ❑ WtiL':ED ,UERNEY ❑ OTHER _ PATIENT CONDITION: �,>rjT4a DRIVER_�I p���� 1� «� `_�!1 ''!!© EMT-tA_ I TECHNICIAN_ A1L � '71B PARAMEDIC Hx: _C ) _.. --- - - -- -- --- DISPATCHER: ` CHIEF COMPLAINT: _. .GC.LI( �C4H1� L __„ DRY RUN Cl YES XNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X.__.._—____-- MEDICAL COVERAGE:py INDUSTRIAL ❑ YES �Kv0 NO. OF PATIENTS: S.S. a __,n,11 f PRIVATE INS. CO.:�— _— BASE RATE: xTU'iJ , KAISER #: MULTIPLE PTS. BASE RATE � I BLUE CROSS N: TOTAL MILES: "� X t��* MEDICARE #: _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (1900-07:00) CCHP;PPRP#: — EMERGENCY RUN: •U MEDT-CAL#: CODE 2 J 3 • OTHER: OXYGEN: (PER TANK) 017 �} `l�) ) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED; _.._ —_ STANDBY: (OVER 15 MIN.) E.K G.: (PER EPISODE) >R f IF A(ik6 i HFI A I II F HF�i1'(V I`iIHI F PAH I Y IV IPFII AnMIN) X 0111101 11'rIl AI)MIN) X NAMfv�'A" �T<R V Y1R-/ftEA/TIONSHIPc�___ ___.. E O.A.: (IF NOT REPLACED) AnDRFSS: Iv2 ' ��><�c l.L=.__,-,._ __- ORAL AIRWAY: (IF NOT REPLACED) CITY: _2�s-`. __ STATE_—ZIP:—_ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: .(AUTHORIZED) EMPLOYER: r_'P :t<tc'cl__..____ OCCUPATION: OTHER: ) I ADDRESS --- -- ------- -- - I J�OPI f. 1 CITY ... _.___ STATE:. COMMENTS:__ - - - - - _ UC425 --- TOTAL PATIENT RECEIVED BY: X �L (SIGNATURE) t CONTRA COSTA COUNTY AMBU—"CE. L PRE-HOSPITAL CARE FORM 1 UNIT tx7j AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES 1 TO 1 DATE: tE t PATIENTS NAMEI R ❑ M 13F COMPANY N C ADDRESS AGE CITY STATE ZIP DOB— ❑ Sn ❑ M ❑ TW O Th ❑ F ❑ S DRIVER'S LICENSE N PHONE _— NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: ktEgUESTED BY: TIME- (24 HOUR CLOCK) ' (, /rfLl cc TO SCENE- O. CALL RECEIVED ✓�� i J _sL 6 P.D. TIME 10-8 �� d PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 n n 1 A l ❑ PSAP TIME 16-49 /"' l/ 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 *? 1:1 PATIENT ❑ DIRECT ❑ OTHERCALL BACK N: AMBULANCE �C'AO`MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: v RESPONSE ZONE�� ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER - EMT-1A TECHNICIAN N,-7 Z 0PARAMEDIC - Hx: DISPATCHR: E�` •(' I I l�l q CHIEF COMPLAINT: DRY RUN: IYES 13 NO REASON FOR DRY RUN Ali 41mJ3l2,Lftr_rf AUTHORIZA ION FOR DRY RUN(EMS USE ONLY) 5 999 PATIENT REFUSED SERVICES: (SIGNATURE) X 51�- 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.Q.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR:,(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) Ati EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: } -- - TOTAL:� � PATIENT RECEIVED BY X . ®® .) L th`ri irr rrte'. vhi t• .! ^i.;f 4r h.. ., .. (SIGNA tL1AFl tr ; .. r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N AJ CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 f 'PATIENTS NAME' O M tult: COMPANY N U il) ADDRESS, � _ � ' AGE CITY STATE ZIP DOB- O Sn OM O T I W O Th OF OS DRIVER'S LICENSE N } PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ STATION I(A)_2(B),3(CV,_4(D)_5(E)_ INCIDENT LOCATION) RESPONSE CODE' , OUESTED BY: TIME-- (24 HOUR CLOCK) _ TO SCENE- I�S.O. CALL RECEIVED •r� r. or Sr ..� �,. I O P.D. TIME 10-8 LL PATIENT DESTINATION: V - FROM SCENE- 13FIRE TIME 10 97 •y �Myy/` O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 +_ : -•( S END TIME TIME 10-98 t l;DOCTOR '. ` I PMD/ER START TIME 10-22 5 HOW CHOSEN: TOTAL STANDBY TIME G Vii..O NEAREST-? O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER !!j;CALLBACKN: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE I 13YES, 13NO O WALKED ❑ GUERNEY ❑ OTHER.- 2 - t PATIENT CONDITION:.15L4..., DRIVER t7 EMT-1A TECHNICIAN f CO2-14 T f .' CI PARAMEDIC1) Hx: DISPATC ER �OK� CHIEF COMPLAINT: DRY RUN- YES 13 NO REASON FOR DRY RA�ft flap 1� A RIZATION FOR DRY RUN(EMS USE ONLY NR r, 1!!,:-PATIENT REFUSED SERVICES: (SIGNATURE) !� 0-) 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) i CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: r. 'I CODE 2/3 OTHER: 1 OXYGEN: (PER TANK) P.O.E. STICKER O 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:• RELATIONSHIP: E.O.A.: (IF NOT REPLACED) r ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) I CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) -' EMPLOYER: OCCUPATION: OTHER: ADDRESS: `•-CITY: STATE: ZIP: "COMMENTS: - � r OTA •ty�1�/• 2 7 - PATIENT RECEIVED BY X Pf�+ri.fi•• rvr. !.• t�:•,• ../ p.. : •...;... „ iS1fiNATlIRE1 IM VRE NTRA COSTA COUNTY A BULANCE 0SPITAL CARE FORM I UNIT AUTHORIZATION N CHECK ORTILL INAPPROPRIATE SPACES DATE: 9 - U PATIENTS NAME iJ T �\ U IU ❑ M ❑ F COMPANY a pg 1t ADDRESS AGE U Ir CITY STATE ZIP DOB ❑ Sn ❑ M' ❑.ek� O Th ❑ F O S 1 l DRIVER'S LICENSE k _ PHONE NATURE OF DISPATCH--j- TYPE OF TRANSPORT: AMBULANCElal OTHER❑ INCIDENT LOCATION: i RESPONSE CODE: RFQUESTED BY: TIME- (24 HOUR CLOCK) ICS Q n TO SCENE { S.O. CALL RECEIVEDCvVZ� � n Q, (vvv�f P.D. TIME 10-8 1—f- PATIENT DESTINATION: u FROM SCENE777---- ❑ FIRE TIME 10-97 �� r r ) U ❑ PSAP TIME 10-49 �� 1 ' ' v MILEAGE: ❑ OTHER/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 _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANYCIA- PT. .� 'n IA' L PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: V RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER — �� EMT-tA f TECHNICIAN Z MEDIC Hx: I�Z LS l ak) f1A C7— S-GLI1-t-' DISPATCHER: 1 . A . -� CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION F RUN (EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X.Z 44 bAffpCAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: /S f S.S. p P.TE tNS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: 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 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) - CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) L—�-•� I PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: i ADDRESS: I CITY: STATE: ZIP: COMMENTS: TOTAL:-- PATIENT RECEIVED BY: X (SIGNA*11RE) VCONTRA COSTA COUNTY AMBULANCE �( PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M_v 1 Li CHECK OR FILL IN APPROPRIATE SPACES DATE: ( U J )I,PATIENTS NAME W L II-zp0 �C Om f..E COMPANY N 1 '�� ya y TN ADDRESS ' ' J ) • AGE .a :�; CITY�V�-AM-�ND STATE ZIP 7 b V 1 DOB?--Z-Yr OS, OM OT OW O Th OF ❑ S '• DRIVER'S LICENSE MI_ PHONE LS 51-Sg_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION'. RESPONSE CODE: REO Y: TIME— 124 HOUR CLOCK) A� �j 1)'T �,� TO SCENE- O. CALL RECEIVED ._6._ :t'i� . 1 D P.U. TIME 10 8 �` 1 :� c' S.PATIENT DESTINATION: RC Ek V\CN FROM SCENE- D FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98 .iDOCTOR 1 �f� PMD START TIME 10 22 HOW CHOSEN: TOTAL j O STANDBY TIME ❑ NEAREST. D FAMILY ❑ TRANSFER WAIT TIME 7-RATIENT ❑ DIRECT ❑ OTHER QST CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `� RESPONSE ZONE ES ❑ NO A1' LKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVEREI,AT-1A :SI qU i TECHNICIAN rtJ(L-S /) — DIC H": Kf DISPATCHER: &HIEF COMPLAINT: SNI FfING C-UUF DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN l7RAfl�1 �l- El7l/`I(rl� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ,�• ICALCOVER GE: NDUSTRIAL ❑ YES�10 NO.OF PATIENTS: s 72- �Z - 7/ PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES:_ X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO t &(p ❑ YES NIGHT: (19:00-07:00) •� ,,aJ D J /PPRP gW� `� S EMERGENCY RUN: _ _ EDT>rFCCiI: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER '0 YES �NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1/J 7 E.K.G.: (PER EPISODE) Y1 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X - NAM E: -Mc-kzIr IhAP-TINfZ RELATIONSHIP:GR• mO. E.O.A.: (IF NOT REPLACED) _ ADDRESS: S? 1 If;- 51- ORAL AIRWAY: (IF NOT REPLACED) _ _„L CITY: STATE—CmA,ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 23 S� Sg WORK PHONE: DRY RUN: (AUTHORIZED) ."_EMPLOYER: tJ1JL+"l 'C' D OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: __ J TOTAL:��9 a - PATIENT RECEIVFII RY X 1 CONTRA COSTA COUNTY -AMBULANCE 2 j S—• 7 —7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N J 1 l CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME_ `� ❑ M ,D F COMPANY N ADDRESS ! J f' �� AGE CITY^�(o1 _ STATE ZIP DOB_ ❑ Sn ❑ M ❑ T ❑W �-h ❑ F ❑S DRIVER'S LICENSE N _____ __� __ PHONE _�__ NATURE OF DISPATCH— TYPE ISPATCH TYPE OF TRANSPORT. AMBULANCE Q OTHER❑ __ _ STATION 1(A)_2(B)._3(C)_4(D)_5(E)_ •• INCIDENT LOCATION: RESPONSE CODE: ljEPCIESTED BY: TIME— (24 HOUR LOCK) TO SCENE 0._ CALL RECEIVED / O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 11 PSAP t ` �t�l � � 1y__ 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 COMPANY: - PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE _1 ❑ YES ❑ NO ❑ WAL'CED 13 GUERNEY ❑ OTHER i PATIENT CONDITION: DRIVMT-1A I TECHN RAMEDIC Ll j Hv _ DISPATCHER: " 1 I CHIEF COMPLAINT: �. DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN TRIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X _I�t 1).0 i I J�` ic MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 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 l ❑ YES O 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) j� DATES BILLED: STANDBY (OVER 15 MIN.) ^�F E.K.G.: (PER EPISODE) I� 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: 1 ADDRESS: ' 1 CITY: STATE: ZIP: COMMENTS: - TOTAL• c PATIENT RECEIVED BY:X ` t.. Pr-vider retair Whit, ,r,J ri, (SIGNATURE) rF .ictur Ye a%. nIf vh,, E 1 iv, 015-1 q ��. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N Q CHECK OR FILL IN APPROPRIATE SPACES ?' DATE: r• 22 L� / PATIENTS NAME. J OM ❑ F COMPANY N / ,�_ ADDRESS AGE „ CITY STATE ZIP DOB O Sn O M OT ❑ WXTh O F ❑ S DRIVER'S LICENSE N _ _ PHONE — NATURE OF DISPATCH M CY/ TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: (` RESPONSE CODE: R UESTED BY: TIME— (24 HOUR CLOCK) �V /'I+,] /� f ( n+^�^ �,/ TO SCENE-/� 7.0.— CALL RECEIVED r�L c; t i d� r '� }�' 1/'� 1(j� / J O P.U. TIME 10-8 �� J,3 1 PATIENT DESTINATION: FRO SCEN - ❑ FIRE TIME 10-97 I ❑ TIME 10-49 OTHER/PVT i (v� MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 W :32- HOW 3 2-HOW CHOSEN: TOTAL STANDBY TIME I' O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 11 PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: <' / RESPONSE ZONE — 0 YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER -� ~ PATIENT CONDITION: DRIVER - S L7 EMT-IA TECHNICIAN �/ n l`1 Q PARAMEDIC 60 Hx: A DISPATC E : I I 4C4 / CHIEF COMP AIN/T: r ve,✓ DRY RUN. ES ONO REASON FOR DRY RUN Y 7 AUTHOR( 10 FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ O NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: ` KAISER C MULTIPLE PTS. BASE RATE > BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: MEDI-CAL.0: CODE 2/3 � OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 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) i EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: _ TOTAL: PATIENT RECEIVED BY: X A++pir{rr rr'/aa L'hi r; I ri.. L '--rli, - v. . w ,.•�. 1 ------(SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITO�'7 ( AUTHORIZATION N •�.1 CHECK OR FILL IN APPROPRIATE SPACES 1 DATE: fPAtIENTS NAME ❑ M ❑ F COMPANY N ADDRESS; AGE CITY STATJ(�' V ZIP DOB ❑ Sn 13M ❑ T ❑ ❑ F ❑ S i DRIVER'S LICENSE N t PHONE — NATURE OF DISPATCH `22L 4 TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 1(A)_2(B)_3( -4(0)_5(E)-„— l NCDIDE LOCA ON:i ��W C RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C OCK) TO SCENE- CALL RECEIVED Z� ❑ P.D. TIME 10-8 / / 1.•-.' PATIENT DESTINA . N . i FROM SCENE ❑ FIRE TIME 10-97 Q/ , ❑ PSAP TIME 10-49 T EX*, 10 _ ! MILEAGE: ❑ OTHER/PVT. TIME 10-7 (;r-I END TIME 10.98 Si DOCTOR' V PMD/ER START TIME 10.22 _T HOW CHOSEN: TOTAL _ STANDBY TIME !� ❑ NEAREST,.;# ❑ FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMB,U}ANCE COMPANY: C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO _ ❑ WALKED ❑ GUERNEY ❑ OTHER F PATIENT CONDITION: DRIVER uL1C /r. ' EMT-tA TECHNICIAN �L W�� I fc, PARAMEDIC '��-� Hx: DISPATCHER: J CHIEF COMPLAIN DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIEN4 REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.M „ PRIVATE INS.CO.: BASE RATE: I KAISER 0: 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 0:1 ' EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 ✓� OTHER: OXYGEN: (PER TANK) tl P.O.E. STICKER ❑ ES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '—NEAREST RELATIVE/RES 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: A STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WOK PHONE: DRY RUN: (AUTHORIZED)' ""EMPLOYER: O UPATION: OTHER: I ADDRESS: ---CITY: ST TE: ZIP• -COMMENTS: TOTAL:IJV' PATIENT RECEIVED BY:X l CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: V g - PATIENT'S NAME 'hfA.(ZCrZu�Z� S ClA-S 'WM ❑ F COMPANY# /l C ADDRESS n AGE j CITY.,T�CSZ�i1 ( Z't(�s,�ATE_C—" ZIP IDOB ❑ Sn ❑ M ❑ T ❑ W WTA O F. O S -I DRIVER'S LICENSE q PN NATURE 7 NATURE OF DISPATCH- TYPE ISPATCH TYPE OF TRANSPORT: AMBULANCE17`�OTHER❑ INCIDENT LOCATION: r,J RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C 0 TO SCENE- ZIS.O. CALL RECEIVED ❑ P.O. TIME 10-8 C I PATIENT DESTINATION: TLe FROM SCENE - ❑ FIRE TIME 10-97 { ? v ❑ PSAP TIME 10-49 — ' MILEAG ❑ OTHER/PVT TIME 10-7 _ I END TIME 10 98 DOCTOR PM START _�;Y TIME 10 22 HOW CHOSEN: TOTAL _ STANDBY TIME -- /4g--NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER1 CALL BACK#: AMBULANCE COMPANY: SAS` PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: -?1 RESPONSE ZONE_ ' YES ❑ NO ❑ WAL',ED 'KGUERNEY Cl OTHERo PATIENT CONDITION DRIVER G_Q_R_V&5_ S EMT-1A N` TECHNICIAN �(�f�ZSS�-C*C`�?'"" 'PARAMEDIC HX. V_�� .Q.k rb�2_ DISPATCHER: )JIB' / `_( 1 CHIEF COMPLAINT * '_g� A.L� J.. DRY RUN: ❑ YES � NO REASON FOR DRY RUN ,TAUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X I J I MEDICAL C V GE: INDUSTRIAL ❑ YES KNO NO. OF PATIENTS: S.S. w - 2 V_3? PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS" BASE RATE U/ L E CROSS 4: __ TOTAL MILES: X MEDICARE#: _— E.O.B. ATT. ROUND TRIP: ❑ YES ❑ y0, Cl YES 11 /y NO NIGHT: (19:00-07:00) /" ; ��ZlL �•. CCHP/PPHP#: EMERGENCY RUN: 3p,C/v MEDI-CAL a: CODE 2/3 /, c3 _ OTHER: OXYGEN: (PER TANK 77 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBA I DATES BILLED: — STANDBY: (OVER 15 MIN.J l E.K.G.: (PER EPISODE) I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.)_ X NAME t--`L][L1�- ��.�� � �RELATIONSHIP:I%_C_� E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:_ _-___ STATE___ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ��� — WORK P E: . In. DRY RUN: (AUTHORIZED) EMPLOYER:e-aboyZ,0 Ate'k iFd HER; c 00 CITY: K. — STATE:G�ZIP:— 5149 CO NTS. _� S_-� __ \ _( ��C� TOTAL:- - - 33 PATIENT RECEIVED BY:X cS C Jti:+ri arr rrt.. r+r 1': . - 5,•,,n t"; (SIGNATURE)'L' ^)`? nr.' when t i 1'i ng LMS-1 I .,t CONTRA COSTA COUNTY AMBUL r , PRE-HOSPITAL CARE FORM I I liz UNIT AUTHORIZATION N rl. a CHECK OR/ILL IN APPROPRIATE SPACES DATE: PATIENTS NAME Al ❑ M ❑ F COMPANY M f / pat ADORES S AGE �� , CITY TAXL_J.'�IU V DOB .❑ Sn O M O T O W OF Os.- DRIVER'S $..DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:;AMBULANCE D OTHER 0 -- STATION 1(A),2(B) 31 (D)_51E1_ INCIDENT LOCATI ' RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) r I TO SCENE-�VA 0. CALL RECEIVED ❑ P.D. TIME 10-8 —� PATIENT DE TINATION; ; FROM SCEt4E ❑ FIRE TIME 10-97 ' ❑ PSAP TIME 10-49 MIL ❑ OTHER/PVT TIME 10-7 ` YI ` END TIME 10.98 DOCTOR I PMD/ER STAR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST..;! ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE C P PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C / l RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �`Y� L�"`" ` r� 1 EMT-1A TECHNICIAN - \' - ' �' PARAMEDIC t Hx: DISPATCHER: /JO/ CHIEF COMPLAINT: DRY RUN, S ❑ NO REASON FOR DRY RUN `7 10 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) gyV )( PATIENT REFUSED SERVIC S: (SIGNATURE) ?52 2 MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: c S.S.N i PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO t ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT—CAL M: t CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STI KER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES LLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -- NEAR T RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) rX NAM RELATIONSHIP: E.O.A.:(IF NOT REPLACED) ADDR SS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: STATE ZIP. C-COLLAR: (IF NOT REPLACED) PHONE. WORK PHONE: DRY RUN: (AUTHORIZED) ail EMPLOY OCCUPATION, OTHER: ADDRESS: CITY: STATE' ZIP. - COMMENTS: f TOTAL: �a [� PATIENT RECEIVED BY:X Pr. ,.I{.. r�•>r. �+lr r (SiONATIJRE) '{ 'i,: •t Steri,.-. Y ' •v ... t !., ;.w.n !�! i.:. b15-1 CONTRA COSTA COUNTY AMBULANCE ^ aw PRE-HOSPITAL CARE FORM 1 UNITAUTHORIZATION N ® r CHECK OR FILL INAPPROPRIATE SPACES DATE:-- 0/ v 1 ���� l Y PATIENTS NAMFQZt�\`"A�1_�R'��� 7� X M O F COMPAN N ADDRESS-L-1- AGE=1_L�p L 013 I CITY•Y. STATE ')/ ���ZIPSCC DOB/E!.—/.3 ❑ Sn ❑ M OT ❑ W A7Th ❑ F ❑ S DRIVER'S LICENSE N t�B& 1 07 PHONENATURE OF DISPATCH FA�� TYPE OF TRANSPORT: AMBULANCEF OTHER O INCIDENT LOCATION: + S�- ]RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR C�LO[.CK)^ TO SCENE- )Z S.O. CALL RECEIVED yAtbl�l% Q :C�, - 3 ❑ P.D. TIME 10-8 1 •PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 ❑ PSAP TIME 10.49 . �� .' S�•� r• _ �V MILEAG :^ / O OTHER/PVT TIME 10-7 _z5_ 62-12- END oC TIME 10-98 3rDOCTOR S 1 PMD START //�� TIME 10-22 HOW CHOSEN: TOTAL 1 ( STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 'PATIENT ❑ DIRECT ❑ OTHER / CALL BACK#: AMBULANCE COMPANY' QQ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 /� RESPONSE ZONE_____J_ T-CYES ❑ NO O WALKED WGUERNEY ❑ OTHER (� r PATIENT CONDITION: DRIVER EMT-1A /� I TECHNICIAN KUs -- IeEe. .t `='�� PARAMEDIC 51 Hz: ���� DISPATCHER: _J�4��(_���L_ �'I i �j , -) CHIEF(COMPLAINT: L- S F DRY RUN: ❑ YES NO REASON FOR DRY RUN q­zc�,t`c-,� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ _ � �� ;. MED CAL COVERAGE: INDUST IAL O YES 15-NO NO. OF PATIENTS: ` �`� S.S. # S '. PRIV E INS. CO.: BASE RATE: K I N: MULTIPLE PTS. BASE RATE BLUE ROSS#: TOTAL MILES: l X I EDI A{iE N: 42 S99-2-4 E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) rr CCHP/PP P N:' EMERGENCY RUN: 3o d T MEDT-CALI#: CODE 2/3 OTHER: OXYGEN: (PER TANK) I P.O.E. STI C ER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ATES BIL ED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -' NEA ST LATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X r DRUGS: (PER ADMIN.) X -+ NAMR %G0 Ag.S ELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:%:5PQrnV- ORAL AIRWAY: (IF NOT REPLACED) —T -i-CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE r� -� (20WORK PHONE: DRY RUN: (AUTHORIZED) -- EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:_tT C�n�tb�D l)nA61i -V) t \ oc)v r _ , TOTAL: - 7 DO —_ PATIENT RECEIVED BY X _ _. 0 Yn•„idrr r�rr;c Vh,•. -- r,. �.•r;., 11, 1SIGI�A711RE) t- ; CONTRA COSTA COUNTY AMBULANCE 4/457 PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# - CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME u OM OF COMPANY# / " ADDRESS AGE CITY STATE ZIP DOB -❑ Sn OM O T0��--W 13 Th O F��0 S , DRIVER'S LICENSE M __ PHONE__—_____ NATURE OF DISPATCH_L�f-"Z���� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) / 4f O SCENE- O.— CALL RECEIVED `_ t 2�� c"1&Z912/1, -- ❑ P.U.- TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 vO PSAP TIME 1D-49 _ V I MILEAGE: ❑ OTHER/PVT TIME 10-7 ! / END TIME 10-98 :�. DOCTOR - - PMO/ER START l to TIME 10-22 /`1 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK H: AMB A E COMPANY: i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER v PATIENT CONDITION: DRIVER-Le/ �A- U EMT-1A 21 `;•,j ;' TECHNICIAN y 4 PARAMEDIC i Hx: DISPATCHER: CHIEF COMPLAINT: iRYU ES ❑ NO REASON FOR DRY RUN /f�e�ATION F RY ' (EMS USE U LY) — y PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 5� S.S.# PRIVATE INS. CO.: BASE RATE: 1 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: —(+ TOTA��• [� PATIENT RECEIVED BY X 7M' L 1 + CONTRA COSTA COUNTY AMBULANCE }� �j PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N • CNECX OR FILL IN APPROPRIATE SPACES DATE:_ 1 X PATIENTS NAME 1 (+- OM OF COMPANY ADDRESS ©.� t� r`' LAGE I An tan c3 x CtTY , e STATE ZIP DOB ❑ Sn OM OT OW OTh O F OS I '; DRiVEl�' •LICENSE N E t PHQNEW2Z*3_._ ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ 4„ r,J�.. INCIDENT LOCATION! "' ', RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) 1�_r`1•��, i� ! i� TO SCENE- S.O, _ CALL RECEIVED _.2 ❑ P.D. TIME 10-8 : JPATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 MILEAGE: ❑ PSAP TIME 10-49 �� 3 V j� ❑ OTHER/PVT TIME IG-7 � { END `'' TIME 10-98 12—Z :__.6:_0 OOCiTOR �� PMD/ER START-4 TIME 10-22 r HOW CHOSEN: r TOTAL STANDBY TIME O NEAREST, O FAMILY O TRANSFER WAIT TIME t.7 ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK II: AMBULANCE COMPANY: 611 1 PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: t RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER !J ;. PATIENT CONDITION: DRIVER R IS! " Et,AT-1A 110LIT LA,_ . : TECHNICIAN_� �.� �/��� PARAMEDIC lJ�j Hx: DISPATCHER: �� CHI CQ PLAINT: �I� K DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ) AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 2 PATIENT REFUSED SERVICES: (SIGNATURE) X /(3 MBA GE: INDUSTRIAL DYES ❑ NO NO. OF PATIENTS: .� S.S.M PRIVATE IN .CO.: ( i A� BASE RATE: ��✓'` KAISER R:�� t GNFE n/�9}2 MULTIPLE PTS. BASE RATE I ' BLUE CROSS M: D/Q/L lQ/S •` e G 1a 5- TOTAL MILES: X i•�rn Y MEDICARE M: Sd f�'�� t`f C StE.9614 ��UNO TRIP: ❑ YES ❑ NO ' s. /C• �C�/ ❑ YES ❑ NO NIGHT: (19:00-07:00) ? 00 CCRp/pPmP N: EMERGENCY RUN: o MEDT-CAL 8: 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) i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X J' DRUGS: (PER ADMIN.) X n�, ,�� NAME: �� `-�'� 'E� RELATIONSHIP: d ( 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) �„ EMPLOY€R: OCCUPATION: OTHER: 3 ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: �.. . PATIENT RECEIVED BY X Provider retain Vhito rrld Pink ropyNuturu I', '1014 ,ru, (SIGNATURE) }y ! � E.rL. whan }.f t'i nye EMS-I I:(IN I IIA ( (I':I/l (A)I IN I Y AMIIIII ANCr PIIE-HOSPITAL CARE FORM I ci 13NIT '( AUIHORIZATION#_- CHECK OR FILL IN ArrnorpIATF SrACFS I,T DATE: �•� t PATIE=NT'S NAMF(_.__P//� JJ 0( QC91C I ll�j�_�C Q'1gl ❑ F COMPANY It .__/.___- ADDRrSS AGE _ h !1 U SE - - CITY.:_W_ _v-__ STATE__5_L7_.__. ZIP_LG[.. _ .___ D01347 ..-1;1-❑ Sn ❑ M ❑ T ❑ W ❑ Thett6 ❑S i DRIVER'S LICENSE _ PHONE( 3 _.r _Y.�.b�..._ NATURE OF DISPATCH, US•S /� T •t TYPE OF TRANSPORT AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE- �' S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - 2 ❑ FIRE TIME 10-97 1 :SIX-�� ___-__(/- ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END ) 1' TIME 10-98 1 DOCTOR - PMD/ER STAR_ _� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AM L NCE COMPANY: PT AMBU TORY? PATIENT TAKE TO AMBULANCE: ��� RESPONSE ZONE ❑ YES CIO ElWAL'(ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_-�NQ {' TECHNICIAN -_ u� E�Z� -I '� PARA Hx: ----�� I/- - -------_- -_ ___ DISPATCHER. _.1-1__, l I ( , •r ( CHIEF COMPLAINT: JJ(. L.�_- DRY RUN: ❑ YES.P-NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) r �r MEDICAL COVERAGE: INDUSTRIAL ❑ YES WNO NO. OF PATIENTS: S.S. it ._ — --------- - _/\ PRIVATE INS. CO.: ___._.__�_-__.--..-_--.-_ BASE RATE: fig c� Y� KAISER#: __ _.__ — � MULTIPLE PTS. BASE RATE CROSS#_ I ':�) `_ -_l_.) AT 6 C•�V• TOTAL MILES: v X DICAR �E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT (19:00-07:00) CCHP/PPRP#:—.___—__.._._. —_.—_ __-_ EMERGENCY RUN: e7.cz) 0 MEDI-CAL b:— —^ CODE 2/3 E OTHER: OXYGEN: (PER TANK) P O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) DATES BILLED:—__._.. _____ _— STANDBY. (CVER 15 MIN.) �) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE 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: OTHE� / ADDRESS: CITY: _—_-_— STATE: ZIP: �j ---- -- -- — TOTAL' PATIENT RECEIVED BY: X ?T••ui.[rrty,{�. T� cr. ., (SIGNATURE) _ n!. :.I:rr,' 1 . IRJ EJIS-1 r .. I i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR"LL IH APPROPRIATE SPACES DATE: 9 PATIENT'S NAME ❑ M O F COMPANY ADDRESS AGE CITY STATE ZIP DOB ❑ Sn ❑ M 137 13W ❑nTh �F 13S DRIVER'S LICENSE N '" - PHONE NATURE OF DISPATCH ©N &120'1 TYPE OF TRANSPORT:i AMBULANCE❑ OTHER — - . STATION 1(A)_2(8)._3(C)_.4(D)_5(E)_ I INCIDENT LOCATION: RESPONSE CODE' RE ESTED BY: TIME-(24 HOUR CLOCK) �} ^n��, TO SCENE- S.O. — CALL RECEIVED 1` pp a s:�L. 3/2 ❑ P.D. TIME 10-8 . " PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 { ❑ PSAP TIME 10.49 C MILEAGE: ❑ OTHER/PVT TIME 10-7 F 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 N: AMBULANCE% MPANY: j PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONES j ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:' -..1 DRIVER 1. Z!R TECHNICIAN > " AMEDI I{rO HX: DISPATCHER: 7 j 1'1 CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR"DRY RUN(EMS USE ONLY) j ?J� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: lf" &S.N I ! PRIVATE INS. CO.: BASE RATE: KAISER N: ' MULTIPLE PTS.BASE RATE. BLUE CROSS N: ` TOTAL MILES: X f MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:" EMERGENCY RUN: f MEDt-CAL N: CODE 2 13 /.' 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.: (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) I EMPLOYER: OCCUPATION- OTHER: ADDRESS: 1 I CITY: STATE: ZIP: COMMENTS: TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY:X IR.ui,fir rvrnir �'�:..• ..� ,... .. .. (Sr(:NATUgE) �,�PRE-HOSPITAL'CARE CONTRA COSTA COUNTY AMBULANCE FORM 1 UNIT AUTHORIZATION# CNECK OR FILL IN APPROPRIATE SPACES DATE: — ,3 PATIENTS NAME CIM ❑ F COMPANY# l Lp 1 ADDRESS AGE CITY STATE ZIP DOB—T_ ❑ Sn Om O T ,Oq�WO Th OF 13S ` DRIVER'S LICENSE# _ PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEt OTHER❑ __ STATION 1(A) (B)_3(C)-4(D)!5(E)_ f !1 INCIDENT LOCATION:!- RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR 9)LO�K)3 l TO SCENE- AllS.O. CALL RECEIVED ❑ P.O. TIME 10-8 �r PATIENT DESTiNATI FROM SCENE-� ❑ FIRE TIME 10-97 I( { ❑ PSAP TIME 10-49 MILEAG 13OTHER/PVT TIME 10-7 END TIME 10-98 �— DOCTOR PMD/ER START TIME 10-22 :� I i HOW CHOSEN: TOTAL STANDBY TIME _ O NEAREST O FAMILY ❑ TRANSFER WAIT TIME I ❑ PATIENT O DIRECT ❑ OTHER CALL BACK C AMBULANCE MPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE fi O YES ❑ NO . O WALKED ❑ GUERNEY ❑ OTHER ([ PATIENT CONDITION: DRIVER c�/y �f-/�� �. "'_L'� EMT-tA TECHNIC[ - PARAMEDIC 7�1 Hx: DISPATCHER: ` r CHIEF COMPLAINT: DRY RUN:)21'YES C) NO REASON FOR DRY RUN 4T) 22'-UTEl t9� `1 t '/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �5,� PATIENT REFUSED SERVICES: (SIGNATURE)X E MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: X f MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ' O YES ❑ NO NIGHT: 119:00-07:00) E CCHP/PPRP#: EMERGENCY RUN: I� MEDI-CAL#: CODE 2/3 OTHER: OXYGEN:. (PER TANK) P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) " NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 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: �I 00440 PATIENT RECEIVED BY:X _-_ I Provider rvin - Nit• .,,•.l nr,;; .,�•� y,I (SIONATURE) �N CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM 1 (I UNIT r AUTHORIZATION N n S�'7_ CHECK OR FILL IN APPROPRIATE SPACES DATE: /I'l q 1 PATIENT'S NAME (-yowL"//��/ ❑ M COMPANY N ADDRESS 10 3v /�'/4 '-'tffp/`) /C.-Q AGE 2� o iyo y1 ..., CITY 40STATE ZIP OOB��b-6�❑ Sn ❑ M OT ❑ W.O Th � O S "'j qq 4 ((//--�� �l/ I DRIVER'S LICENSE N __ _ PHONE oW a'� _ NATURE OF DISPATCH L TYPE OF TRANSPORT: AMBULANC-Ekq OTHER❑ STATION 1(A)_2(B)_31C (D)_61E)_ r INCIDENT LOCATION: RESPONSE CODE: RE,OUESTED BY: TIME- (24 HOUR CWIC,K) f`~ / � �• TO SCENE- S.O.— CALL RECEIVED j ❑ P.D. TIME 14.8 . �-.. iu_ t PA ENT DESTINATION,: / FROM SCENE- ❑ FIRE TIME 10-97 : 71 N ❑ PSAP TIME 10-49 •, 7 :�� MILEAGE: ❑ OTHER/PVT TIME 14.7 � END PID TIME 10-98 DOCTOR PM R START 'z TIME 14.22 HOW CHOSEN: TOTAL " f STANDBY TIME ❑ EAREST ❑ FAMILY O TRANSFER WAIT TIME J PATIENT ❑ DIRECT ❑ OTHER ( CALL BACK N:1 AMBULANCE COMPAI�Y:' � PT/ AMBULATORY? PATIENT TA TO AMBULANCE: c 7]*RESPONSE ZONE�,,// ss Jm YES ❑ NO ❑ WAL'<ED `GUERNEY ❑ OTHER o PATIENT CONDITION: DRIVER Lv 2 / _7i ' EMT-1 TECHNICIAN PARAMEDIC " A � ��•(� Hx: /9tt%U 0 s �C�l L zc) .Sf f eO DISPATCHER: �•I�. (' --� ' CHIEF COMPLAINT: L t• S c/C / DRY RUN: ❑ YES NO REASON FOR DRY RUN `- ���'n' ;rs � ,Ef r�P� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l PA ENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES<NO NO. OF PATIENTS: S.S. M t PRIVATE INS. CO.: BASE RATE: �• •I I KAISER N: MULTIPLE PTS. BASE RATE ! ! 1 BLUE CROSS N: TOTAL MILES: X (y-fro ' --1 Ir') MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO 'mss I ❑ YES ❑ NO NIGHT: (19.00-07:00) CCHP/PPRP N: EMERGENCY RUN: 1 MEDT-CAL N: CODE 2/3 �OTFTER� G��Oii�lt Z�LS'y OXYGEN: (PER TANK) r P.O.E. STICKER OYES ❑ NO NEONATAL: (INCUBATOR) { { DATES BILLED: STANDBY: •(OVER 15 MIN.) E.K.G: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: IV.: (PER ADMIN.) X COd 1 DRUGS: (PER ADMIN.) X NAME:�� // N RELATIONSHIP: G 5� 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: a1. TOTAL'_ ' - PATIENT RECEIVED BY. _ k_ t'y s� Provider rvtaf,. "it, ,r•1 r•I!: To Artur-, Yr';,L. "Ar 141 (SIGNATURE) dlf-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 3 1 2Ci � CHECK OR FILL IN APPROPR/ATE SPACES DATE: 1�1+ PATIENT'S NAME 1:7n IA N �.t1:> M ❑ F COMPANY# ' I ADDRESS 13 5 zrll) AGE_Z4_ CITY CII-t L►jlrC.C� STATE t^ F}- ZIP DOB~�/"- 1/ - Q Sn ❑ M ❑ T 0 W O Th QEF 0 S DRIVER'S LICENSE# -___...___-__._—_.. PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE - ❑ S.O. —_ CALL RECEIVED C H. Z ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE --_ TIME 10-97 %ICL d i Z ❑ PSAP TIME 10-49 1/,j 11 ^ / U� D tl MILEAGE: OTHER/PVT TIME 10-7 , END 7. Z C.C t ✓'t TIME 10-98 DOCTOR __aP_r I sm 1( 3 PMD/gR START 5 7. !C TIME 10-22 HOW CHOSEN: TOTAL _,L Z STANDBY TIME fl NEAREST ❑ FAMILY TRANSFER WAIT TIME -- ❑ PATIENT 0 DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 RESPONSE ZONE L r ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER . — 4 PATIENT CONDITION: DRIVER t i< 2l d I,AT-tA Fc,' TECHNICIAN lii4�< < .� ( PARAMEDIC / �] HK: T A NYl:) Fc,' P.-to I,u r{ISI DISPATCHER: 77 CHIEF COMPLAINT: ��s.�� �.to DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) I�C PATIENT REFUSED SERVICES: (SIGNATURE) X ,g� -79 13CAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: J PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE o' BLUE CROSS#: TOTAL MILES: A/ X - DICAR�#: Y V6 ��� - C�� ��� E.O.B. ATT. ROUND TRIP: 0 YES ❑ NO ' -� O YES ❑ NO NIGHT: (19:00-07:00) 9 US CCHP/PPHP#: EMERGENCY RUN: ao MEDI-CAL#: CODE 2/3 �` L OTHER: OXYGEN: (PER TANK) �/1U7 P.O.E. STICKER 0 YES 0 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: llabc1cf, RELATIONSHIP:_ E.O.A.: (IF NOT REPLACED) ADDRESS: ZN - 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: IP:COMMENTS: -- _ ._..._ .—.—_......._. . .. ._.. ..... TOTAL a s- jU, DO PATIENT RECEIVED BY. X �.i1J4.4!� ...�� ��lL ISIGW TUR CMS-I J t CONTRA COSTA COUNTY AMBULANCE �[, PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION M �QQ��3 J" ✓ CHICK ON FILL IN AIPIIOfltIATF SPACES DATE: to U 11 PATIENTS NAME OM OF COMPANY tr (2� S^ ADDRESS ' AGES_ CITY STATE ZIP__,______ DOB ❑ Sn O M O T O W 13 Th O F S DRIVER'S LICENSE N .- 1 PHONE NATURE OF DISPATCH t 0 t g f - - i TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 11A)._2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION ' RESPONSE CODE: RE ESTED BY: TIME- (24 HOUR CLOCK) ! TO SCENE- iS.O. CALL RECEIVED � ❑ P.D. TIME 16.8 PATIENT DESTINATION: i FROM SCENE ❑ FIRE TIME 10-97 D PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 5-DOCTOR '%` ` PMD/ER START TIME 10-22 0 ; HOW CHOSEN: TOTAL STANDBY TIME r•n_ ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULAA�NQMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE NE ❑ YES. ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER cSaO-CXVo'�)AI-�C- - ( EMT-IA � TECHNICIAN /L-1A PARAMEDIC__p___ ` Hx: DISPATCH 1(�D CHIEF COMPLAINT: DRY RU �YE O REASON FOR DRY RUN `f RI TI N F -Y RU MS USE ONLY) PATIENT REFUSED.SERVICES:(SIGNATUR MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: KAISER tr: MULTIPLE PTS. BASE RATE _�— BLUE CROSS 8: TOTAL MILES: X MEDICARE#:.- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT:(19:00-07:00) CCHP/PPHP N: 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 J 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: Qj RUN• (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: - CITY: STATE* ZIP: I COMMENTS: 1��`► �� TOTAL: �J'Q PATIENT RECEIVED BY:X I P-Vidlr retain White wd Pink ropk potur r••' t. (SIGNATI1nF) CONTRA COSTA COUNTY AMBULANCE i 8 _ PRE-HOSPITAL CARE FORM I IINIr AUTHORIZATION a-._ CHECK OR FILL INAPPROPRIATE SPACES DATE: ( '��'D '� PATIENT'S NAMEU_I �.I _._ _-13�!?.�1.�-C�---- — �KM F.F COMPANY# Z G -` 3 ADDRESS —1-7 `� --__(�L'1.1 I I 1 I i .I L.. - --- --... AGE Z c014014-3. y CITY__. '1-• ..!__.L._.i�l..la STATE-__.����.____ ZIP�_y C.�_ DOB_�1=L S j❑ Sn ❑ M ❑ T ❑ W ❑ Th O F�$ ! DRIVER'S LICENSE d _ _ _._.. . • PHONE _Y_�_�-�L-T-t- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,_ I ! ( TO SCENE - YS.O.— CALL RECEIVED 0 0 :_2L --rt_ 5 � 4Pti t{� "�^ --- -._ ❑ P.U. TIME 10-8 G � PATIENT DESTIN�,TIONI FROM SCENE - ❑ FIRE TIME 10-97 0 :_z Z- ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END1 — TIME 10-98 C DOCTOR .— ti� )i.�))c; L.-'-:)j �/ - PM ER START—ft, TIME 10-22 i HOW CHOSEN. / TOTAL — I ' STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT 11 DIRECT ❑ OTHER ( . ! ) CALL BACK#: AMBULANGCOMPANY: 1 i EAMBULATORY? PATIENT TAKEN TO AMBULANCE: ' RESPONSE ZONE YES ❑ NO WALYED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER _ 4A13" EMT-tA -2-0 I iII TECHNICIAN f.4 D PARAMEDIC - Hx: _.C�L�SC�_�. 1 �'.- --------_- DISPATCHER: -r- /�Q1 4' r CHIEF COMPLAINT: 5� _���_e-�_!. t` DRY RUN ❑ YES tZ 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: X, DS.S. # ti_f, 1- Z_ S PRIVATE INS. CO.: - BASE RATE:! KAISER#: — MULTIPLE PTS. BASE RATE I BLUE CROSS a: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO l ❑ YES ❑ NO NIGHT: (19:00- 07:00) .v� I 1 CCHP;PPHP#: EMERGENCY RUN: 3D•Cr7� 1 / MEDI-CAL#: —_ COD 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: Al I?-�ibEitCabrBELATIONSHIP:41tci-C E.O.A.: (IF NOT REPLACED) ADDRESS:_-�./ ___._ .—�__._ ORAL AIRWAY: (IF NOT REPLACED) CITY: ____ _._-___... .___ ..__. STATE . ___ZIP:__ C-COLLAR: (IF NOT REPLACED) - PtiONE WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: _--..__—.. OCCUPATION: -_ OTHER: ADDRESS: CITY: STATE:_ ZIP:_._ I COMMENTS:___.--_-- -- — --- --- TOTAL: -- — — - — _ - ^---' -- PATIENT RECEIVED BY:� � G�1 j '�Pmlvi,.'rr rrf t%::!r , INATURE) .. �.p Fr.�r Yr':.. rap: �•.� chrn f;i'iaj OIS-1 t rll\pCONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACES DATE: C n0 PATIENTS NAME O M ❑ F COMPANY M ADDRESS , I I AGE i CITY - STATE ZIP DOB ❑ Sn ❑ M ❑ T OW OIITh'' D F XS DRIVER'S LICENSE 0 PHONE — 'NATURE OF DISPATCH--F4LL1_ i TYPE OF TRANSPORT:.AMBULANCOC OTHER — STATION 1(AI 2(B)-3(C)-4(D)-5(E)— INCIDENT LOCATION: I RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLWK) 1 nI (� / TO SCENE- S.O. CALL RECEIVED P.D. TIME:10-844 - PATIENT DE TINATION: `—_ FROM SCENE- FIRE TIME 10.97 _ y_,L_ n JO ASAP TIME 10.49 w %22 MILEAG O OTHER/PVT TIME 10-7 Y` END TIME 10.98 DOCTOR ' PMO/ER START TIME 10.22 HOW CHOSEN: TOTAL. STANDBY TIME ❑ NEAREST,.;' O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COM NX Et PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: / RESPONSE ZONE (( ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER �;Cy PATIENT CONDITION: DRIVER - T-1 �I TECHNICIAN ' PARAMEDIC Hx: / DISPATCHER: J CHIEF COMPLAINT: DRY RUN. gY/Es' 1�140 AUTHORIZATION FOR DRY RUN SEMS USE ONLON FOR DAY Y/ N G[.�l U�\� i PATIENT REFUSED SERVICES: (SIGNATURE) X y4� MEDICAL COVERAGE: INDUSTRIAL ❑ YESfqrNO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE j BLUE CROSS M: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES 713 NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I 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) i 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: CITY: STATE: ZIP: COMMENTS: J TOTAL•%m / I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N Q tJ CHECK OR FILL IN APPROPRIAT[SPACES DATE: -to3 PATIENTS NAME OM ❑ F COMPANY« Q ' ADDRESS I AGE I QVULAI CITY STATE ZIP DOB '❑ Sn ❑ M ❑ T ❑ W ❑ Th O F 05S DRIVER'S LICENSE N I - PHONE NATURE OF DISPATCH 0 1 - TYPE OF TRANSPORT:,AMBULANCE& OTHER❑ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: i RESPONSE CODE: R�QUESTED BY: TIME—(24 HOUR CLOCK) n/I,-�_ D n/7' f, TO SCENE 15+ S.O. CALL RECEIVED " ' ry4�1-CJ O P.D. TIME 10-8 �wIIY. PATIENT DESTINATION: --? FROM SCENE- O FIRE TIME 10-97 O PSAP TIME 10-49 13OTH t MILEAGE: OTHER/PVT TIME 10-7 END TIME 98 1pOCTOR PMD/ER START IME t0 2 SIL :_LL - -' HOW CHOSEN: TOTAL \ STANDBY TIME t)"L: 13 NEAREST'— ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J , RESPONSE ZONE 0 YES O NO O WALKED ❑ GUERNEY O OTHER' PATIENT CONDITION: ' DRIVER EMT-IA / TECHNICIAN PqRAME 1G� Hx: DISPATCHER: CHIEF COMPLAINT: 1 DRY RUN: NKYES ❑ NO REASON FOR DRY RUN H LO�l SCGN(i AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE:_ INDUSTRIAL ❑ YES 0 NO NO.OF PATIENTS: 9 52 S.S.« , PRIVATE INS.CO.: BASE RATE: KAISER«: MULTIPLE PTS. BASE RATE SLUE CROSS«: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) r - , CCHP/PPRP N: 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:10 D R_ e3cAioc TOTAL: PATIENT RECEIVED BY:X (SIONATIInE) r4 I ( ` CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I AUTHORIZATION It L) X11 CHECK OR FILL INAPPROPRIATE SPACES DATE: • //�/`~ I PATIENT'S NAM `�� Y�)_._�. '�_.—� (�C ��' 1 O M MIF COMPANY# ! ADDRESS \ V v� AGE 0 , Z ~ M CITY`���' TA EC A ZIP �DOB �O Sn D M D T D W O Th O F L"S " a DRIVER'S LICENSE# ��_!�J � r�-� PHO# NATURE OF DISPATCH T' TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ _ -- STATION 1(A)_2(B)_3(C) 4(D)_61E1--,.-...:. + INCIDENT LOCATION: RESPONSE CODE: REO TED BY: TIME- (24 HOUR CLOCK) ^� I' TO SCENE`- [VS.0. CALL RECEIVED ' 1 �y yq 1 I 1 1), -old C v 11P.D. TIME 10-8 2 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 07,a- :C`Q D PSAP TIME 10-49 MILEAG D OTHER/PVT TIME 10-7 } l.�1 END �� TIME 10-98 ��.. . DOCTOR y PMD R STARTS TIME 10-22 HOW CHOSEN: TOTAL �'r STANDBY TIME D NEAREST D FAMILY �❑�TRANSFER WAIT TIME wj D PATIENT D DIRECT 'OTHER�I,- CALL BACK#: AM E COMPANY: PT. AMBULATORY? PATIENT TAKEN ZO'AMBULANCE: RESPON E ZONE +� 24ES D NO D WAL'<ED m-IGGUERNEY D OTHER PATIENT CONDITION: DRIVE 1 AV� ^ EMT-IA I ��� p TECHNICIAN PARAMEDIC- ) Hx: 1ti DISPATCHER: ( � CHIEF COMPLAINT: ` ' v-- DRY RUN: D YES GlKNO REASON FOR DRY RUN -' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL D YES OKNO NO. OF PATIENTS: �,�?j 46 S-S. k PRIVATE INS. CO.: BASE RATE: 150' KAISER#: MULTIPLE PTS. BASE RATE / Ch BLUE CROSS#: TOTAL MILES: /0 X MEDICARE k: E.O.B. ATT. ROUND TRIP: D YES D NO D YES .D NO NIGHT: (19:00-07:00) VD0 CCHP/PPRP k: EMERGENCY RUN: �oO� MEDT-CAL#: CODE 2/3 I - OTHER: OXYGEN: (PER TANK) P.O.E. STICKER D YES D NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.)' E.K.G.: (PER EPISODE) • 7 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: 1 STATE: ZIP: COMMENTS: -_- -�'" TOTAL',2 7c _7) L - 4 71, .. PATIENT RECEIVED BY:X Provider retain white vd Pig% +p� 4rf�r+� Yv:ir•t.• -npi t• !7�!° L,h,n hi7'ino (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M h.l - CHECK OR FILL IN APPROPRIATE S!tH - DATE: 'PATIENTS NAME 1 \ 0 y (DI )is I ❑ M ❑ F COMPANY N ( •{ � �� / ADDRESS,. AGE CITY STATE----, ZIP ! DOB + O Sn O M O T O W O Th O F g DRIVER'S LICENSE N 1- PHONE NATURE OF DISPATCH 'SE17 9CE& - TYPE OF TRANSPORT: AMB ULANC OTHER 0 — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:r_ - j ''• RESPONSE CODE! RE ESTED BY: TIME– (24 HOUR CLOCK) cc JC TO SCENE- S.O. CALL RECEIVED >� 1 (� L��OU��%_f O P.D. TIME 10-8 . P!A�IENT DESTINATION: ------.I FROM SCENE_ ❑ FIRE TIME 10-97 O PSAP TIME 10-49 i ��c�.�.i�l:• `�� MILEAGE: ❑ OTHER/PVT TIME 10-7 -I END TIME 10.98 ss.DOCTOR fPMD/ER START--- T E 10 2 1% HOW CHOSEN: s . _.- TOTAL \ S TIME !,..0 NEAREST. O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE�I'-4,A �� NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO, ., ❑ WALKED ❑ GUERNEY ❑ OTHER t PATIENT CONDITION-- DRIVER 1 1 L.) ,�,,nn l ^ni:f�% EMT-IA ' _ 1 TECHNICIAN ` 1J��.PA AMEDI Hx: DISPATCHER: er' CHIEF COMPLAINT: DRY RUN: YES O NO REASON FOR DRY RUN »''22 1� 3 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) () �" 3y41 :: 'PATIENT REFUSED SERVICES: (SIGNATURE) X 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 C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES -O NO NIGHT: (19:00-07:00) CCHP/PPHP N:" ' EMERGENCY RUN: MEDT-CAL N: CODE 2/.3 OTHER: OXYGEN: (PER TANK) t 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:J�'ZZ gs?q-gvm�gY 8- TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: �ONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �/ AUTHORIZATION# Mu " 11SU002 •� CHECK OR FILL IN APPROPRIATE SPACES `O DATE:-- C� 10-8 `PATIENTS NAME OM OF COMPANY N ADDRESS- AGE-1 n t✓ /V ) CITY STATE ZIP DOB O Sn O M ❑ T �0 W O Th ❑ F B'S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE W OTHER _ STATION I(A)_2(8).s3(C)_4(D)_5(E)_ �\ INCIDENT LOCATION:; - ' RESPONSE CODE: RE90ESTED BY: TIME- (24 HOUR CLOCK) TO SCENE'- S.O. CALL RECEIVED _L�_ : C R 31X ❑ P.D. TIME 10-8 PATIENT DESTINATION: ... .i FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END-���------ TIM 098 Y DOCTOR i i PMD/ER START M£ 10-2 HOW CHOSEN: TOTAL / \ STA TIME r NEAREST:.:, O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER � ) CALL BACK#: AMBULANC" NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZOK O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER . 1 PATIENT CONDITION: DRIVER U L IGS? " ) 1 EMT-IA TECHNICIAN r ic- �P RAM Hx: DISPATCHER: qoo CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FO DRY RUN M-Z 2 .) ICS'SS AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Uu� 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 M: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C. EMERGENCY RUN: MEDI-CAL C CODE 2/3 OTHER: OXYGEN:I (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: SSTATE�: ZIP:- COMMENTS: t / Ro f ' - TOTAL 1 G::5v• L,104 v- PATIENT RECEIVED BY: X r. h 0 i... (SI(1NA rIJRFI r ANTRA COSTA COUNTY ' AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT r , AUTHORIZATION#0 �S 6-21&— CNECK OR FILL IN APPROPRUTE SPACES DATE: / a- g? PATIENTS NAM I A 1 O M O F COMPANY MC S G oADDRESS AGE 1; •v CITY ST ET._ ZIP DOB - O Sn OM OT O W O Th O F ID'S DRIVER'S LICENSE 0 ( PHONE -- NATURE OF DISPATCH Vornb4-ec.4-L, p TYPE OF TRANSPORT: AMBULANCE 13 OTHER 0 7 — STATION 1(A)_2(B)_3(C) 4(D)_51E1_ INCIDENT LOCATION: -� j RESPONSE CODE: UESTED BY: TIME- (2 4 HOU R�CLOCK) 3� O P.D. TIME 10-8/C� TO SCENE f.O. CALL RECEIVED �L PATIENT DESTI ATION: , FROM SCENE- ❑ FIRE TIME 10-97 - ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 END �- TIME 10-98 ` fi DOCTOR` " " ''� I PMD/ER START ' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME �( r ❑ NEAREST::_, O FAMIL� O TRANSFER WAIT TIME -- . O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE CQ PANY: PT. AMBULATORY? I PATIENT TAKEN TO AMBULANCE: cRESPONSE ZONE S� O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION; - DRIVER k 1,c cl EMT-1A 3'T j t ) TECHNICIAN SC 1 F E' PARAMEDIC Hx: DISPATCHER: (�00 CHIEF COMPLAINT: /1 DRY RUNES ONO REASON FOR DRY RUN "Z2 C CI r6'� I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (��rt PATIENT REFUSED SERVICES:(SIGNATURE) X %�STa MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S.0 PRIVATE INS.CO.: SASE RATE: KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE 0: E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES 'O NO NIGHT: (19:00-07:00) CCHP/PPRP 0, EMERGENCY RUN: MEDT-CAL M: 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: I.V.: (PER ADMIN.) X r I DRUGS: (PER ADMIN.) X -- NAME: ' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: 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: TOTAI PATIENT RECEIVED BY: X_ Pn+ii,iir• ►At.t!n Nits r4 P:n: •.+F 5at:.r— v,.•• (SIGNAWRE) CONTRA COSTA COUNTY AMBULANCE i PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N js 3 J��T y CNECK OR TILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME__n�_n.L.r....•�..__t_:'_L`_. '- Q M ❑ F COMPANY N 1 G t ADDRESS .__L.L�._L�"�_l_}�S' } — AGE 3 c CITY L Lr_1( /�.� 1_�t_ STATE— C11 ZIP�� �c�_ DOB_r LVY7 ❑ Sn ❑ M ❑ T ❑ W O Th O F WS- 1 DRIVER'S LICENSE a ___.___._ .. PHONE__�. __�� _�. NATURE OF DISPATCH // -A71 TYPE OF TRANSPORT: AMBULANCE 11 OTHER ❑ _.__ _ �'_ `_'' '� INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) } 1 TO SCENE- 7 [IS-0. CALL RECEIVED �yL --L—�tG:� -- ❑ P.D. TIME 10-8 t PATIENT DESTINATION: FROM SCENE- _ ClFIRE _— TIME 10-97 • ` � ❑ PSAP TIME 10-49 =L j `•1` f 1 ►' r�C\ ( ' (� ' MILEAGE: OTHER/PVT TIME 10-7 END CCxIt• TIME 10-98 DOCTOR /?. r. •� �R1v�i6R START_L7..ir� TIME 10-22 HOW CHOSEN. J TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER l WA17 TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER - CALL BACK a: AMBULANCE COMPANY: ) LA•J ZZ) PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Z Q§ YES ❑ NO WAL':ED X GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_W.19__LAe e 3`" EMT-1A ZC7 TECHNICIAN t� C F7N K Iz(' PA FDIC /I ! Hx: _ �-L n L�---�_�u.�iC�S DISPATCHER: ( CHIEF COMPLAINT: -J_�__�(5_tJt �C DRY RUN: ❑ YES NO REASON FOR DRY RUN ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) J l AICAL COVERAGE: INDUSTRIAL ❑ YES�NO NO. OF PATIENTS: -�cl PRIVATE INS. CO.: BASE RATE: Po _ .1 KAISER a: _ MULTIPLE PTS. BASE RATE BLUE CROSS a _ TOTAL MILES:_ X cO � . .MEDICARE a: __ -E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP,'P_PHP a: EMERGENCY-RUN: MEDT-CAL a:• COD 2/3 COTHER: -_ OXYGEN: (PER TANK) L P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR)` DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.. (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME. Lr`y RELATIONSHIP:_A E O A.: (IF NOT REPLACED) ADDRESS:_— -)�y_� _-. __../---__ ORAL AIRWAY: (IF NOT REPLACED) CITY' —_._ _.-_/__.._____..____ STATE--ZIP:_— C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: __ OCCUPATION: — OTHER: ADDRESS: CITY: —__-____ STATE: ZIP:_. — COMMENTS: TOTALg UUU45 PATIENT RECEIVED BY- -- IYwidrr r�tr-. ��: r:•I:, �r:.r. Yr', 4• • Ly • v%L" hry fr1 f (SIGNATURE) OIS-1 CONTRA COSTA COUNTY AMBULANCE S I56 PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N 0 `xp AJ': -C."CK CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M'❑ F COMPANY N ADDRESS AGES_ V CITY STATE ZIP�_ DOB - I •❑ Sn Om ❑ T��Iw DIN O Th 13 F a S 1 62 e!� DRIVER'S LICENSE N = PHONE NATURE OF DISPATCH " TYPE OF TRANSPORT: AMBZNCE`V OTHER❑ STATION 1(A)._2(8)_3(C)_4(D)_5(E)_• INCIDENT 40CATION: f RESPONSE CODE: R59ACtSTED BY: TIME- (24 HOUR CLOCK) 400 TO SCENE- S.O. CALL RECEIVED Mb IV I l=la� t`1 1�� KJ ❑ P.D. TIME 10-8 PATIENT DESTINATI N: _1 FROM SCENE- ❑ FIRE TIME 10-97 l ' ❑ TIME 10-49 `) OTHER/PVT �C- Iy MILEAGE: ❑ OTHER/PVT TIME 10-7 END CIM 98 DOCTOR'"' ` I - PMD/ER START �102 -7 HOW CHOSEN: _ TOTAL Y TIME ;•t ...0.NEAR EST� O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �� RESPONSE ZONE ❑ YES ❑ NO ❑.WALKED O GUERNEY ❑ OTHER ` PATIENT CONDITION: I ER DRIVQ �' I E TECHNICIAN U(,(A , t'_ ARAMEDI 1 Hx: - DISPATCHER00 : I C: C I L., C)(_',Ll L!l CHIEF COMPLAINT: I DRY RUN: YES 13 NO REASON FOR DP.Y RUN 1d-Z7 C f:2 UTL� qqq AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X 9 5.?- MEDICAL COVERAGE: .-. .. INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: S.S.N f 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 .0 NO NIGHT: (19:00-07:00) CCHP/PPRP N:,' ' EMERGENCY RUN: MEDI-CAL C 3 1 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/RESPONSIB E 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: W RK PHONE: DRY RUN:' (AUTHORIZED) —. EMPLOYER:- - CCUPATION: OTHER: ADDRESS: CITY: TATE: ZIP: COMMENTS: (b^ Z 2 (2Q TOTAL• _ PATIENT RECEIVED BY: X ➢t jai fi^ 1Yrn/n V5i f• «1 /'i••: r.,, w r;, (SIGNATURE) i CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNIT Pt AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME `` f_. _�/iC,rk��SM ❑ F COMPANYpZIT ADDRESS V � }�7/1 L- rC FAL- AGES c 1 6 CITY�L�i STATE ,( ZIP DOB• ��� Sn O M O T Cl W O Th O F E318— DRIVER'S 8•-DRIVER'S LICENSE p _._ __ PHONE`�j � o� NATURE OF DISPATCH S• ' l3 ' — — �+_-- ..1 TYPE OF TRANSPORT: AMBULANCE39 OTHER❑ _ _ STATION 1(A),2(B)_3(C)_4(D) 5(E)-L i INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY: TIME-(24 HOUR C�LUt;K) �S v 7L TO SCENE- S.O. CALL RECEIVED 1 t L) cy P.D. TIME ID-8 r: 'I — PATIENT DESTINATION: H , FROM SCENE - ❑ FIRE TIME 10-97 �-� n ElPSAP TIME 10-49 .:_ 7 �'{• ! V , �� MILEAGE: ❑ OTHER/PVT TIME 10-7 END_g _ TIME 10-98 1 -7 DOCTOR �il/1��Cil/L PMD START TIME 10-22 HOW CHOSEN: TOTASTANDBY TIME -) ❑ NEAREST O FAMILY ❑ TRANSFER / WAIT TIME _ ) PATIENT ❑ DIRECT ❑ OTHER �1 CALL BACK N: AMBULANCE COMPANY: EY BULATORY? PATIENT TAKE TO AMBULANCE: ,. RESPONSE ZONE❑ NO ❑ WAL'CED UERNEY ❑ OTHER �+ _j PATIENT PATIENT CONDITION: DRIVER V •` YVI Q CC" MT-11A �+u r 1 _ TECHNICIAN D t t1 TA t-1510}4 PARAMEDIC Hx: �1� DISPATCHER: lib CF{IE,F COMPLAINT: ,'r F )DRY RUN: ❑ YES -)k-NO REASON FOR DRY RUN "f •d ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ -) MEDICAL COVERAGE: INDUSTRIAL ❑ YESjlrNO NO. OF PATIENTS: tl Jl I S.S. # PRIVATE INS. CO.: BASE RATE: •QO_J KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X •��� aft. avM MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ❑ NO --�•1 O YES ❑ NO NIGHT: (19:00-07:00) 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/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 1 DRUGS: (PER ADMIN.) X NAME:���A^"��'h, -1-,-IAA RELATI�Ot�SHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: � C��'�E��✓P_ ORAL AIRWAY: (1F NOT REPLACED) CITY: C'oNt >� D STATE. C-COLLAR: (IF NOT REPLACED) PHONE: 7�� �7�C 7 0 WORK PHONE: A (0-Llrn DRY RUN: (AUTHORIZED) EMPLOYER:JL.'! �' e-5- OCCUPATION: OTHER: ADDRESS: rnr:" CITY:Or?/y co&> STATE-Ci ZIP: C MME TS: ON F_4o 44t i Aca1(e_ ill5,:'�%-+�� _ PATIENT RECEIVED BY:X a k L* C -,Ir? t (SIGNATURE Provider Yeti:,. hitr xd •o p • ietur YeNow . !%C when b'iing ) DIS-1 CONTRA COSTA COUNTY AMBULANCE , PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 CHECK OR FILL IN APPROPRIATE SIAC[df� �J o /� DATE: / v x7 ' l ' ' ' yy nL�.) � !J 7 L l� I 1 "PATIENTS NAME (i�,t f1A -COQ F COMPANY N�- yQli3., ADDRES .v7.)OC1 41tA/ 1s�2 1 ' AGE,rG-- I40 s CITY -STATE ,ZIP _,. DOB ❑ Sn ❑ M ❑T O W 13rh O F .�s3 DRIVER'S LICENSE`N L. "PHONE Z13 s:-.: NATURE OF DISPATCH F TYPE OF TRANSPORT% AMBULANCE OTHER❑ � - STATION i(A)_2(8)-3(CI_4(0)_5(E).,- INCIDENT.I,OCATION ��j H? RESPONSE CODE! f REQUESTED BY: TIME-(24 HOUR CIL K) TO SCENE- �'S.O. CALL RECEIVED "�O R. .. - - � , w0 P.D. TIME 10-8 • _� PATIENT DESTINATION:••-- FROM SCENE- Q FIRE LJJ_ TIME 10.97 ❑ PSAP TIME 10-49, r ,G•.L MILEAGE: p 13OTHER/PVT TIME 10.7 'E END f S TIME 10.98. 1� SLbbCTOi%1Tvrft _L.A` - PMD START TIME 1022• 7t lr HOW CHOSEN: __ - I.TOTAII . , STANDBY TIME t T - <� -fl•❑'NEAREST,-p. AMIL� ❑ TRANSFER WAIT TIME, ' ' ' ❑ PATIENT a ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANGYI '11 J1 tri. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _. �` F V RESPONSE ZONE _ O YES NO �. , 13WAL KED GUERNEY ❑ OT HE tin ' PATIENT CONDITION - DRIVER E,`1 EMT-1A ~] );lIBU's ) ' �) TECHNICIAN ��, V PARAMEDIC Hz: C - DISPATCHER: <e CHIEF COMPLAINT: I DRY RUN: ❑ YES_/'QlNO REASON FOR DRY RUN 1 rr AUTHORIZATION FOR DRY RUN(EMS USE ONLY) RAJ L;D;PATIENT REFUSED SERVICES:(SIGNATURE)X ,a EDI L COVERAGE: ._. INDUSTRIAL ❑ YES�NO NO.OF PATIENTS: 7C ,.i ass I )so 1 IVAT S. CO.: BASE RATE:- S' .4 i.:►' SER N: _y r MULTIPLE PTS. BASE RATE "I ;l BLU CRO S N: TOTAL MILES: X 1�s�(10-- MEDIC C, I E.O.B. ATT. ROUND RIP: ❑ YES ❑ NO ❑ YES -❑ NO NIGHT: (19:00-07:00) . 1 CCHP/PPRP N:J-'�. ( � EMERGENCY RUN: ' r• °' "� . MEDI-CAL N: - L rt- CODE 2//3 rl I • OTHER: • : ,I^ OXYGEN:- (PEE;TANK) P.O.E. STICKER 13YES ❑ NO ° 'NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ' E.K.G.: (PER EPISODE) f` @'*•NEAREST RELATIVE/RESPONSIBLE PARTY: -- -- I.V.: (PER ADMIN.) X-- - t. DRUGS: (PER ADMIN.) X '�*"NAME:bQMR GJ-4CN'?01� RELATIONSHIP: o E.O.A.: (IF NOT REPLACED) -- :N­�l ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) "= "CITY:- - - STATE ZIP: C-COLLAR: (IF NOT REPLACED) 'I PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) 4� --EMPLOYER--- OCCUPATION: C-K/Lb OTHER: j .'-' : ADDRESS: "CITY: - STATE: ZIP /�. —COMMENTS: -- 5 ;''�'•. - TOTAL: . L, S 4 PATIENT RECEIVED BY:X ($IpNA-URE) • [wt-t 1 . CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M l S"loci CHECK OR/ILL IN APPROPRIATE SPACES DATE: I�• t / d i 'PATIENTS NAME `/ ��Y� Om- ❑ F COMPANY N ADDRESS ` AGE - t` U CITY STATE_--,,ZIP DOB - -❑ Sn O M ❑ T O W O Th OF S ' DRIVER'S LICENSE N PHONE NATURE OF DISPATCH LJ`n�bY�N m TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION I(A)_2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION:'. I RESPONSE CODE: REQUESTED BY: TIME–(24 HOUR CLOCK) TO SCENE-3 {,S.O. CALL RECEIVED \��' �lo� �riS YY�Fid T 'j �k3CllT;• O P.D. TIME 10-8 L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 ►�/ YI ❑ PSAP TIME 10-49 ` -{23C� MILEAGE: ❑ OTHER/PVT TIME 10-7 ENDS a tom_ TIME 10-98 StbOCTOR ' PMD/ER START �— TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST; O FAMILO TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: C A S PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: c. RESPONSE ZO E STI ❑ YES ❑ NO 13WALKED 13GUERNEY O OTHEFL �{v s PATIENT CONDITION: - DRIVER In (ten I'I ` ' EMT-lA . .."__ TECHNICIAN PARAMEDIC Hx: DISPATCHER: -�1 •� ' ( L qqq CHIEF COMPLAINT: DRY RUN:A YES 13 NO REASON FOR DRY RUN 119 tL v.'d L.F, CMI AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 I I •,, PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N i PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROS N: TOTAL MILES: X MEDICARE E.O.B. ATT. ROUND TRIP: ' ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: I EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "'NEAREST RELATIVE/RESPONS 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) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: - COMMENTS:- TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY:X P"oWder rvtaf. Air, .,..I I•ic: "r MJr4+' 1. — 1 „ (SIGNATURE) ►w5-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M_� CHECK OR FILL IN APPROPRIATE IPA CES DATE: "— YPATIENT'S NAME__ ._.. f.--_ - ❑ M F COMPANY M / G•- 'J C O 1 ADDRESS -�� --. :✓ � - - AGE r ---�--! Do CITYSTATE__ .._ _ - ZIP-__ DOB 0 y " Sn ❑ M ❑ T ❑ W ❑ Th ❑ F DRIVER'S LICENSE _._. ... PHONE ___`�__�_ .-_ NATURE OF DISPATCH L f TYPE OF TRANSPORT: AMBULANCE THER❑ INCIDENT LOCATION: �? RESPONSE CODE: REOUESTED BY:. TIME- (24 HOUR4K) (- - I �j I TO SCENE- O. CALL RECEIVED ' �y.._! 1 _ �...---- - -2— P.D. TIME 10-8 PATI T DESTINATI N: FROM SCENE ❑ FIRE TIME 10-97 —( ❑ PSAP TIME 10-49 (& MILEAGE: D 1 ❑ OTHER/PVT TIME 10 7 ENDTIME 10-98 , DOCTOR - FMD/ER START Q��. TIME 10-22 HOW HOSEN: TOTAL - STANDBY TIME AREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: rr 1• PT AMBULATORY? PATIENT T KEN TO AMBULANCE: U RESPONSE ZONE S ❑ NO ❑ WAL':ED UERNEY ❑ OTHER PATIENT CONDITION. DRIVER -7 ^ �v EMT-1A / TECHNICIAN OIC - , Hx: _. =V- --- / f� _, - DISPATCHER: X� ./ ,n ) / CHIEF COMPLAIN RUN: ❑ YES REASON FOR DRY RUN t -- AUTHORIZATION OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X L C V RAE INDUSTRIAL 13YES NO. OF PATIENTS: �� - ,�C, G S.S. a S-._L�- (e_13I SATE INS. CO.:___.—_-__— BASE RATE: KAISER$I: _-__ ___ MULTIPLE PTS. BASE RATE BLUE CROSS a: — �E TOTAL MILES: X S� 77, MEDICARE a: E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19.00-07:00) ( CCHP;PP _____-..___.___-- - EMERGENCY RUN: 3o•��C��' MEDI-CAL �___ __ COD 2/3 �'., O _ l OXYGEN: (P7 R TANK) { , .\o O.E)TICKER ❑ YES NO -NEONATAL: (INCUBATOR) ti DATES BILLED: - - STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPOr LE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIO HIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _ ' _ ORAL AIRWAY: (IF NOT REPLACED) CITY: _ _—_____ S TE.-._ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _.__-_- WO PHONE DRY RUN: (AUTHORIZED) EMPLOYER -. -.._..__..._.._____ OCCUPATION: .-_ OTHER: ADDRESS` CITY: ,__ STATE: ZIP: _ COMMENTS: -..-__ ------ - --- TOTAL:f •.50 PATIENT RECEIVED BY:X ti,-.,,. r.:. CFr'.. , _r: '•rr:. ..- �h�: !:1'ino�r -('SIGNATURE) Y. 015-1 CONTRA COSTA COUNTY AMBULANCE C 3 r { C PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 4 l J J .,.._ CHECK ON FILL W APPpOPIIIATE 1PACEJ DATE: 9 �r 1 PATIENTS NAN4E S{'-f� t-F I �� �1 ►'� �M ❑ F COMPANY N ADDRESS,,4t*:�L yZ2 AIrQ • Sje"tt- Url_ AGE66 1 �O CITY STATE Z P a5 9 2- ' 4QOB � OS, OM ❑ T OW OTh ❑ F �S n DRIVER'S LICENSE N PHO E�L �—LeL4_1��ATURE OF DISPATCH TYPE OF TRANSPORT:.AMBULANCEH OTHER❑ STATION 1(A) 2(B)._31C)._4(D)_5(E)_ w� L INCIDENT LOCATION:�T } RESPONSE CODE!- RE�UESTED BY: TIME- (24 HOUR C K) �� TO SCENE- 4?S.O. CALL RECEIVED _ _ I S�t� '.�S�s..-�_a.i�(11 1 `� ��•• � ❑ P.O. TIME 10-8 PATIENT'DESTINATION: J FROM SCENE ❑ FIRE TIME 10-97 (� S ❑ PSAP TIME 10-49 _ ! �+ �� FcScc1P MILEAG ❑ OTHER/PVT TIME 10-7 + p(` /J�\ END TIME 10-98 : I` dtiCTOR� YLC v PMSTART TIME 10-22' 1 I HOW CHOSEN: TOTAL A STANDBY TIME NEAREST:•1, ATIAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER 3 CALL BACK>r: AMBULANCE cwP�Y: ' PT.,AMBULATORY? PAT NT TAKEN TO AMBULANCE: - �� RESPONSE ZO YES ❑ NO WALKED ❑ GUERNEY D OTHER •' ' } PATIENT CONDITION:­-- DRIVER (Jso H �V EMT-1A ' TECHNICIA C PARAMEDIC I Hx-c �l roln<< .. �'TG''J DISPATCHER: �." C c�'✓ `, i CHIEF COMPLAINT: V VA cl-b(k' T10 C c-f e DRY RUN: O YES _ tQO REASON FOR DRY RUN ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) t- PATIENT REFUSED S RVICES: (SIGNATURE)'x' -• :4.; MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: 'M1} S.S. n5 726 Zf5 1 ;k. PRIVATE INS.CO.. BASE RATE: SO•Cm ;.11 �SER K: � MULTIPLE PTS.BASE RATE ;G. BLUE CROSS 0: TOTAL MILES: �X _77-16 MEDICARE M; E.O.B. ATT. ROUND.TRIP: ❑ YES ❑ NO 13 YES ❑ NO NIGHT: (19:00-07:00) I CCHP/PPHP..N:•' • EMERGENCY qUN: ag t4' MEDT-CAL II: - ' COD2/1/3 i "..; OTHER: - Q C OXYGEN: (PER TANK) P.O.E. STICKE, ❑ YES ONO �'L""-�`` NEONATAL: (INCUBATOR) ti. DATES BILLED: _�/�a�ca STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) '.." REST RELAT VE/RESPONSIBLE PART YS tr / I.V.: (PER ADMIN.) X 94i DRUGS: (PER ADMIN.) X '•' w"NA T a Sa.GJ�oRELATIONSHIP: �) E.O.A.: (IF NOT REPLACED) ADDR S: c-•- ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: LOC WORK PHONE: DRY RUN: (AUTHORIZED) s.r1j t EMPLOYER: Lv`QQ OCCUPATION: OTHER: ADDRESS:1rki ?-like z CcsF;rr_eIf, • v^`CITY: STATE• ZIP: OMMENTS:- UlA i[1y- CC-_f cL�" TOTAL: c U ^" PATIENT RECEIVED BY:X ( 1 Provider rero:, Lh,r.• ,�.f I•r.:t .•.r . c,r,,r Y, , "I (SIGNATURF) CONTRA OSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION I# R CHECK ON FILL IN APPROPRIATE SPACES DATE: ^ lo - PATIENTS y -PATIENT'S NAME " A/ OI M ❑ F COMPANY ADDRESS AGE— CITY GE CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑W ❑ Th [IF ' DRIVER'S LICENSE N _ PHONE — NATURE OF DISPATCHI�� TYPE OF TRANSPORT: AMBULANCE O OTHER❑ _ STATION 1(A► 2(8)_3(C)_4(0)_5(El_ INCIDENT LOCATIONS RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) n TO SCENE- ;S.O. CALL RECEIVED �cy', R VM al i L VL, DO IrAg E �= O P.D. TIME 10-8 PATIENT DESTINATION. FROM SCENE- ❑ FIRE TIME 10-97 f� l / ❑ PSAP TIME 10-49 L_ /� MIL E: 13OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR ' PMD/ER START TIME 10-22 I` HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST I; ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANI(� c ./J. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 1 ❑ YES ,❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER ,44,aWAm 5 `4 u _) I� TECHNICIAN PARAM Hz: DISPATCHER: `_- x lk CHIEF COMPLAINT: DRY RU . ❑ YE ❑ NO REASON FOR DRY RUNI'11 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /ti iJAIA—U P10 Al / PATIENT REFUSED SERVICES: (SIGNATURE) X P rU MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N PRIVATE INS.CO.: BASE RATE: KAISER N:r 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 ❑ O NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESP 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: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: C19 4 5 8 PATIENT RECEIVED BY:X Provider retaic Aitr ,«.i Pi 1 :•,n c,;r -• v.. .. ..� (SIGNATURE) FH CONTRA C JSTA OUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 �� G R CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑'M ❑ F COMPANY 01 12- fZ V ADDRESS I I AGE _ Uv CITY STATE ZIP DOB O Sn OM OT Ow O Th O F F(S DRIVER'S LICENSE N ' PHONE NATURE OF DISPATCH 79 TYPE OF TRANSPORT: A MBU LANCED OTHER O _ STATION 1(A)_2(B)_3(C)_4(D)_5(E) INCIDENT LOCATION: , RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED y"AP:D. TIME 10-8 I . PATIENT DESTINATION: _ FROM SCENE 13 FIRE TIME 10 97 U ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 tt END TIME 10.98 RDOCTOR '' " L �} PMD/ER STAR TIME 10-22 I I HOW CHOSEN: TOTAL STANDBY TIME NEAREST ., ❑ FAMILY 13TRANSFER WAIT TIME O PATIENT . DIRECT DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANYAS ' I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `jv RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION::--- - 1 DRIVER 1`I _ EMT-1A _• i TECHNICIAN PARAMEDIC Hx: DISPATCHE-R/: Unn�j� CHIEF COMPLAINT: DRY RUN: C YES ❑ N REASON FOR DRY RUN r'►'ti I V" AUT RIZeTION FOR RUN(EMS USE ONLY) LlYll 7 c.j t!;,;PATIENT REFUSED SERVICES: (SIGNATURE) qz MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO NO.O ATIENTS: S.S.M s .. .. PRIVATE INS.CO.: BASE RATE: KAISER N`. MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:p. 1 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) �a�! EMPLOYER: OCCUPATION: OTHER: ADDRESS: --CITY: STATE: ZIP: - -COMMENTS: - TOTAL: � 40 PATIENT RECEIVED BY:X (SIQNAIURE) tM I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M! 1 Coco Cl A.1 n CHECK OR"LL IN APPROPRIATE SPACES DATE: `1 ,PATIENTS NAME �k �1,n f OM ❑ F COMPANY 0 ADDRESS + AGE`= ) CITYSTATE ZIP�_. DOB ❑ Sn ❑ M OT OW O Th OF kS DRIVER'S LICENSE N I PHONE NATURE OF DISPATCH f - TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 STATION 1(A)_2(B),3(C)_4(D)_5(E)..._ INCIDENT LOCATION:' _I RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) (- L TO SCENE-3 1p S.O. CALL RECEIVED �CVL> ��.T.T "UVA bgi• . , , O P.D. TIME 10-8 PATIENT DESTINATION: ✓A.; FROM SCENE- ❑ FIRE TIME 10-97 �) "� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 !DOCTOR I`� .' ) PMD/ER STAR TIME 10-22 _ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST-;, ❑ FAMILY ❑ TRANSFER WAIT TIME ^_ I O PATIENT ❑'DIRECT ❑ OTHER CALL BACK w: AMBULANCE COMPANY: CAS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: so RESPONSE ZONE O YES. ❑ NO O WALKED ❑ GUERNEY ❑ OTHER S PATIENT CONDITION: DRIVER 1../ + E EMT-1A J TECHNICIAN )�•+ �• ) D (I F` PARAMEDIC�X Hz: DISPATCHER/ CHIEF COMPLAINT: DRY RUN: 0 YES ❑ NO REASON FOR DRY RUN A"'A N �V� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I r qq .7 PATIENT REFUSED SERVICES: (SIGNATURE) X 5� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS K: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:�I EMERGENCY RUN: MEDT-CAL III: 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: ?OTA 1 eVv ` Q_f 43 6'lJ PATIENT RECEIVED BY:X .... ,... .. (SICNA URF) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZAATTION/MJ��f/,3/� C4CK OR FILL INAPPROPRIATE SPACES DATE: 1.— `� Cl PATIEN S NAME 1 M. ❑ F COMPANY# _( t ADDRES ' 1 11 a�1 AA___­J�z� '' �' j CITY STATE ZIP_ (�l _ OOO Sn ❑ M ❑ T ❑ W ❑ Th OF S DRIVER'S L CENSE # _ ___-__--_-__—__ PHONI�.i'_�.� TJNATURE OF DISPATCH.__ LS TYPE OF TR NSPORT: AMBULANCE 11 OTHER❑ INCIDENT L CATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- S.O. —____ CALL RECEIVED �'- �C Oam�q__ ?Z- ✓_ P.U. TIME 10-8 PATIENT DES (NATION: FROM SCENE- ❑ FIRE TIME 10-97 I' C ❑ PSAP TIME 10-49 J1 MILEAGE: _ ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD START TIME 10-22 HOW CHOSEN: CCVVVV// TOTAL - STANDBY TIME NEAREST ❑ FAMILY O TRANSFER WAIT TIME _- ❑ PATIENT 11 DIRECT ❑ OTHER �� ;. CALL BACK q: AMBULANCE MPANY: PT. AMBULATOR ? PATIENT TAKEN TO AMBULANCE: _ RESPONSE ZONE Jbi4a YES ❑ NO O WALKED GUERNEY ❑ OTHER PATIENT CONDITI N: DRIVER_ Q 1 ! EMT-1A TECHNICIAN f I PARAMEDIC Hx: DISPATCHER: j 5 7 CHIEF COMPLAINT: CV DRY RUN: ❑ YES O REASON FOR DRY RUN 1 /, AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qI o`1 PATIENT R FUSED SERVICES: (SIGNATURE) X_ 1 MEDICAL COVERAG INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: L`�-- I ` S.S. # 10 PRIVATE INS. CO.: BASE RATE: KAISER#: C1:5 MULTIPLE PTS. BASE RATE / BLUE CROSS#: t TOTAL MILES: J X _U 4..s o MEDICARE#: E.O.B. ATT. ROUND TRIP: D YES ❑ NO DYES ❑ NO NIGHT: (19:00- 07:00) _D•�'O ��� / CCHP/PPRP#: EMERGENCY RUN: 10•(�` �`. MEDI-CAL#: CODE 2/'3' OTHER: OXYGEN: (PER TANK) I �ofi� P.O.E. STICKER ❑ YES ❑ NO . NEONATAL (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESO+NSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME:` �{ RELATIONSHIP: Win E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: �rORKlPdONE: DRY RUN: (AUTHORIZED) EMPLOYER: Ll`'04PATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _- TOTAL • .. - -- LO461 — -. PATIENT RECEIVFD BY Xc-�V[CI_. 14. ri.lor r�l.r.•- w:i., .! --------_._'.., _ ISIGNAiunE rn CONTRA COSTA COUNTY AMBULANCE r 1 PRE-HOSPITAL CARE FORM I UNIT ` Z AUTHORIZATION N CHECK OR Flll IN APPROPRIATE SPACES DATE: _ ` --� PATIENTS NAME (1 I �r - r^ �`�•' 1 � M ❑ F COMPANY a Ld �1`_3F' 1/-I� 7 L / j ( ADDRESS f - —1 —J 1 LJL.2_{75�---�-�1-------------... AGE 1 l CITY 1 >r- �+l `N STATE 1_L ZIP__.____.-_._.-__. DOB( ' ��("'C I D Sn ❑ M ❑-T ❑ W ❑ Th/► 3 F �\S. DRIVER'S LICENSE M _.___._ _--_ PHONEart L'( NATURE OFA n� TYPE OF TRANSPORT: AMBULANCE OTHER O INCIDENT LOCATION: / RESPONSE CODE: REQUESTED BY TIME (24 HOUR C�QCK) _,1) TO SCENE- ❑ S.O. �______ CALL RECEIVEDct7 71 ❑ P.U. _ TIME 10-8 Z- J^ PATIENT DESTINATION: FROM SCENE- Z- ❑ FIRE __._._—__ TIME 10-97 / c 1 t `q Co PSAP TIME 10-49 MILEAGG l OTHER PVT/ TIME 10-7 END `)�J —_ TIME 10-98 111— c� DOCTOR Zeller 21"474- PMD/ER START 2 _— __ _. TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY Cl TRANSFER WAIT TIME _ PATIENT ❑ DIRECT ❑ OTHER / CALL BACK(s: AMBULANCE COMPAY n �T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 !,. I RESPONSE ZONE jYES ❑ NOWALKED ❑ GUERNEY ❑ OTHER- _— --. PATIENT CONDITION: DRIVER— _! ( ___-- EMT-1A •X TECHNICIAN_ i ' PARAMEDIC Hx: �� oDISPATCHER: / l C CHIEF CSOMPLAINT:E D r` L DRY RUN: ❑ YESNO REASON FOR DRY RUN AUTHORIZATION FO DRY RUN(EMS USE ONLY)--- PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. a PRIVATE INS, CO.: BASE RATE: o.t e) KAISER a: _. MULTIPLE PTS. BASE RATE BLUE CROSS R: TOTAL MILES:.__ X � ���� I oti 1'�' MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO \l Dr? 3 191 ❑ YES 0 N NIGHT: (19:00-07:00) CC HP EMERGENCY RUN: J L IIC)TAP KFN1 CODE 2/3 �C,)f�803 EDI-C # U763031 OTHER: OXYGEN: (PER TANK) J� E. STICI. .0`)9 3 N G 4 MPJ NEONATAL: (INCUBATOR) DAT L — STANDBY: (OVER 15 MIN.) E-K.G. (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I V.: (PER ADMIN) X >> i r Y .I , DRUGS: (PER ADMIN.)_______. X — NAMEI — RELATIONSHIP:. (G E.O.A.: (IF NOT REPLACED) ADDRESS: N ORAL AIRWAY: (IF NOT REPLACED) CITY: - ��J STATF Ol ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: -- -_-- CITY: � STATE: ZIP ( COMMENTS: :1 )o?� j 1 1 F��1�l ( i"11 ' Cry rX 4 --- ---- - I( �— TOTAL --... I•AIif riI Irl ( I ivi-I. we x f f) SEP IO II 53 ��, IEP IO II 53 PH '8 9 � 2 3 �. . v , / SO NIJ"RfR ,,j 5 'J11 CAH RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 [/>;• ra CALLED BY— PATIENT INFORMATION �� t N y NAME: ---- --- _ _ 3: �.�. C) IL! AGENCY: S'U _ CUSTOMER #(PT. 1): DOB: C �r•� D V DEPT;FLOOR/ROOM #: __ ___ NAME: T�i !� K AIA Z N n a CALLBACK # __._- ____�_c�1� ��D AVe INS. TYPE: PVT AR Ln. KHP PHP VA IND CHAMPUS �• . V w INCIDENT LOC ue_ poHeY/MCAL V 1 " Z . f�C��nlp�;�•�E'fS� m __ -- _ MCAR#: m W m CROSS STREET: _ VERBAL PRIOR: o JURIS: ---- City t Y?u c- DOCTOR: ret kd l"'ITy v -- DESTINATION: _ U Y1- 1.�. CS(�i I_C�( _ PT. #2 NAME: DOB: NATURE: COST. # PT. #3 NAME: DOB: '7D o TYPE OF CALL: TRANS TIME UNIT # I'Z OUST. # n �•: m w CREW: _ OO S�Y1.C��1� _��QtF WAIT TIME: YES NO REASON: m f Z O UNIT TYPE: ALS LST WC RESPONSE CODE: 0 1 © 3 4I REASON FOR 10-22: p 1V c Q INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1(D 3 4 CANCELLED BY: m v BY: END MILEAGE: J80 COMMENTS: p =30+. a TI — BEG MILEAGE: �Z8 FIS TCHER: TOTAL MILES: 00463 C=. 10 X l NOIIVIS 1V 3DNVlf19Wv I 61-01 JNINsnI vin9Wv 86-DL 31OVIlVAY 3JNVU19WV L-01 1VIIdSOH 1V 3DNV1f16WV ',' ',�•. 1 � 1 FSK 9E ul- ZI I I r, 1 CONIIIA (,07.TA COUNTY �� AMRULANCE G- PRE HOSPITAL CARE FORM I „N,1 AUTHORIZATIONM - ( �26 � f 1 Q cf+rcK on rittINA PPROPR,Atr IPA Il DATE:' PATIENT'S NAME ( . , O M 6F COMPANY# ADDRESS _L��-�(- l- `._ ( I i �'! '► (..� _ AGE -3 (, .L'Z Z --- 14 STATE _(...-I- — ZIP _� L_-. DOB.�. i y �L CITY.. -°- 1 ��- J _ (.'�} ❑ Sn OAA ❑ T ❑ W ❑ Th CI F KJ 3 ( -- \/ 7 DRIVER'S LICENSE e .. _.. _ . - PHONE \_` `-}_ C � NATURE OF DISPATCH �t� v f TYPE OF TRANSPORT A4BULANCE® OTHER❑ INCIDENT LOCATION: RESPONSE CODE. rUESTED BY: TIME- (24 HOUR C,LO K) i ! I l TO SCENE- r' S.O. CALL RECEIVED ) ❑ P.U. TIME 10-8 PATIENT DESTINATION: Y FROM SCENE - ► ❑ FIRE TIME 10-97 /� oq 1 '`- ❑ PSAP TIME 10.49 MILEAG ❑ OTHER/PVT TIME 10-7 :► 7 END_ r �*7_ _ — TIME 10.98 DOCTOR _ _.L-�1____.____- PMD/ER START r- TIME 10-22 _ HOW CHOSEN: TOTAL — _ STANDBY TIME , NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE Crp • PT AMBULATORY') TIENT TAKEN TO AMBULANCE: ('' RESPONSE ZONE p'YES ❑ NO WAL':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER-IJU-94 � � 3 7 _ EMT-1A x TECHNICIAN �L =�' ? — PARAMEDIC Hx: !' .. DISPATCHER' i. �. CHIEF COM CAINT: _.Cr._'�?'rL•.'�_I_._-�_-__1�!- DRY RUN: OYESNO REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X____.-____..___�-__ MEDICAL C, VERAGF -INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. CO. _ __.___ _ BASE RATE: f�U•� KAISER #: -.-_— _ MULTIPLE PTS. BASE RATE t BLUE CROSS#:— --- _— TOTAL MILES: Xy �'✓ `� MEDICARE #: ____---. E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ( \\ ❑ YES ❑ NO NIGHT: (1900-07:00) �0 jCCHP,'PPHP N:` _--_-_�- _ EMERGENCY RUN: L MEDT-CAL#: __— - CODE 2/3 _ / OTHER OXYGEN: (PER TANK) ` 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I/ ( DATES BILLED: --.-.___-.____ __. STANDBY: (OVER 15 MIN.) !Iy E.K G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAMES_nn L� �I?0_'_1112._- RELATIONSHIP:a/ .. E.O.A.: (IF NOT REPLACED) ADDRESS:__-__-.__--.___-_.____.-._-_____. _. ORAL AIRWAY: (IF NOT REPLACED) CITY __ _ __._. __ STATE-__ZIP:._._._ ._ C-COLLAR: (IF NOT REPLACED) PHONE: -) ! �_�i— WORK PHONE. _ DRY RUN: (AUTHORIZED) EMPLOYER: -_ OCCUPATION: OTHER: ADDRESS: CITY STATE' ZIP: C.' --'--------- - --^ rl CONTRA COSTA COUNTY AMBULANCE IS22 21 PRE-HOSPITAL CARE FORM i UNIT � AUTHORIZATION MAJ CHECK OR FILL INAPPROPRIATE SPACES DATE: v �'•— ,�,,�, { 'PATIENT'S NAME O M ❑ F COMPANY 0 ADDRESS AGE'N 14 CITY =-STATE ZIP DOB • 6 Sn ❑ M O T O O Th (a F D S- `. ' ' DRIVER'S LICENSE M - ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:; AMBULANCE OTHER — STATION I(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:; ~ ' > RESPONSE CODE: REOUESTEO BY: TIME— (24 HOUR CLOCK) `,` p + ^ f TO SCENE-3 kS.O. CALL RECEIVED :_ _.•, L C r �,(,1 �� NA of 'I I C&.U1 P_5 C�(4 O P.D. TIME 10-8 PATIENT DESTINATION: i FROM SCENE- ❑ FIRE TIME 10-97 "1 ❑ PSAP TIME 10-49 + ' b• (� �CnMILEAGE: ❑ OTHER/PVT TIME 10-7 -• END' TIME 10.98 — ,~:+. . F DOCTOR T ;'I' ' I PMD/ER START 'TIME 10-22 % - sl:"v HOW CHOSEN: . ~_ • •.� TOTAL, STANDBY TIME E O NEAREST:' ❑ FAMILY ❑ TRANSFER WAIT TIME 'i O PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: it T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER 1'n PATIENT CONDITION: DRIVER �� E EMT-IA ✓' TECHNICIAN PARAMEDIC _ 3 Hx: DISPATCHER: (I,U�: CHIEF COMPLAINT: DRY RUN: IXYES ❑ NO REA ON FOR DRY RUN Ug `7'T l :'.. - - UTH N F RY S SF�NLx S;/�al,,;.,,PATIENT REFUSED SERVICES: (SIGNATURE) X , 1 �, (� l (�' ) MEDICAL COVERAGE: _ INDUSTRIAL 13YES O NO NO.OF PATIENTS: :n•sr•'ta•. ' ' S.S.M - "' PRIVATE INS. CO.: BASE RATE: KAISER C ' MULTIPLE PTS.BASE RATE "I •a . :`.? BLUE CROSS M: TOTAL MILES: X E.O.B,ATT. ROUND TRIP: ❑ YES ❑ NO ' �fa:•. MEDICARE M:' ' ❑ YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M: ` ' ' EMERGENCY RUN: ` MEDI-CAL M: CODE 2/3 s OTHER: '' ' I OXYGEN:, (PER TANK) 3 P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) >> ` E.K.G.: (PER EPISODE) ;;.;` -NEAREST RELATIVE/RESPONSIBLE PARTY: - LV.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ;4 NAME:- RELATIONSHIP: E.O.A.:(IF NOT REPLACED) y ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: - STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) _ri 1 •; .� PHONE: WORK PHONE' DRY RUN: (AUTHORIZED) !.j-!—EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: (STATE! r ZIP: -CO ME TS - � !n l� toC� (1 QA P TOTAL: `.r/• PATIENT RECEIVED BY: X /`r•1•i�•., r. Nei 1... (SIGNATURE) • 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I \ UNIT l ' AUTHORIZATION M [6 ) 3 I CHECK OR FILL M APPROPRIATE SPACES DATE: cl I I �C?Fir J('4N G , - C cz PATIENTS NAME 1 ❑ M F COMPANY(M� �- ADDRESS u f)%4Q w•, AGE 'S 7 ` ,n } ' CITY Q Ft FJ Oft STATE 0'A ZIP DOB - -'O Sn OM ❑ T OW tO-yTh OF OS DRIVER'S LICENSE N _p 1A PHONE NATURE OF DISPATCH 1 V K - 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) JF TO SCENE- 7 S.O. CALL RECEIVED cl -youz$/ �letl,.� Il/I 1 •L�11) �' ❑ P.U. TIME 108 !/ PATIENT DESTINATION: FROM SCENE- "1 ❑ FIRE TIME 10-97 C ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 0 ENDU ?' TIME 10-98 7DOCTOR PMD/"R STAR T TIME 10-22 HOW CHOSEN: TO AL a ' STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER I WAIT TIME ❑ PATIENT ❑ DIRECT Ia OTHER SPE L:jPIC Ser CV-6 _ CALL BACK K: AMBULANCE COMPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: (' RESPONSE ZONE YES ❑ NO O WALKED. XGUERNEY ❑ OTHER PATIENT CONDITION: 5.0 04(-L Z0 h`f t"'�,--DRIVER L kC-p, 1A EMT-tA kk,� 1'p�P i-j sc.um TECHNICIAN C1S't�Q PARAMEDIC Hx: P Fd,l/ID it) t�;xlu Qql n`) l DISPATCHER: �z i:I t 5 CHIEF COMPLAINT: T71 SOC l el�7-E� DRY RUN: OYES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) G 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 / �,, l�2 BLUE CROSS#: TOTAL MILES: �� X , � MEDICARE K; E.O.B. ATT. ROUND TRIP: OYES 9 NO O YES ❑ NO NIGHT: (19:00-07:00) �d CCHP/PPHP M: EMERGENCY RUN: .�so cyj � G� MEDI-CAL M: CODE 3 OTHER: OXYGEN: (PER TANK) 'J P.O.E. STICKER ❑ YES �r NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:p4 w(LL /Al•7 ci. ye. 4A r N 0046 t0642 -----. TOTAL:. 1, •�D- --- -- --- — PATIENT RECEIVED BY: _1�_ { ISIr, A ori CONTRA COSTA COUNTY �, AMBULANCED� PRE-HOSPITAL CARE FORM 1 \ UNIT L� AUTHORIZATION 0. D J , I j' CHECK OR FILL INAPPAOPRIA'IE SPACES DATE: _s-( I / PATIENT'S NAME 41� JC� 1�.� t��' ❑ M (PF COMPANY N ADDRESS�L,K= C-C.F'-' TT,2• AGEiT=a5 \ q CITY._ ' C STATE r� - ZIP L DOBE 7 Sn Om ❑ T O W O Th OF OS-­ DRIVER'S S--•DRIVER'S LICENSE# ---- PHONE-���L��/- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE,0 OTHER❑ ____—__ STATION 1(A)_2(B)_3(C).%,,--4(D)_S(E)_.- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) n TO SCENE- k_S.O. CALL RECEIVED �'' ��+ 3 ❑ P.D. TIME 10-8 ... _LL - t PATIENT DESTINATION: FROM SCENE- "� 13 FIRE TIME 10-97 c 7 r 1 ❑ PSAP TIME 10-49 MILEAGE: a 3 ❑ OTHER/PVT TIME 10-7 END ' TIME 10 DOCTOR � PMD R� START I -�-(� TIME 10-22 :_;- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER ( l WAIT TIME ja PATIENT ❑ DIRECT ❑ OTHER \/) 1 CALL BACK M: AMBULANCE COMPANY: _._. lets PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: � `'1 RESPONSE ZONE T --- QP YES ❑ NO ❑ WAL'CED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 6Y,It 9., � 5 EMT-.IA' 'f ' TECHNICIAN l_(Cla3a 10 PARAMEDIC Hx: _4<_4 et- DISPATCHER: CHIEF COMPLAINT: — -Sr 1 DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X t "' t.' MEDICAL ClEAGE: INDUSTRIAL ❑ YES 11 NO NO. OF PATIENTS: S.S. q �U� - PRIVATE INS. CO.: BASE RATE: / KAISER is - MULTIPLE PTS. BASE RATE (fin ( BLUE CROSS.#: t q c'9 j TOTAL MILES: X G �t� �-•.1 MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00.07:00) 3U'�� z Uk+ CCHP/PPRP p: EMERGENCY RUN: J v MEDI-CAL a: CODE 2/3 _ OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) !� DATES BILLED: STANDBY: (OVER 15 MIN.) (�- ��I/"j E.K.G.: (PER EPISODE) _ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME AC(-"19 4(-Z RELATIONSHIP:�y� E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: SLY/- I 2i3 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ^/ ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL- PATIENT RECEIVED BY:X Provider rrtair. Whitr ..rd !'i•.:. r^pr 5rtnr+ Yr:ioV �np;, t• pfr Lh, DiZ:inp (SIGNATURE) as r� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#TI CHECK OR FILL INAPPROPRIATE SPACES - DATE: ~' �IT PATIENTS NAMEr�. v O M ❑ F COMPANY � /d ADDRESS AGE !"t CITY STATE ZIP DOB— OSn ❑ M O T ❑ W ❑ Th O F ❑S DRIVER'S LICENSE# __, - _____� PHONE NATURE NATURE OF DISPATCH��`I TYPE OF TRANSPORT: AMBU r . y 7 INCIDENT LOCATION: RESPONSE CODE: REO ESTED BY: TIME— (24 HOUR CL K) C �` TO SCENE - S 10. CALL RECEIVED c / l �qCr-��I-n � `► r_ � O P.U. TIME 10-8 PATIENT DESTINATION: FROM CENE - ❑ FIRE -- TIME 10-97 O PSAP TIME 10- 9 r ' MILEAGE: ❑ OTHER/PVT TIME 10-7 END . TIME 10-98 DOCTOR I I PMD/ER START TIME 10-22 ' :37 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AM�ffY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVERt �SO h t F I pp (EMT-1A TECHNICIAN (1 h `roARAMEDIC Hx: DISPATCHER: C L'U CHIEF COMPLAINT: _ DRY RUN: WYES ❑ NO REASON FOR DRY RUN ff qok�✓� RFL l AUTHORIZATION FOR DRY RUN (EMS USE ONLY) L.IJIq 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: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X DRUGS-. (PER ADMIN.)_ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) • ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN:.(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: L 004 — _—. TOTAL: .._ PATIENT RECEIVED BY: X_ .. ICIf;NATI InF.1 CONTRA COSTA COUNTY AMBIANCE - PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATI N a�3tS�7 CHECK OR FILL IN OPRIATE SPACES DATE: PATIENTS NAME OM OF COMPAN # ' ADDRESS AGE CITY. STATE ZIP DOB_-____ P Sn ❑ M ❑ T ❑ W O Th OF OS DRIVER'S LICENSE N _ PHONE ._—_._ NATURE OF DISPATCH_e TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ INCIDENT CATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CL CK) TO SCENE g'S(O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROMCENE ❑ FIRE TIME 10-97Q— ❑ 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 -- 13 PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER t EMT-1A TECHNICIAN — _0_/A9_(P_ PARAMEDIC Hx: DISPATCHER �P CHIEF COMPLAINT: DRY RUN YES ❑ NO REASON FOR DRY RUN PATTEN EFUSED SERVICES: (SIGNATURE) X AUTHOR" TION FOR DRY RUN(EMS USE ONLY) 7 MEDICAL COVERAGE: INDUSTRIAL D 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 O YES O NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: ,,/ MEDI-CAL#: CODE 2/3 / OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) 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:._..- - - ----- PA,TIFt)T nrCFlvrn nY X ------- CONTRA COSTA COUNTY AMBULANCE p7 S1 `O PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M O J t o CHECK OR FILL IN APPROPRIATE SPACES DATE: 4 'P imislTS NAME ' \Q�1 I�/�V1 1 • �M�❑�F COMPANY k AD ` ADDRESS3 p �I rn S� ' AGEC2! 1 14 CITY E l Cei kTp- ��. Z _ STATE ZIP rte_.DOB^�L,� Z �Sn ❑ M ❑ T ❑ W ❑ Th ❑ F O S DRIVER'S LICENSE M ! "'� PHONE EZ�1 1-43-tNATURE OF DISPATCH /ACOFI& TYPE OF TRANSPORT:.AMBULANCW OTHER❑ _ INC IDENT`LOCATION:I a! RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C CK) ti Q^ (--' 'y` TO SCENE- S.O. CALL RECEIVED V �� �., Ce(\i 1�: ►1 ❑ P.D. TIME 10-8 ' H PATIENT DESTINATION: FROM SCEN 13 FIRE TIME 10-97 •-"} Sg ❑ PSAP TIME 10-49 MILEAGE ❑ OTHER/PVT TIME 10-7 END57 TIME 10-98 f DOCTOR S �PM119 START TIME 10-22 HOW,CHOSEN: TOTAL; STANDBY TIME :.J S NEAREST. ' ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE OMPAN PT. AMBULATORY? PATIENT TAKEN,10 AMBULANCE: J RESPONSE ZO ❑ YES 1pr<O. ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION:: DRIVER ' �^ < < 3L 6.) EMT-1A TECHNICIAN ne(s�� 'J C PARAMEDIC R r DISPATCHER: U CHIEF COMPLAINT: _ _L_o.0- DRY RUN: ❑ YES 2 � REASON FOR DRY RUN ?D. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL IND TRIAL ❑ YES ❑ NO NO. OF PATIENTS: �v PRIVATE INS.CO.: --I BASE RATE: -'-"� KAISER M.' 1 MULTIPLE PTS. BASE RATE / 1 BLUE CROSS 0: TOTAL MILES: w - x MEDICARE C ' E.O.B;ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07.00) CCHP/PPHN M:Q ( 1 EMERGENCY RUN: U y MEDI-CALM: CODE 2/3 f' O ' OTHER: OXYGEN: (PER TANK) d,�•u'J 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) iI E.K.G (PER EPISODE) 1 � � ^NEA REST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ---NAME: DlQ MS 'E44"t� RELATIONSHIP:LJ k FC E.O.A.: (IF NOT REPLACED) ADDRESS:-At� ORAL AIRWAY: (IF NOT REPLACED) `jam CITY: rcj2 Cc_ STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ����Z2U�JORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: _ ADDRESS: /, CITY: STATE: ZIP: CO MENTS: C PATIENT RECEIVED BY.X. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# 1, '� - �1 76 j CHECK OR FILL INAPPROPRIATE SPACES DATE: r �-- 93 PATIENTS NAME ❑ M OF COMPANY# ADDRESS AGE CITY_ STATE ZIP DOB���_ M O T ❑ W O Th O F ❑ S DRIVER'S LICENSE# - PHONE __ NATURE OF DISPATCH -T���1 TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ _ __. INCIDENT LOATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL CK) Y Al�^ �1 �� TO SCENE � S.O. CALL RECEIVED C 7 -�`�- t _� !A'1 TIME 10-8 PATIENT DESTINATION: FROM SCENE- © ❑ FIRE TIME 10-97 - ❑ PSAP TIME 10-49 MILER ❑ OTHER/PVT TIME 10.7 END TIME 10-98 � � ':DOCTOR PMD/ER START + TIME 1022 r✓�?__ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ZT7 ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULA £p1 E1(JWANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �7 Lt RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: RIVER I t C-14—T- lA TECHNICIAN Hx: DISP v Ll /� C COM P AIrT: 2 T� RY RU e�CES O REASON FOR DRY RUN r�§ f S Aura 1 U O ZAT ON,f OR Y R EMS USE ONLY) L-,1.1 q PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES Cl NO NO. OF PATIENTS: -�1' ✓ S.S. PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES A 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 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) �' o PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:-n ZIP: COMMENTS: P/V/�f-N T 5 / �r a,6 ��5m12 f J64 _---- TOTAL: PATIENT RECEIVED BY: X- -----________ Pr oidnr rvrrtin White _nd Nnk -Opp Rotwrn Y.•'1,w :'j py t• Pki. uhrn Li t in., (SIGNATURE) 1J15 1 ,; g •,lw III : •� , CONTRA COSTA COUNTY AMBULANCE /) PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ❑ M ❑ F COMPANY �a ADDRESS 'S AGE E CITY STATE ZIP_. DOB-_-- ❑ Sn OM O T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# _ -_ PHONE ___`- NATURE OF DISPATCH t O '�-� (: TYPE OF TRANSPORT: AMBULANCE❑ OTHER O _ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)^ �/ . TO SCENE- 3 S.O. CALL RECEIVED —_ ��� TIME 1(}8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 13 PSAP TIME 10-49 MILEAGE: 11OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR }-'I - 1 PMD/ER START TIME 10-22 _- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST 11 FAMILY . '❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE C9WANY: EYES BULATORY? PATIENT TAKEN TO AMBULANCE: ,� (� RESPONSE ZONE 7L - ❑ NO O WALKED 1113GUERNEY OTHER / PATIENT CONDITION: DRIVERFA-z 1 TECHNICIAN ��� r' PARAMEDIC Hx: DISPATCHER: 'Al 1 HIEF,C/OMP,LNNT- r Z s: G1/L DRY RUN: YES ❑ NO REASON FOR DRY RUN���• / lG 7 s `� AUTHORIZATION FOR DRY RUN (EMS USE ONLY) '(1 PATIENT REFUSED SERVICES: (SIGNATURE) X i MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: cS S i 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: (1F 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 -- --'� �----...- -—- PAT If NT RFCIFIVFn RY X - - I r fir: CONTRA COSTA COUNTY AMBULANCE ©� c PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IM APPROPRIATE SPACES DATE: 11 VAfliNT'S NAME I , OM OF COMPANY R O749 ADDRESS ( AGE% . .._ 1. ... .� -- CITY STATE__._.- ZIP��-T DOB WCOM OT Ow ❑ Th OF O 3 DRIVER'S LICErNSE N ' PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT:, AMBULANCE 0 OTHER❑ STATION 1(A)_2(8)_3(C) (D)_5(E)_ 1 INCIDENT LOCATION! ( RESPONSE CODE: R�TED BY: TIME- (24 HOUR CLOCK) TO SCENE- a, S.O. CALL RECEIVED oZQ C Y7 (A ❑ P.D. TIME 10-8 PATIENT DESTI ATION: .._ ._: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: 11OTHER/PVT TIME 10-7 I: END , TIME 10.98 S'i iSOCfOR I.t �"T' PMD/ER STATIME 10-22 �© - HOW CHOSEN: TOTAL STANDBY TIME NEAREST FAMILY ❑ TRANSFER WAIT TIME ~ ❑ PATIENT DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: -) C a PT. AMBULATORY? I PATIENT TAKEN TO AMBULANCE: Q RESPONSE ZONE _ ❑ YES. ❑ NO ❑WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: - DRIVER ��� ��\�.� C��� EMT-lA US I$U': . ; ...._�� TECHNICIAIJ� N A Y,A t) 3 _. . PARAMEDIC Hx: DISPATCHER: 2 n Cc CHICOMPLAINT: o, �I L DRY RUN: ES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I `7 7 qA jf;;;)PATIENT REFUSED SERVICES:(SIGNATURE) X 175 ! MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.K - - PRIVATE INS. CO.: / BASE RATE: - KAISER#' MULTIPLE PTS.BASE RATE { BLUE CROSS M: TOTAL MILES: X --_j MEDICARE 0)., E.O.B.ATT. ROUND TRIP: ❑ YES 13 NO 11 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0:¢.'_L � _ EMERGENCY RUN: MEDI-CAL N: _ ", CODE 2/3 1 OTHER: ,, " ? I OXYGEN: (PER TANK) ---t P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) --NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN:) X NAME- - RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: — - STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) �"V - -EMPLOYER:. OCCUPATION: OTHER: ADDRESS: -CITY: STATE: ZIP: --COMMENTS: )2=AC, 00473-' TOTAL• PATIENT RECEIVED BY: X CONTFTA COSTA COUNTY 'rF� AMnULANCE �� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION III , r v CHECK OR FILL IN APPROPRIATE SPACES ( 1 ):. -F - DATE:. . PATIFNT'S NAMF ._�I� S V'_ T'- ❑ M ❑ F COMPANY a --- S.1p f P44 Z Z r ADOR �S __..�� r� ... . (���c-R. AGE----.- , CITY �(/� /, - STATE. .._ _ ZIP-____ DOB1-f Sn 11.M ❑ T ❑ W ❑ Th 0 F O S;. DRIVER'S LICENSE a .___. --_ __._._ PHONE_ ,1J_` k7 NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCtAZOTHERO .-_.�__._. ___. •�- INCIDENT LOCATIO t. = RESPONSE CODE: RE TED BY: TIME- (24 HOUR - _ . CLOCK TO SCENE -MS.0. CALL RECEIVED �� rj ❑ P.U. TIME 10-8 ' PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 i MILE E: ❑ OTHER/PVT TIME 10-7 b,j' ` _. � --------------- END TIME 10-98 1 I DOCTOR ___ PMD/ER START_— TIME 10-22 an- 'R � HOW CHOSEN: TOTAL — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a AMBULANCE C MP PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �' RESPONSE ZONE ❑ YES ❑ NO ❑ WAL';ED b GUERNEY ❑ OTHER _--_ PATIENT CONDITION: DRIVER_D__ l Is( MT-1A TECHNICIAN '' .` ��?�PARAMEDIC Hx �-e 2 _ DISPATC R: CHIEF COMPLAINT: O �. �;� __.(�.C� _r-_ DRY U Ja YES ❑ REASON FOR DRY RUN A O N OR R R U ONLY) i ) r PATIENT REFUSED SEF7VICES (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO. OF PATIENTS: S.S. a--- --------- - PRIVATE INS. CO.:------___ BASE RATE _ KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSS a TOTAL MILES: X MEDICARE a: _ E.O.B. ATT. ROUND TRIP: ❑ YES O NO OYES ❑ NO NIGHT: (19:00-07:00) CCHP,PPHP a: _.__.. 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 1l AJ�f� DRUGS: (PER ADMIN.) X NAME _.__.-��___ ___ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS, ORAL AIRWAY: (IF NOT REPLACED) STATE.__—ZIP:-__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: ______ OCCUPATION: OTHER ADDRESS: _ CITY: --_ . STATE: ZIP: COMMENTS.----- z UQ4 14 -- -- ----- ---- .... - - ---- -- --- TOTAL -A'—Os ----------------- --- __-._ PATIENT RECEIVED PY X ... r•.. ----.. - - •eir..,�_•rnri Al JeG" CONTRA COSTA COUNTY LAMBULANCE /� f�a PRE-HOSPITAL CARE FORM 1 lr © AUTHORIZATION# 1J d +��1 CHECK OR TILL IN APPROPRIATE SPACES DATE: 2 �f 'PATIENTS NAME ❑ M 11O F COMPANY# �v' 70 ; ADDRESS AGE D U (. I i CITY STATE ZIP DOB ❑ Sn OM O T O W O Th OF OS I DRIVER'S LICENSE N _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ INCIDENT LOCATION'' " w �' RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)O TO SCENE- O'S.O. — CALL RECEIVED `DX A114 1; It � [J�/Q�L � 3 ❑ P.D. TIME 108 � Q� PATIENT DESTINATION: FROM SCENE- ❑ FIRE__ TIME 10-97 a� yJ ❑ PSAP TIME 10.49 �12 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: J PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ? RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER p J•'F PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN PARAMEDIC Hx: DISPATCHER: Z — I CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) G C 9/ ( PATIENT REFUSED SERVICES: (SIGNATURE) X N 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES D NO NO. OF PATIENTS: Al5�W, S.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#: 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: f ADDRESS: CITY: STATE: ZIP: COMMENTS: w' TOTAL:--. ..— s ZJ.CX/__. ._ - _ PATIENT RECEIVED BY: X (SIf1N%TURF) [Mt l CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM i uNlr AUTHORIZATIION 0 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY«___JL �40 ADDRESS AGE CITY STATE ZIP DOB 5n ❑ M ❑ T O W O Th O F ❑S DRIVER'S LICENSE M _ PHONE ___ NATURE OF DISPATCH 5L C UA TYPE OF TRANSPORT: AMBULANCE❑ OTHA❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR C OCK) C (A� s. TO SCENE- S.O. CALL RECEIVED C� Uj, 1 O P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �""- ❑ PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END 98 DOCTOR PMD/ER START 1 2 n HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY- ^C PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSEZONE�tI ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY Cl OTHER PATIENT CONDITION: DRIVER �C� � I I_ EMT-1A TECHNICIAN G CA n t• 5 PARAMEDIC_ t Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN:/YES ❑ NO REASON FOR DRY RUN S-�1 ��(� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS M: 1 N TOTAL MILES: X MEDICARE q: E.O.B.ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ �rt7 TOTAL: � PATIENT RECEIVED BY: X CONTRA COSTA COUNTY AMBULANCE Q�_� \Jr� y PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION.P-1 7 U CHECK ;1,71 INAPPROPRIATE SPAC S DATE: PATIENTS NAME ❑ M ❑ F COMPANY p 01 ADDRESS AGE CITY STATE ZIP DOB— pRln O M ❑ T OW ❑Th Oc F ❑ S DRIVER'S LICENSE M PHONE —_ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LO ATION: RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR CLOCK) //�. TO SCENE- S.O. CALL RECEIVED Z' VIP ❑ P.O. TIME 10-8 , PATIENT D STINATION: FROM SCENE ❑ FIRE TIME 10-97 �1 13PSAP TIME 10-49 1O [oA, �-� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START ME HOW CHOSEN: TOTAL E. ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER _::::�CALL BACK M: AMBULANCE COMPANY- . �e,A PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: .'L' RESPONSE ZONE a ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ''' 'r ' EMT-IA TECHNICIAN G G, 714 �L?_ PARAMEDIC i Hx: DISPATCHER: CHIEF COMPLAINT: _ DRY RUN- YES ❑ NO REASON FOR DRY RUNTC2'2-Z t 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 p: TOTAL MILES: X MEDICARE#: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP M: 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/ 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: 7 TOTAL:--./ _ 0047 PATIENT RECEIVED BY: X.____ (SIGNATURE) `n I � CONTRA COSTA COUNTY �" AMBULANCE PRE-HOSPITAL CARE IfORM I UNIT AUTHORIZATION M VJ-)S 7S-G CNECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME t. -✓"4. ^�_'z_-,�y�__�L�� C� _ iff M ❑ F COMPANY# I cSy ADDRESS ,�-i s�1,_1.�_.�_�sti�_ J Ao AGE I C, STATE-_57/_4'- ZIP.--- DOB 1' Sn ❑ M ❑ T 0w ❑ Th•O F ❑ S DRIVER'S LICENSE a'_-- _ ,- __...._ . PHONE 3.G ���6CSNATURE OF DISPATCH A%1155 IS o ti=R TYPE OF TRANSPORT: AMBULANCE-0 OTHER[] INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CgL.qCK) TO SCENE - .0. CALL RECEIVED t2}_a.._F�- r r-- ----- 3 ❑ P.D. TIME 10-8 _ j.� PATIENT DESTINATION: FROM SCENE - TIME 10-97 �� r- 0 ❑ PSAP TIME 10-49 •-_ •: �� MILEAGE: ❑ OTHER/PVT TIME 10-7 .p-3 Af . . J END—.ZC_v__ TIME 10-98 J DOCTOR __—S_L.�1.Y - PM START L�_ TIME 10-22 HOW CHOSEN: TOTAL . Z_-_ STANDBY TIME iE7 NEAREST ❑ FAMILY ❑ TRANSFER. -, WAIT TIME ,- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: /4s PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: `'l RESPONSE ZONE_, ❑ YES_ ' O Cl WAL',ED--43�GUERNEY Cl OTHER PATIENT CONDITION: DRIVER.1`•�-f- — EMT-tA TECHNICIAN PARAMEDIC Hx: DISPATCHER: _ CHIEF COMPLAINT: -/_�i_ _1 t._f,�w.w_1tN_�_- DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) X._ ICD MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO, OF PATIENTS: 1 S.S. a- - - PRIVATE INS. CO.: _._ BASE RATE: KAISER t+: -_ __--. MULTIPLE PTS. BASE RATE BLUE CROSS a _._-_ TOTAL MILES: X MEDICARE K: _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO - ❑ YES ❑ NO NIGHT: (19 00-07:00) CCHP/PPHPM: EMERGENCY RUN: G � ' MEDI-CAL#: __- CODE 2/3 THER: � OXYGEN: (PER TANK) O.E. STBKER ❑ YES 11 NO NEONATAL- (INCUBATOR) '( d D TES I LED: _ STANDBY: (OVER 15 MIN.) ` I E.K.G.: (PER EPISODE) _ NEAR T 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: d ADDRESS: G CITY ------ STATE:. -ZIP:--- COMMENTS: IP:--COMMENTS: T• Gif,JA/�C .Z 5 /G &R_ 3qvs -nfNL_4Lt__/Atr_Q_ - -- - -.- TOTAL:__ PATIENT RECEIVED BY: X ' 004'78 lr.,n:•.. .. •r•. � .,. .. (SIGNATURE) • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# •. zap fi1� CHECK OR FILL IN APPROPRIATE.SPACES DATE: A✓• PATIENT'S NAME_�Q1 C (�/���jM ❑ F COMPANY# ���DRESS --fc2__.t=��A JCJ'r AGE , t CITY. k STATE---C-Z9— ZIP(`� ( DOB�`GI: O Sn KM O T .O W='OITh, ELFA❑ DRIVER'S LICENSE# ------- PHONE 2 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULAiJCE OTHER❑ i .. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME,— (24 HOUR CLOFK);a '` `'�`•' RC� C / TO SCENE- S.O. 273 CALL RECEIVED L _����_�2h . ✓T. ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- � ❑ FIRE • TIME 10-97 Cl PSAP TIME•10-497 N44 MILEAGE: ❑ OTHER/PVT TIME 10.7 {' %� �L END a TIME 10-98 Jam- ►., DOCTOR - /4 PMD/ER START I TIME 10.22 HOW CHOSEN:, TOTAL -J STANDBY TIME; .�: �� 11 NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT ❑ DIRECT XOTHERj56lV / CALL BACK#: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKE TO AMBULANCE: 1 f ' 5/0 RESPONSE ZONE YES ❑ NO O WAL::EDGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-11A T /C TECHNICIAN PARAMEDIC y t"� Hz: J�a T❑ SL i' . i'I) i :i::r.` CHIEF COMPLAINT. (Qf �LIi DRY RUN: O YES�CN REASON FOR DRY RUN I `' !� ..f ' G� ' AUTHORIZATION FORDRYRUN(EMS USE ONLY) � ' ��''• � _J PATIENT REFUSED SERVICES: (SIGNATURE) X L COVER G INDUST AL ❑ YESXNO NO. OF PATIENTS: ffKS INS. CO.:-- BASE`RATE: _ #: _ MULTIPLE PTS. BASE RATE "(� I7ROSS#: TOTAL MILES: 7 X l¢�) 3' 0 MEDICARE#: E.O.B. ATT. ROUND TRIP:` O YES ❑ NO kDATE ❑ YES ❑ NO NIGHT: (19:00-07:00) - CH\P/PPHP#: EMERGENCY UN;__i is��T,IIT:'F t; AIM , EDI-CAL#: COD 2 3 ' THR: OXYGEN:` TANK) O.E. STICKER OYES ❑ NONEONATAL: (INCUBATOR)BILLED. STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) EAR T RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X '. --•��y� DRUGS: (PER ADMIN.) X .._...—z-,•.,., _ ��` NAME " " rah _LL1 F��j__ 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: C Cl'FlY: STATE: ZIP- /�� COMMENTS: :."4 TOTAL: "L PATIENT RECEIVED BY:X -� • Prn:?r r' r�1n'. ;4: n: •7.,. ^rf:. �•� _•hr. .t SIGNATURE) 1 I i� I • CONTRA COSTA COUNTY AMBULANCE �( PRE-HOSPITAL CARE FORM I IJNIT AUTHORI ATI N# v� j�Q 1n CHECK OR FILL IN APPROPRIATE SPACES - DATE: PATIENT'S NAMELVYV�J �M ❑ F COMPANY# ADDRESS `—��- ±iJ`-`• AGE 3q __l� CITY P __ STATE� _ ZIP DOB �J�!f� ❑ Sn ❑ T ❑W O Th 0 F Os DRIVER'S LICENSE a _-- -__ -_ .._ PHONE NATURE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: �.�<i� ` RESPONSE CODE: UESTED BY: TIME- (24 HOUR CLOP K) TO SCENES O. CALL RECEIVED (eh�) AW /� 1�1} `V/�1(Y\1 ❑ P.U. TIME 108 : PATTEN EST INATION::dd� FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAPTIME 10-49 bZV oo �� � ' '`� _ _ 1.41LEAG�.{ � ❑ OTHER/PVT TIME 10-7 L END J TIME 10-98 c� DOCTOR _T _ — PM /ER START-1_+ l TIME 10-22 HOW CHOSEN: TOTAL -LL1__ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME P TIENT ❑ DIRECT ❑ OTHER / CALL BACK#: AMBtIRi��E COMPANY: "TPL.. ff``�� -. T AMBULATORY? /y I NTAKEN TO AMBULANCE: I J RESPONSE ZONE YES ❑ NO AL­,ED ❑ GUERNEY ❑ OTHER Q/� PATIENT CONDITION: DRIVER_ Sc.. S��t etj _�J_�—(Ao _ EMT-1A _ �- TECHNICIAN _ �^� 1yG'� IO PARAMEDIC Hx _ - DISPATCHER: (� CHIEF COMPLAINT: __ _�- -_F-'�`� -_ _ ( ' DRY RUN: Cl YES REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j PATIENT REFUSED SERVICES: (SIGNATURE) X—____—_ — 1 MEDICAL CqJ5EINDUSTRIAL ❑ YES NO. OF PATIENTS: PRIVATE INS.CO.: BASE RATE: �5O KAISER#: MULTIPLE PTS. BASE RATE ^ � BLUE CROSS# — TOTAL MILES: / X C� _QS1U 1 MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO '^ ❑ YES ❑ NO NIGHT: (19.00-07:00) 30.tZ6 CCHP/PPRP#\ EMERGENCY RUN: •riu08 MEOI-CAL#: COD(2/3 1, \� OTHEA_ _ 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 t 1- DRUGS: (PER ADMIN.)_ X NAME:,�1C_�c1��A -`� 4a D__ RE�LATIONSHIP1C E O.A.: (IF NOT REPLACED) ADDRESS: LSA \I^-L. ___ ORAL AIRWAY: (IF NOT REPLACED) CITY- ��- ��'� i7_ STATE__—ZIP:,.__ C-COLLAR: (IF NOT REPLACED) ._ PHONE: s.�l �0� WORK PHONE:----jj DRY RUN: '(AUTHORIZED) EMPLOYER: `_- C' UPATION �- V.lL -0THER: .. ADDRESS: -- - -- --`�----- -- CITY:_ _ STATE: ZIP:____-- C(1MA1FNIS -� -- ---- -- — TOTAL.,,-7,Fl PA-'Err iE_EiVED BY X (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE p PRE-HOSPITAL CARE FORM i UNIT � AUTHORIZATION N c) CHECK OR FILL IN APPROPRIATE SPACES DATE: :) PATIENTS NAME �1 A C �\t L,f SS OOF COMPANY a ADDRESS C '4c Cit) Lo L� AGE_Q2 r•)It Z- � 1 1 CITY('0A)C0IC 1� STATE�1_ ZIP���-��I D.!OBBZJs J6,❑ Sn �_M -DT ❑ W 13 Th 0 OS . Li I DRIVER'S LICENSE N — PHONE6r -��_S_ �l'L NATURE OF DISPATCH 11 -7 TYPE OF TRANSPORT:(AMBULA OTHER O __ ___ -__. STATION 1(A) ^218)_3(C)_4(D)_5(E)_ c_ .. INCIDENT LOCATION: N , RESPONSE CODE: ESTED BY: TIME- (24 HOUR CLQCK) Ci� C TO SCENE- CALL RECEIVED D P.D. TIME 10-8 i,,['-�1 : I� PATIENT DESTINATION: / FROM SCENE- 13 FIRE TIME 10-97 ElPSAP TIME 10-49 ;,, _.I MILEAGE: I ❑ OTHER/PVT TIME 10-7 iJ I' ` J END E r TIME 10-98 DOCTOR I -�r JT PMD ER START 0 ( TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O_NEARE6T, ❑ FAMILY ❑ TRANSFER / WAIT TIME PATIENT ❑ DIRECT ❑ OTHER / CALL BACK K: AMBULANCE COMPANY: r_� s Eo AMB TO Y? PATIENT TAKEN@ AMB)ULANCE: �, RESPONSE ZON YES D WAL'<ED GU Y ❑ OTHER PATIENT CONDITION: DRIVER Y) TECHNICIAN PARAMEDIC HK: a 1 d DISPATCHER: i f� C IEF PLAINT: L A Ie P DRY RUN: ❑ YES NO REASON FOR DRY RUN LAAUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS.CO.:-1�1 RC�k t�C S BASE RATE: LLSG:S1�' l.. AI$ER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: L MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES NO, ❑ YES ❑ NO NIGHT: (19:00-07:00) -GCHP/PPRP C EMERGENCY RUN: _ U•C,� / MtOI-CAL N: CODF 2/3 OT\ER: k4�A 12T (OI,4 j) OXYGEN: 'PER TANK) .O. . STICKER Q YES ❑ NO NEONATAL:. (INCUBATOR) D ES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: v-pr I`413 <� RELATIONSHIP: ter E.O.A.: (IF NOT REPLACED) ADDRESS: S I� ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 27WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYERELL� ,��� 1 (� OCCUPATION:. OTHER: ADDRESS: r J CITY: STATE: ZIP: �OMMENTS: LUq(�fCS T 1 -o 4��In�Ks ���I� 1►Lc� L.A IZ V'��� NCS-;r AKe 4 n (��_ TOTAL:• _1 L . . --Z 3 - - -- 004 PATIENT RECEIVED BY X . I•'.0 JJ�lt4 �. CONTRA COSTA COUNTY AMBULANCE tt,, PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION a—V3 CjJ� r I CHECK OR FILL INAPPROPRIATE SPACES DATE: .._.J.I-�-�� ,:PATIENT'S NAME 11JA�3.��1.1L` ❑ M XF COMPANY a_ 'ADDREESS �d1904' AGE — CITY-11LC STATE X1.1— ZIP 94_UJQ _. DOB -.��OZ ❑ Sn ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE a __._._____ _ _ -_ PHONE . ' /v !- I .. NATURE OF DISPATCH._- TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: NR UESTED BY TIME — (24 HOUR CLOCK) _ TO SCENE_ CALL RECEIVED c U t_ TIME 10-8 r PATIENT DESTINATION: FROM SCENE- ❑ FIRE __ TIME 10-97 Z ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ,y� y END yS TIME 10-98 DOCTOR CAP <<— `ie R PMD START_!fl__T_ TIME 10 22 HOyW�CHOSEN: TOTAL —�'�—__ _ STANDBY TIME -NEAREST Eo FAMIL ❑ TRANSFER WAIT TIME ❑ PATIENT DIRECT ❑ OTHER ' CALL BACK a: AMBUUL N E COMPANY: 3AATORY? PATIENT T N TO AMBULANCE: YRESPON�SJE ZONE NO ❑ WAL"ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER. t_`r+jcl.,_ EMT-IIA— f 1 , n �� -' tTECHNICIAN —��--"_�1��� > > ' - PARAMEDIC �,)3 Hz: —1,�1f(•� CI,'LJ c Tl l ►`I6� 01 16PATCHER: 2i CHIEF COMPLAINT: r --� DRY RUN: ❑ YES 0.. REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY). PATIENT REFUSED SERVICES: (SIGNATURE) X_ _.--- J MEDICAL COVERAGE: INDUSTRIAL ❑ YES N NO. OF PATIENTS: S.S.a -- -- PRIVATE INS. CO.: BASE RATE: 30,00 LD KAISER a: MULTIPLE PTS. BASE RATE Sa. -- TOTAL MILES: — X 711p/ppo!ps�#: —, N E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO YEd ❑ NO NIGHT: (19:00-07:00) r EMERGENCY RUN: MEDI-CPCL a: CODE 2/3 OTHER: OXYGEN: (PER TANK) - L 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: iNc)14RELATIONSHIP_014c, E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: .(IF NOT REPLACED) _. Z CITY: ) 1 STATE--ZIP: C-COLLAR: (IF,NOT REPLACED) PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS:— — -- — — -- ----- --- -- ',,. CITY: STATE:—.--ZIP:--.—.—. ---...... -- COMMENTS: TOTAL - -- ---� - 00482 IIA IIEN1 111 CEIVI II Illy x f1m,IlATIFW I _ CONTRA COSTA COUNTY AMBULANCE •7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK ON FILL IN APPAOPAIAIE SPACES DATE: t' PATIENT'S NAME ''� ( ❑ M F COMPANY N 1 = I ADDRESS �.i.n r, 1 L� AGE I L CITY011 o STATE 11 i' ZIP I`! I ) 1 DOB fLI❑ Sn O M ❑ T ❑ W ❑ )t❑ F ❑ S �1-L3- DRIVER'S LICENSE q __-____.._._ __ ______. ._-_.__ PHONE - ��_11 J- -�NATURE OF DISPATCH � f�'eC' �� TYPE OF TRANSPORT. AMBULANCF�El OTHER❑ .-_.. _-........_____ _. -. STATION 1(A)_2(8)_3(C)_4(D)_5(E)! • t INCIDENT LOCATION:r-J utl�;,, RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C(OCKI I t �r TO SCENE- S.O. CALL RECEIVED _L(2 ' i ,s ❑ P-L) TIME tae 1— ..1,,C. • J rPATIENT DESTINATION FROM SCENE- 11 FIRE TIME 10-97 J t ❑ PSAP TIME 10-49 �.�� - •j MILEAGE. Cl OTHEFVPVT TIME 10.7 ' ff ''__ -- END= .y� 7-� TIME 10-98 DOCTOR � PMD/ER START 1 TIME 10-22 HOW CHOSEN: TOTAL — V STANDBY TIME ❑ EAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ! ATIENT ❑ DIRECT ❑ OTHER t r CALL BACK N: AMBULANCE Mm NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: f RESPONSE ZONE -�- YES ❑ NO CVAL'CE ❑ GOER EY .Q OTHER PATIENT CONDITION: DRIVER TECHNICIAN PAIa1{1RED1C ( Hz: T�1 }v.F CHIEF COMPLAINT: e r Y �' t t(SPATCHER: RY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR RY RUN(EMS USE ONLY) /f/ 7 PATIENT REFUSED SERVICES: (SIGNATURE) X_ q MEDICAL COVERAGE: INDUSTRIAL ❑ YESVNO NO. OF PATIENTS: --p S.S. N s� '-7 3 PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE CBLUE CROSS»: TOTAL MILES: X MEDT q` E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 CCHPIPPHPEMERGENCY RUN: Q I�CI G MEDI-CAL It.i. COD 2,13 t tj OTHER: OXYGEN: (PER TANK) __-- P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) '' E ' 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:�la_f'f td 1 1—f'`4 RELATION �� 1E.O.A.: (IF NOT REPLACED) .- . I ADDRESS: r'` I 7 10 ,ORAL AIRWAY: (IF NOT REPLACED) CITY: ', -` o' _ STATE_.ZIP- C-COLLAR: (IF NOT REPLACED). _ _- PHONE: •l S 1 r t '12 S WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: ST�ATTE: - ZIP: COMMENTS•L 'b-t, I_L1-_!S4`� n 0 4 Q 3. ----_--__ TOTAL _C _�O --- _ PATIFNT RfCEIVFD BY /nrni•frr• e•rt,t:.. 41%,1., .s,( 1'u.• ( L. CONTRA COSTA COUNTY AMBULANCE J l� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M(]• �� ` I 1 CHECK OR FILL IN AGPROGRIA/1.SGA 1711 r� 1 DATE:/,Z- i \ i f PATIENT'S NAMjE_ _�( J 1 (Jj.L ( �.LI-l`-.---------.--..----- )�M ❑ F COMPANY p ADDRESS 1�.- r - ------- -- AGE—M— r GE_ M f n r (.TTY ';:`� , 1. 1_.:; I _ STn.1F �:' I _. ZIP .___._ ....-.- DOB-/.. 1.. `J<--❑ SnM ❑ T Oy�l OTh OF O$i DFUVER'S LICENSE PHONE/t _�_D^__ 1;./ 14ATURE OF DISPATCHII(f TYPE OF TRANSPORT AMBULANCE T,HER❑ INCIDENT LOCATION:',:I )(-1- •JI� I RESPONSE CODE: R,�EPUESTED BY: TIME— (24 HOUR COCK) , ) I / ' l TO SCENE- 14 S.O. CALL RECEIVED f ❑\P.U. TIME 10-8 - I ... lJ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 °Z— ❑ PSAP TIME 10-49 C QIP J _ T/� C{�✓�� MILEAGE: I � ❑ OTHER/PVT TIME ID-7 11 TTIME 10-98 1� END 111 DOCTOR _PR_ r �_--�PMQ11=R START_ 3f l TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE - YES ❑ NO WAL`,ED ❑ GUERNEY ❑ OTHER _ .. PATIENT CONDITION DRIVER:' AT-1A . 1 TECHNICIAA _ �- �'� PARAMEDIC-- Hx _ DISPATCHER: �11 (7 CHIEF COMPAINTI/: , _r.i�__)i IDRY RUN: ❑ YES NO REASON FOR DRY RUN �'�1L�1— �� -C.__.._.__. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 � PATIENT REFUSED SERVICES (SIGNATURE) �) ? MEDICAL_COV R E "DUSTRIAL ❑ YES A NO NO. OF PATIENTS: ! C` PRIVATE INS. CO.:— BASE RATE: KAISER aMULTIPLE PTS. BASE RATE a16.�c BLUE CROSS tI: --.— _ ___.__ — TOTAL MILES: 4/ X G• SO MEDICARE a. _--_ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) nn/ CCHP_PPHP NJ EMERGENCY RPN• V b CODE 2//3) OTHER:__ _. OXYGEN: (P�_RAANK) 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: THER ADDRESS: ------ ��• �� CITY: ___.__ STATE: ZIP: V Ti COMMENTS. --- -. ..- -- - -- TOTAL- PATIENT OTAL PATIENT RECEIVED BY:X 0048 — --- (SIGNATURE) Lk5-1 A I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ® AUTHORIZATION M -... C CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'Sl50A-1 ME �� �o:t— Flr��q. M ❑ F COMPANY M % '+ ADDRESS �< y f� AGE 3 / CITY_ �1 C STATE (-A ZIP �U DO 1� �50 ❑ Sn M ❑ T 13W O Th O F E3 S DRIVER'S LICENSE __.__ -- _ PHONE _ 52�,3� NATURE OF ISPATCHf e12.cdL --- TYPE OF TRANSPORT: AMBUL-ANC OTHER❑ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ •-- INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME-- (24 HOUR C(_OICK)n TO SCENE-�� S.O. CALL RECEIVED !, -�/- ''- ❑ P.U. TIME 10-8 •r 'I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ` ❑ PSAP TIME 10-49 MILEAGE / ❑ OTHER/PVT TIME 10-7 lam- '< END JAI o TIME 10-98 - DOCTOR LIL2- PMg5 START-5�_ TIME 10-22 HOW CHOSEN: ( TOTAL 5•,x STANDBY TIME t ❑ NEAREST FAMILY ❑ TRANSFER WAIT TIME _.._ N�R;ATIENT ❑ DIRECT ❑ OTHER ` .) CALL BACK 0: yA1�11rANCE COMPANY: �L jj''VV J I PT MBULATORY? PATIENT TA TO AMBULANCE: I �1 RESPONSE ZONE S ❑ NO ❑ WAL'CED UERNEY ❑ OTHER f 1 PATIENT CONDITION: DRIVER pr_ 6Lp_ ��)T �l EMT-1A - J TECHNICIAN y^ILL' C.` C PARAMEDIC G?C Hv 5-11I7-U�Z DISPATCHER: !-j CHIEF COMPLAINT: <" DRY RUN: 13YES REASON FOR DRY RUN ...C __� AUTHORIZATION F110A DAY RUN(EMS USE ONLY) / PATIENT REFUSED SERVICES: (SIGNATURE) X__ MEDICAL COVERAGE: INDUSTRIAL ❑ YES Nb NO.OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: /SD•Gv_ KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS M: 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 UN: o '1 MEDT-CAL N: 1_) p f�C1 {' ".� ^"�'" S CODE 2 P3 OTHER. ` OXYGEN: JPER 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'. RrjRhRELATIONSHIP..Q 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: V ADDRESS: CITY: STATE: ZIP: -- ,) COMMENTS: -� If )) _ TOTAL cz� / •(0 •• PATIENT RECEIVED BY:X ___004815_ (_ Prodidrr Pet a r. Vhitr rd Pi-.; 'Ph 9rturn Y'r';; bi1'ing (SIGNATURE) -.�r t Rr,^ uh�n DIS-1 CONTRA COSTA COUNTY I AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZA' 71N- CHECK I N CHECK OR FILL IN APPROPRIATE SPACES DATE: I -Z lJ PATIENTS NAME OM O F COMPANY N ADDRESS - AGE - plLfte L / CITY STATE ZIP DOB O Sn ❑ M ❑ T OW O Th OF OS DRIVER'S LICENSE N PHONE __ NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE 0 OTHER 0 _ — STATION I(A)_2(8)_VC)_4(D)_5(E)_ I INCIDENT LOCATION% RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) I 1 [` \ TO SCENE- O. CALL RECEIVED lJt v 6 O S� D P.D. TIME 10-8 r r PATIENT DESTINATION: O(/ a FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 \/ ( MILEA D OTHER/PVT TIME 10-7 �i END TIME 10-98 T DOCTOR' - PMD/ER START TIME 10-22 HOW CHOSEN: TOTA STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME D PATIENT ❑ DIRECT D OTHER CALL BACK N: AMBULANCE CObAPANYj PT. AMBULATORY? PATIENT TAKEN 7O AMBULANCE: \, 1 . RESPONSE E O YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER j✓ PATIENT CONDITION: 1 DRIVER EMT-11A TECHN I S-PARAMEDIC 7 7/ Hx: DISPATCHER: t� CHIEF COMPLAINT: DRY RUN: YES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) "II4 l/ PATIENT REFUSED SERVICES: (SIGNATURE) X 5;'- MEDICAL COVERAGE: INDUSTRIAL ❑ YES D NO NO. OF PATIENTS: S.S.N 'A PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE N; E.O.B.ATT. ROUND TRIP: ❑ YES ONO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: ' EMERGENCY RUN: MEDT-CAL C J CODE 2/3 \ OTHER: 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• J I 0048P , PATIENT RECEIVED BY:X -- Prouf}ir rural: Vhitr ,rf pr I ,.,,1. q,•r„re r, ti,.,. I: ISIGNATUHE) TM V ( 1 I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# R3 I58Y/ I CHECK OR FILL INAPPROPRIATE SPACES DATE: *3 r PATIENTS NAME yy ` ��_ I IJE _ �2i-I E ❑ M ft F COMPANY / r ADDRESS CI.D AGE 27- L) CITY M\Z- STATE �-� ZIP DOB ' i jQ�6n A M O T O W O Th D F O S, , DRIVER'S LICENSE# _ _ __. PHONE- & ��_ONATURE OF DISPATCH I-ALJ--' J TYPE OF TRANSPORT: AMBULANCE 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- o S.O. CALL RECEIVED 430 (t��` P.D. TIME ID`8 +-rL6, :�`. 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ .- :-11.--•-� i-• ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ., ENO TIME 10-98 DOCTOR PMDQ START 10. 2. TIME 10-22 HOW CHOSEN: TOTAL �_� STANDBY TIME ._ (NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 1: b PATIENT ❑ DIRECT ❑ OTHER ( �, CALL BACK#: AMBULANCE COMPANY- PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 �� RESPONSE ZONE__ ❑ YES NO ❑ WALKED GUERNEY ❑ OTHER j 1 PATIENT CONDITION: DRIVER `7 EMT-1A " v TECHNICIAN -1—7 PARAMEDIC Hx: DISPATCHER: Al R y 7 ' " CHIEF COMPLAINT: FrALL_ DRY RUN: ❑ YES � NO REASON FOR DRY RUN ..� (� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 9 5 I PATIENT REFUSED SERVICES: (SIGNATURE) X— a0MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ~ S.S. # PRIVATE INS.CO.: BASE RATE: s0�` KAISER#: MULTIPLE PTS.BASE RATE BL OSS#: A `- `J cov. TOTAL MILES: � X E ICARE SR - 1Z` I�Z�o' E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -❑ NO NIGHT: (19:00-07:00) C P/PPH #: 6 r= �+ EMERGENCY R " O AL#:� / ' -�� '�c7 l.7CODE 2 � '.. ..._�� _ OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIELE PARTY: I.V.: (PER ADMIN.) X . _. DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP- - - COMMENTS: r TOTAL: • 5 PATIENT RECEIVED BY: X Provider retain. white Lrd Plea rope Return Te:204• mp. t F]NS when bil:ina (gl G•NATURE) DIS-1� 1,.. CONTRA COSTA COUNTY AMBULANCE 5...9 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONM— s c:/ A. (1- r�- 3 CHECK OR FILL IN APPROPRIATE SPACES DATE: -- PATIENT'S ATE: _PATIENTS NAME-�Ll_ � AR��_�— 10 ❑ F COMPANY a ADDRESSTx/�^ AGE CITY R STATE_C-A— ZIP y DOBy_ _ 70 gn4P0 T ,/❑� W O Th O F 0 S DRIVER'S LICENSE 4 , PHONE____._ - —_— NATURE OF DISPATCH—pi f orc/ L. TYPE OF TRANSPORT: MBULANCE a OTHER O d INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)-� y� PZTo (� S i A-MAI TO SCENE- � Z CALL RECEIVED GG.i � .'f f R � —1_ _-- ® P.U._�� TIME 10-8 :y— PATTENT-DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ) G ( ❑ PSAP TIME 10-49 I MILEAGE:yG ❑ OTHER/PVT TIME 10-7 END �(,—e6 TIME 10-98 - DOCTOR 1- MD/ R START�_�'��j TIME 10-22 HOSEN: TOTAL y STANDBY TIME E O FAMILY ❑ TRANSFER 4 WAIT TIME ❑ PATIENT 0 DIRECT ❑ OTHER % CALL BACK p: AMBULAWE COMPANY: PT. AMB Y? PATIENT TA ULANCE: ` RESPONSE ZO E O, YES NO ❑ WALKED RNE ❑ OTHER -•sPATIENT CONDITION: DRIVER _ EF,AT-1A TECHNICIAN rn-L �^L4_ 1 ) PA AMEDIC Hx: SCSzuRtS DISPATCHER: / ( C, 7.53 CHIEF COMPLAINT:' C DRY RUN ❑ YES NO EASON FOR DRY RUN_ P05 <7r AUTHORIZATION FOR RY RUN (EMS USE ONLY) �C1 PATIENT REFUSED SERVICES: (SIGNATURE) X _ 99--MEDICAL COVERAGE: INDUSTRIAL ❑ YE O.OF PATIENTS: -- S.S. a _ PRIVATE INS. CO.: BASE RATE: —N,";AISER#: _ MULTIPLE PTS. BASE RATE —� _LD LUE CROSS M: TOTAL MILES: X �b' MEDICARE M: y O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES 0 NO NIGHT: (19:00-07:00) ^� CCH #: EMERGENCY RUN: 0 COQ�2� 3 OTHER: OXYGEN: (PER TANK) P.O.4 STICKER YES ❑ NO NEONATAL: (INCUBATOR) DAT 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:U-1)G 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:- 0 0 4 8 8 IP: n0488 COMMENTS: PUS T O A," h P 1 1d0 i SCHANETTE - -- --- __ TOTAL C!iA8 07609439226404 - ---- �: _ PATIF NT RECEIVFD nY X . ._ ..�,...sirs• iCl:���ll:♦r��>1L�"�4� ... • �t��l� 4 , EP I2 4 311 12 4 .0-1123 4 34 PI S 33 I, SO NUMBER � � Z: CAH RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10-8 fn i CALLED BY ' PATIENT INFORMATION o NAMEw f'V A(,ENC-Y CUSTOMER #(PT. 1): w DEPT!FtOOR;ROOM a: _.. -- - -- -- NAME. .__._r^.�_.�/T' !' "r�� /✓tir�C t,r n .0► Iz m .F CALLBACK a -____-.__. _. __.__-___-_._____._-__ INS. TYPE: PVT ,MCAR (MCAt KHP PHP VA IND CHAMPUS > w i ! cl. civ n INCIDENT LOC .. -_ t i POCtCY MCAT n: ( L 9 z m a - - -- — -- -- ------- —_-_ MCAR a: — - n c� �'• G .� n m m CROSS STREET VERBAL PRIOR: V o W _. ._ JURIS Gty: C �_� I l U - -- - DOCTOR: - r � DESTINATION: 1 -� _.. .- --------_---__-._. PT, tr2 NAME: DOB: > NATURE .--- - --- - - --- --- - CUST. # 3m C� _-- ----_----- PT. #3 NAME: DOB: c .p TYPE OF CAL . EMG.l TRANS TIM UNIT n _ .�,.±✓ CUST. a _ - z w CREW: _ ` . U O CL "� WAIT TIME: YES NO REASON: J_ m Ty F r z O UNIT TYPE: AlS Bl5 WC RESPONSE CODE: 0 I� 3 4 REASON FOR 1022: O .� c INCREASE'DECREASE CODE.2 3 10.49 CODE: 0 1 2 3 4 CANCELLED BY: N U. BY: _----__--. _— END MILEAGE; t _,— ' COMMENTS: = z TIME --. -----_-.. BEG MILEAGE: _? I D TOTAL MILES: �_-. I 00489 I -• m _ a - /L' l�l - XL 1S IV 3DNv1(18wv I 61.01 `JNINdn L 3DNV1F1BWV I 86-01 31OV11VAV 3DNviF19Wv L•01 1V11dSOH 1V 3:)NV1F18WV no 11 d33 rJ4 ,> Up tp :.� yLs�` ���•��Sf� _Z'-�r`LY� ��'�.v ��-�i-i� '� -.��.,fit. �! l ' . • i,'"��Il 1'•jaw �.��;..�" 'i. * - ,f . ♦ _ Y.[ Y 1 � J 1 Ilk YL a^� :17. �! s'� '�-�`� i•t ''�7;�i�i k��"< y Yah. ;. . , M! r ?:-st r.R43t:;.i-� .3. ''�,:�'•�"'WM-� fi* ^�.,• to �. VV / i - .. J� 1� CONTRA COSTA COUNTY AMBULANCE zs PRE-HOSPITAL CARE FORM 1 UNIT � AUTHORIZATION M 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ,', Ll �("_ �C, I C V! ❑❑ M F COMPANY a ADDRESS / NAGE D ' CITY ,)J 'y - STATE ZIP DOB _ O Sn M O T,❑•• W ❑ Th.O F E 38 -- �- DRIVER'S LICENSE a ____ PHONE �_� NATURE OF DISPATCH � TYPE OF TRANSPORT: AMBULANCE P OTHER❑ __ _ — STATION 1(A)._2(8)_3(C)_4(D)._5(E) I ? INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ' TO SCENE- RS.O. _ CALL RECEIVED 17 O P.D. TIME 10-8 ( PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �_ ❑ PSAP TIME 10-491 cc MILEAGE:S ❑ OTHER/PVT TIME 10.7 ENO TIME 10-981 �.�[ DOCTOR PMD/ER START TIME 10-22 ".�...,__j HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME I ❑ PATIENT ❑ DIRECT 13 OTHER ( i L� } CALL BACK a: AMBULANCE COMPANY .~ PT AMBULATORY? PATIENT TAKE TO AMBULANCE: n RESPONSE ZONE _ ❑ YES ❑ NO ❑ WAL`(ED GUERNEY ❑ OTHER R� PATIENT CONDITION: DRIVER J U L.1 --� �- ftAT-JA - I - TECHNICIANS _ UDj :l/ 7J PARAMEDIC Hx: Sv ( 1 ^f �. DISPATCHER: '7 /Z71 A CHIEF COMPLAINT.-:::UT' �C S J C t Q-' DRY RUN: ❑ YES 940 REASON FOR DRY RUN CSS ` '7�(� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) F aS ynPATIENT REFUSED SERVICES: (SIGNATURE) X - --' I.. MEDICAL COVERAGE: INDUSTRIAL ❑ YES 94N0 NO. OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE �7T� BLUE CROSS a: TOTAL MILES: MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES 1:3 NO O YES ❑ NO NIGHT: (19:00-07:001 CCHP/PPHP a: EMERGENCY 9UN: MEDI-CAL a: CODE,24 3 �p 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: ��: - %T/�.' >fJ 5.02) 7O CITY: STATE: ZIP: 00496 COMMENTS: Pr U >J 00 1CA,4 Ps3 C•r iU -r (:'LU t Lc-!Ai I ►��� rf— `'Loo TOTAL: -- PATIENT RECEIVED BY:X�1. IQNAT RE► Provider retain Whiterd Pin's -r4 Actum Yr;1tw ro p t, v.%r uhen D(T:inp OIS-! ►�'- ` ' CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION# 585'0 CHECK OR FILL IN APPROPRIATE SPACESGATE. I �� PATIENT'S NAME S 1 EL-L A V . CL-A�f� ❑ M �i F COMPANY# J 77,9 1 �• ADDRESS JSI U C'�f �3 L UL1• 2304 AGE _ . CITY LA-'�- STATE r� ZIPCL`l DOB- I 01 ❑ Sn 4M OT OW OTh OF OS " ' DRIVER'S LICENSE q __ PHONE - NATURE OF DISPATCH 464�t lile 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 9 S.O. � CALL RECEIVED _r}_ 1 1`i r _ ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-'7 O FIRE TIME 10-97 .Z L ❑ PSAP .TIME 10-49 A,- I� 1 T M t✓�• t`� �� - MILEAGE: ❑ OTHER/PVT TIME 10-7 'v END— '3- a` TIME 10-98 DOCTOR i�'lrlw�`t PMD/k5,,) START 3),5 -- TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME AJ PATIENT ❑ DIRECT ❑ OTHER (� ' CALL BACK#: AMBULANCE COMPANY: -• CA-7S 1 P . AMBULATORY? PATIENT TAKEN TO AMBULANCE: .t 0 , RESPONSE ZONE YES r4 -0 Cl WAU<ED 0 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER Li )I EMT-IA r TECHNICIAN J PARAMEDIC 1 Hx: 4k) ,Aar DISPATCHER: 1577 CHIEF COMPLAINT: � `�t f-j D uf'VL_'6 DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN -7AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -. PATIENT REFUSED SERVICES: (SIGNATURE) X S� MEDICAL COV AGE: IND TRIAL ❑ YES ❑ NO N0.OF PATIENTS: Ck PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS# X11`' } - ( - � , ` GOV TOTAL MILES: 1X ,r• o �� - inntDICARE Ir,� ��� d� s� h E.O.B.ATT. ROUND TRIP: OYES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) - CCHPlP.PHP,a: EMERGENCY RU 30'c80� MEDI-CAL N:�t"1`7 1 01 '512 7a. 62-2 S' CODE A �THER: OXYGEN: (PEIR-UNK) _ J2 _0 07 P.O.E. STICKER :P�YES ❑ NO NEONATAL: (INCUBATOR) 3 1 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: sli Rc OCCUPATION: OTHER: ` ADDRESS: ���17�1� t-'�- /D•� I CITY: STATE: ZIP: COMMENT 0 TU L I i t kAAU -, �+2,A C.. lrt(.a(,,-n ()UY Cao G,'1 TOTAL: G� /xx PATIENT RECEIVED BY:X Provider rvtQir White vid Nn. r.• � .vo— (SIGNATURE) \.__ ATIENT'S NAME: Streeter,Pilar ADDRESS: 123 Los Cerros Walnut Creek,Ca. DATE OF SERVICE: 09-12-83 AUTHORIZATION NUMBER: 83-15852 AMOUNT DUE: $231.00 INCIDENT LOCATIO14: 1805 YgnaCio Valley Rd. w.r. PATIENT DESTINATION: Contra Costa County Hospital 00492 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 3 CHECK OR FILL IN APPROPRIATE SPACES DATE:_� — ( ^ u q 4PATIENT'S NAME', T r�Ce Tar 1 !/�1 1 L4 r, I" O M WF COMPANY N `_ AGE E CITY C- STATZIP�� 10 ' _ DOB_v _ O Sn ❑ M O T OW ❑ Th OF OS DRIVER'S LICENSE N _ _ PHONE(L Q_1�_ �_�NATURE OF DISPATCH TYPEOFTRANSPORT: AMBULANC OTHER❑ STATION 1(AI_2(B)-3(C)_4(D)-5(E)_ INCIDENT LOCATION: RESPONSE CODE: REO STED BY: TIME - (24 HOUR CLOCK) � f v(� TO SCENE-� p/S.O. CALL RECEIVED V r i[ O P.D. TIME 10-8 ' PATIENT DESTINATION: FROM SCENE -,Z ❑ FIRE _ TIME 10-97 :T� ❑ PSAP TIME 10-49 MILEAGE:. ❑ OTHER/PVT TIME 10-7 END -�� L TIME 10-98 DOCTOR • - r�l�' PM ( START /1./ TIME 10.22 HOW CHOSEN: TOTAL . STANDBY TIME ❑ NEAREST, .,, ❑ FAMILY ❑ TRANSFER t� WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER \ I CALL BACK N. AMBULANCE COMPANY:Cis Ec3 AMBULATORY? PATIENT TAKEN TO AMBULANCE: ` � RESPONSE ZONE YES ❑ NO ❑ WALKED ❑ GUERNEY 13 OTHER �f J r1; PATIENT CONDITION: DRIVE F�� ° ' �L EMT-tA TECHNICIAN PARAMEDIC Hx: TT DISPATCHER: HOl. i_.t'_L A / CHIEF COMPLAINT: DRY RUN: ❑ YES R�NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) rK.f PATIENT REFUSED SERVICES: (SIGNATURE) X_ _ IJJ . MEDICAL COVERAGE: INDUSTRIAL ❑ YES �•NO NO. OF PATIENTS: f1 - S.S. N "A►(- • et,.,, --� PRIVATE INS. CO.:t✓ CE-n-lyee, (ITRti L-/FIC BASE RATE: KAISER it: MULTIPLE PTS. BASE RATE I BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TROP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 \V\ CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) / (p, 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: H ,L� ~ 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: — A COMMENTS:CHCC/�/�1 [a, ACc i. 110-3-Zit -Irl Q L-C-! octI -77-S 664 1 _ _ TOTAL: 1 O p „� QQ �h 7 '� j �1C/7_ PATIENT RECEIVED BY. X ISIGNATUNF) , hvvilor rctair• Whit, ;J,( r,r:, r•pp "'tum t. '1 •,, t '.>C,' uh,n 1 i t r..; [MS 1 i I CONI RA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �� AUTHORIZATION 0 v CHECK OR FILL IN APPROPRIATE SPACES - DATE: O El PATIENT'S NAME_�Ll�s'..�C.:_1 �..�.�1t.1.L� ((__ M F COMPANY w�- ADDRESS I '�� LI.Cii �C `-.I A AGE 101— i� L� 13 3 CITY +� V)'C, STATE C(� ZIP Lb DOB�ZL XSn ❑ M O T ❑ W O Th,D F O S " DRIVER'S LICENSE» PHONES`��9 NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_2(8)_3(C)_4(0)_5(E)_­- INCIDENT (A)_2(8)_3(C)_.4(D)_.5(E)_.«.INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C CK TO SCENE- Ja'/S.D. CALL RECEIVED _ ❑ P.D. TIME 10-8 �r- f PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 t ( ❑ PSAP TIME 10-49 PIS MILEAGE: ❑ OTHER/PVT TIME 10-7 ;L_-- END__7 TIME 10-98 DOCTOR _ -aC-KC,C PMD,® START ! ( TIME 10-22 HOW CHOSEN: TOTAL ! STANDBY TIME K NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME Q PATIENT ❑ DIRECT ❑ OTHER ' CALL BACK N: AMBUIJjNCE COMPANY: {•---. (� _ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 y� RESPONSE 2 NE OYES ❑ NO ❑ WAL'<ED &GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER. �c 580 EMT-1A TECHNICIAN (c v 33 PARAMEDIC Hx: �s,'Ncirf, DISPATCHER: '- CHIEF COMPLAINT: � .�Y• +� S•O +� DRY RUN: ❑ YES X NO REASON FOR DRY RUN " AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES XNO NO. OF PATIENTS: S.S. q� Z�`� Z�c )� 1_.._.. PRIVATE INS. CO.: BASE RATE: KAISER a MULTIPLE PTS, BASE RATE '- 1 BLUE CROSS a: TOTAL MILES: MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHPlPPHP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 �- r OTHER: OXYGEN: (PER TANK) Q2Scle P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) c G DATES BILLED: STANDBY: (OVER 15 MIN.) /'�J cuy V . j E.K.G.: (PER EPISODE) f. Iid NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X / 1 DRUGS: (PER ADMIN.) l X _ rd NAME: RELATIONSHIP:.6t'Ar_ E.O.A.: (IF NOT REPLACED) ADDRESS: A , 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: ZIP: — C MMENTS: + u ' —� TOTAL�I6 5,0 PATIENT RECEIVED BY:X Providrr r�r�;� :nils n',; (SIGNATURE) Y .401f-L i:. .Ji r`CrtCYr+• YP:IvW MSL f` �/$ YIItM btl�tnp ' CONTRA COSTA COUNTY AMBULANCE niq ,,6- PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: `PATIENT'S NAME M ❑ F COMPANY 0 / „> ADDRESS ' AGE " --STATE�.,r._ZIP CITY- DOB Sn ❑ M ❑ T ❑W ❑Th ❑ F ❑ S r - �� I DRIVER'S LICENSE N -1 PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHHERI❑ STATION 1(A)^2(B).._3(C)-4(D)_5(E)_ lie INCIDENT LOCATION)5TA W Le /lESPONSE CODE: RE� STED BY: TIME— (24 HOUR CLOCK) TO SCENE- IrS.O. CALL RECEIVED Cl P.D. TIME 10-8 , PATIENT DESTINATION- ^� FROM SCENE-O O FIRE TIME 10-97 11PSAP TIME 10-49 L _\ MILEAGE: ❑ OTHER/PVT TIME 10-7 Al Tf END TIME 10-98 DOCTOR 1' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST O FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M AMBULANCE COMPANy'''-`�� PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: j RESPONSE ZONE `` !! �� OYES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER - -- PATIENT CONDITION: DRIVER ' S f /?r EMT-lA I TECHNICIAN 5L"- 'o— "'� ���PARAMEDIC 1� Hx: DISPATCHER CHIEF COMPLAINT: I DRY RU ❑ N EA O OR DRY RUM l y UTHO IZATI FOR RU / ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X !� MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M PRIVATE INS. CO.: BASE RATE: KAISER AMULTIPLE 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/PPHP M:'' I EMERGENCY RUN: MEDI-CAL C 1 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/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 HONE: DRY RUN: (AUTHORIZED) EMPLOYER: OC PATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 496n TOTAL:__.,,, PATIENT RECEIVED BY. X_ I'>..ni f•� r.r.rl- tai r. .. I n:.. .. .,,.. ,. (SIGNATURE) Lr CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N��-/� Z W 3 , ,CHECK OR FILL IN APPROPRIATE SPACES DATE: s� Z•' r S - I '0ATIENTS NAME D(M UF COMPANY If "• I ADDRESS); jy E� i/¢y T AGE �� ) i CITY STATE ZIP ter.DOB' gSn D M ❑ T ❑w'13 Th ❑ F ❑ S i •DRIVER'S LICENSE N PHONE .- NATURE OF DISPATCH 17 1 TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 1(A)._2(8)-3(C)_4(D)_5(E)_ INCIDENT LOCATION:.- i APT RESPONSE CODEf REQUESTED BY: TIME- (24 HOUR CLO K) (k a= v4� I C A� �R �TO SCENE- 3 i'� D. CALL RECEIVED :Q� �S Y I ❑ P.D. TIME 10 8 ; il?l PATIENT DESTINATION: _" Q'D• FROM SCENE- ❑ FIRE TIME 10-97 ) E ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10 7 END TIME 10-98 � TT AbOCTOR ( PMD/ER START I TIME 10-22 :.L• HOW CHOSEN: TOTAL STANDBY TIME `j•., D NEAREST, ❑ FAMILY ❑ TRANSFER WAIT TIME D PATIENT O DIRECT D OTHER CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: v RESPONSE ZONE ❑ YES ❑ NO D WALKED ❑ GUERNEY D OTHER I i PATIENT CONDITION: - -- DRIVER r" � EMT-1A TECHNICIAN -3 eT PARAMEDIC Hx: �! DISPATCHER h 11 id-p- 2 Y00 . CHIEF COMPLAINT: 0 DRY UN:` YES ❑ NO REASO FOR DRY RUN T• CJ c �•iQV7J " HQ PyTIL OI�FOR DR U (EMS USE LI 1/7 PATIENT REFUSED SERVICES: (SIGNATURE) G /' q5 MEDICAL COVERAGE: 1 INDUSTRIAL ❑ 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 C j E.O.B, ATT. ROUND TRIP: D 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 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 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: �ilCr 01, SLic-,4c rj -7 qS TOTAL PATIENT RECEIVED BY: X ` _., .... (SIGNATURE) y ( •I V�L 1 l 1• t'� CONTRA COSTA COUNTY AMBULANCE �) -• PRE-HOSPITAL CARE FORM I UNIT ' AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ` v ❑ M X F COMPANY ADDR-SS AGP— NATURE .� 1 CL STATE ZIP_ ! DOB �❑ Sn ❑ M ❑ T ❑ W O Th O F OS DRIVER'S LICE SE k PHONff �l�_�_� OF DISPATCH ^ OTHER-OFTRANSPORT: AMBULANCTYPESTATION 1(A)_2(B)_31C41D!_5(E)^ INCIDENT LOCATION: RESPONSE CODE: REgUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE�3P"S.O. — CALL RECEIVED 11 :_ r _ P.D.- TIME 10-8 PATIENT DESTINATION: ` FROM SCENE ❑ FIRE TIME 10-97 O PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 END r TIME 10-98 ^� %•DOCTOR Y_� R START PSTIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER �.. , % CALL BACK k: AMBULANCE COMPANY:- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: . RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CON TION: DRIVER TECHNICIAN -� %f y L"� PARAMEDIC Hx: J DISPATCHER: e-9 , C a /��, 1 c CHIEF COMPLAI - DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN )C 14 lcll�>-1 1. Al I ., A AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /C C`V PATIENT REFU SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. k PRIVATE INS, CO.: BASE RATE: KAI6ER-g: !'-1 ✓!%-' �' MULTIPLE PTS. BASE RATE TOTAL MILES: X \\\ lul=nl _7 )~ EA H- ATT- ROUND TRIP: OYES ❑ NO OYES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP k: EMERGENCY RUN: MEDT-CAL k: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) p P.O.E. STICKER ❑ YES f -❑ NO NEONATAL: (INCUBATOR)} V DATES BILLED: STANDBY: (OVER 15 MIN.) I D E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPQVSIBLE PARTY: I.V.: (PER ADMIN.) X it DRUGS: (PER ADMIN.) X NAME: -(--5` `6 ECATIONSHIP: 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: / vv\ pRr5p . uo4ble To ,1 D .I v'eti , cIe r �I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION r G� CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ) - O'M ❑ F COMPANY 0 ✓ -L 7 ADDRESS AGE CITY STATE - ZIP DOB_ - B�'Sn ❑ M O T ❑ W ❑ Th O F O 8 DRIVER'S LICENSE N ( PHONE NATURE OF DISPATCH y TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION t(A)_2(8),_31C1.�0(D)_5(E)_ INCIDENT LOCATION:I ; RESPONSE CODE'. REPESTED BY: TIME- (24 HOUR CLOCK) [' L I �- TO SCENE- RF S.O. CALL RECEIVED = ` ❑ P.D. TIME 10-8 PATIE T DESTINATI N: FROM SCENE- ❑ FIRE TIME 10-97 - -- -! O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 S/ END TIME 10-98 .;bOCTOi% PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEARESTZ! ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULLAANNCE C�OMMP_lpVZ' .o PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: L RESPONSE ZONE ❑ YES ❑ NO .. ❑ WALKED D GUERNEY ❑ OTHER S �1. PATIENT CONDITION: DRIVER �-SOh "v �'-'L EMT-1A v TECHNICIAN ne«+l -t PARAMEDIC ✓ C r� Hx: DISPATCHER: 1 CHIEF COMPLAINT: -�"�- DRY RUN:IA PES ❑ NO REASON FOR DRY RUN '(- Sozc_ do.r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) gin PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.# PRIVATE INS. CO.: BASE RATE: KAISER I#` PTS. BASE RATE BLUE CROSS 0: t TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES •❑ NO NIGHT: (19:00-07:00) ! CCHP/PPHP N:� ` l 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: ' J c� ' TOTAL: — C. PATIENT RECEIVED BY: X (SMNATURE) i ONIRA COSTA COUNTY AMBULANCE FAE-HOSPITAL CARE FORM I I l UNIT a AUTHORIZATION# 7 I CHECK OR FILL INAPPROPRIATE SPACES DATE: 0 Z'`- e '�� - / J PATIENT'S NAME (.�` _(J _1!y_�ncl_r��i O M �Zf COMPANY# ADDRESS _ _'_kms�)l;.lily - AGE 0 /217o 7 - CITY " STATE ZIP DOB1�V O Sn �M D T O W O Th O F O$ • ...:.DRIVER'S LICENSE# ___ -_ PHONE /,� NATURE OF DISPATCH /-� L ' -y TYPE OF TRANSPORT: AMBULANCE OTHER❑ STATION 1(A)_.2(B)_3(C)-4(D)_5(E)_ iNCI ENT LOC 6,iION: RESPONSE CODE: R OUESTED BY: TIME-(24 HOUR CL CK) / o. / /✓1�.:�`' TO SCENE- S.O. %' CALL RECEIVED F I1'I ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM ScEN - ❑ FIRE TIME 10-97 ❑ PSAP ' TIME 10-49 1: MILEAGE:7G ; � D OTHER/PVT TIME 10-7 �--' END TIME 10.98 DOCTOR ILL Lle__ Pmq/ER START /0- TIME 10-22 HOW CHOSEN: TOTAL - STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME •�: I ;'PATIENT ❑ DIRECT ❑ OTHER S CALL BACK 0: AMBULANCE NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. 5 Q RESPONSE ZONE ES ❑ NO ❑ WAl'<ED UERNEY O OTHER t _J e PATIENT CONDITION. DRIVER EMT-1A t TECHNICIAN ' PARAMEDIC Hx: 4 1� / 2 DISPATCHER: r - 1 I CHIEF COM AINT: -�� .��4 �ORY RUN: ❑ YES /eNO REASON FOR DRY RUN �)q •/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (I PATIENT REFUSED SERVICES:(SIGNATURE)X_ MEDICAL C V E: `� INDUSTRIAL 11YESANO NO. OF PATIENTS: �•�-� t� PRIVATE INS. CO.: BASE RATE: 15o.�zz- KAISER#: MULTIPLE PTS.BASE RATE IT BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES D NO O YES ❑ NO NIGHT: (19:00-07:00) �..L aLd�•`-' CCHP/PPHP#: EMERGENCY RUN:, __� �Q l MEDT-CAL#: CODE 2/3 \OTHER` ��111 P�LE � y0 r� G 7 a0 (L OXYGEN: (PER TANK) �� P.O.E. STI KER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �-- -� (ETES BY1.ED: STANDBY: (OVER 15'MIN.) { �' - : . E.K.W (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) XU'Ly � DRUGS: (PER ADMIN.) X NAME: -- RELATIONSHIP: E.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: -» ADDRESS: CITY: STATE: ZIP: COMMENTS: / r ` ' S TOTAL: Q03t PATIENT RECEIVED BY:X _. PMvidrr )YtC7r, Whitevd t;.: ,.RPh SetLr+ Y�':en m (SIGNATURE) t, EY45 when tf1'in p1S-I ----.CONTRA COSTA COUNTY AMBULANCE r PPF-!l('"^ITAL CARE Fnr.• I ?i UNIT AUTHORIZATION AS CHECX OR Fill IN APPROPRIATE SPACES / r DATE: PATIENT'S NAME_.._�Q!�' �/> r C__" j1- D M COMPANY# so :ADDRES - q AGE ' CITY ^- STATE ZIP DOBE 130 S„ A o T. Q w -Q rn O Fp 8 PHONE NATURE OF DISPATCH •_.• r DRIVER'S LICENSE# _ _ _ �� — _ TYPE OF TRANSPORT: AMBULANCE bTHER11 _ STATION 1(A)_.2(8)r3(C)-4(D) _5(E) INCIDENT LOCATION: �''' `� RESPONSE CE: REOUESTED BY: TIME- (24 HOUR C CK) TO SCENE- S.O. CALL RECEIVED D P.D. TIME 10-8 `? PATTIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 PSAP TIME 10-49 c — ' J MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98,! DOCTOR C'� :!! �ER l START TIME 10-22 �•�'�'O'�` 1 HOW CHOSEN: TOTAL STANDBY TIME --T_': ❑ NEAREST "'�6AMILY ❑ TRANSFER WAIT TIME ❑ PATIENT D DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPA C .+ PT. AMBULATORY? PATIENT T KEN TO AMBULANCE: I S RESPONSE ZONE ' YES O N O WAL'CED UERNEY D OTHER L PATIENT CONDITION: DRIVERIYEN _ EMT-1 rl T TECHNIU PARAMEDIC_�- ` /, Hx: ^C' y- ' � C- DISPAT�HIf�F COMPL T: -- DRYRUO REASON FOR DRY RUN�� AUTHOY RUN(EMS USE ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X_ c �c .r►c1 �AL COVERAGE,,, D STRIAL ❑ YE O NO. OF PATIENTS: ' y � PRIVATE INS. CO.: BASE RATE. KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS# TOTAL MILES: X •50 MEDICARE#: - E.O.B. ATT. ROUND TRIP: ❑ YES D NO ` D YES ❑ NO NIGHT: (19:00-07:00) i j CCHP/PPRP#: EMERGENCY RUN: t } MEDI CAL# `� 'l x CODE 2/3 i OTHER: OXYGEN: (PER TANK) P.O.E. STICKER�?-YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED, STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ' NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) - X "r 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: -L--- - --••---- �+""�� ADDRESS: CITY- STATE: ZIP: - COMMENT - �s a� 1 TOTAL:, • 6V - PATIENT RECEIVED BY, Provider reta'_*. White cid Pink copy Return Yt'I,. rnpp t• EN.S (SIGNATURE) when bi1'inq qS-1 CONTRA COSTA.COUNTY AMBULANCE •7/) /�a PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION(N . ?' -, CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME I D P.�1- O M ❑ F COMPANY a I ADDRESS AGE 0 CITY STATE ZIP DOB O Sn SM ❑ T Ow O Th OF OS DRIVER'S LICENSE N PHONE NATURE OF DISPATCH QWyt A-1657 TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ —_ STATION 1(A) 2(e)_3(C)._4(D)-_.-5(E), BN/C�I�DEtN/TLOCATION: I RESPONSE TO SCENE CODE: RAQUESTED BY: CALL RECEIVED R C�K) ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 13 PSAP TIME 10-49 Pu MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR' S PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: S PT- AMBULATORY? PATIENT TAKEN TO AMBULANCE: c.: RESPONSE ZONE 0) ' ❑ YES ❑ NO ❑ WALKED O GUERNEY O OTHER l�6 ,; PATIENT CONDITION: DRIVER_. _ EMT-1A i TECHNICIAN C1��2 PARAMEDIC Hx: . DISPATCHER: „n CHIEF COMPLAINT: DRY RUN: WYES ❑ NO REASON FOR DRY RUN 10a;2 Sz S '� ( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ✓t� IF--PAD 1Q7-, , PATIENT REFUSED SERVICES: (SIGNATURE) X CDR. 1 ���-- 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 C TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ) O YES .❑ NO NIGHT: (19:00-07.00) , CCHP/PPRP N: EMERGENCY RUN: 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 RELATIVEIRESPONSIBLE PARTY: "" I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X -- NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) f ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) " CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) �� PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) a.tle_ EMPLOYER: OCCUPATION- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: ( O A : GoNe vn> 1 J AL_ TOTAL: r PATIENT RECEIVED BY:X Provider retain, White and Pink copy Return Ye'!uu ropy t I V45 when bil:ing (SIGNATURE) LNS-1 CONTRA COSTA COUNTY AMBULANCE Q; PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION n U AI' g f 221Y3 CHECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME ❑ M ❑ F COMPANY k Az 3 ADDRESS AGE CITY TATE ZIP DOB ❑ Sn pM OT ❑W O Th OF ❑S. DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ STATION 1(A) )._3(C)_4(D)_51E)-_ INCIDENT LOCATION:' RESPONSE CODE! REOUESTED BY: TIME–(24 HOUR COCK) 1 TO SCENE- a.D. TIME 0-8 EIVED PATIENT DESTINATION: �— FROM SCENE- ❑ FIRE TIME 10-97 PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 CC � DOCTOR.- I PMD/ER START TIME 10-22 _ HOW CHOSEN: TOTAL STANDBY TIME [3 NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME i ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK W AMBULANCE COMPANY: C� PT. AMBULATORY?-.. PATIENT TAKE IMBULANCE: RESPONS�ZONE �.a d YES ❑ _ ❑ WAL' GUERNEY ❑ OTHER TIENT CONDITION: A DRIVER ( cc- EMT-tA 1: c` TECHNICIAN_ �� � � PARAMEDIC HX: DISPATCHER: j 2 CHIEF COMPLAINT: DRY RUN:RYES ❑ NO REASON FOR DRY RUN ` � (� AU OR17ATION F F DRY UN{EMS USE ONLY) 1trJr( ? ^T�o �I(�y ;PATIENT REFUSED SERVICES: (SIGNATURE) X ��L17f' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS:, _ C , S.S. M PRIVATE INS,CO.: BASE RATE: KAISER 0: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHF/PPRP C EMERGENCY RUN: MEDI-CALK: 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) " 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) —EMPLOYER: OCCUPATION: OTHER: ADDRESS: " CITY:" STATE: ZIP:— COMMENTS:— TOTAL:-9 IP:COMMENTS: TOTAL: rr PATIENT RECEIVED BY:X \1 . Pmn(Ai� rvatf.. V4i n• .-I Iiq: r'Y u„r.,... . .�,. •r• (SIGNATURE) f , , I L , t , CONTRA COSTA COUNTY AMBULANCE ,/ PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N 3_I`•f 3// CHECK OR PILL IN AP ROPRIAre S►AC[! DATE:�z 2 Z PATIENTS NAME M O F COMPANY N (X ... ; _ ADDRESS - 4 � AGE 3 G CITY P (♦ STATES' . ZIP - `1-1 ❑ Sn O M ❑ T O W O Th O F OSDRIVER'§LICENSE N PHONE VB fma NATURE OF DISPATCH 1.1 TYPEOF TRANSPORT: AMBULANCE OTHER❑ - STATION 112(B)_31C1_4101_5(E)_ INCIDENT LOCATION RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR C O K) ' q f / TO SCENE- S.O. CALL RECEIVED t P.D. TIME 10-8 PATIENT DESTINATION: I FROM SCENE- 2 O FIRE TIME 10-97 O PSAP TIME 10-49 �}j�� •""` MILEAGE: � ❑ OTHER/PVT TIME 10-7 � •�' [ 1- L END TIME 10-98 DOCTOR ' _ ` lt alz_ PMCo STARTso TIME 10-22 HOW CHOSEN: TOTAL—�.---- STANDBY TIME r ,'•� NEAREST""' O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT E3 DIRECT 13 OTHER �j CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE a LYES ONO .; �L WAII<ED 13GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER / EMT-lA 1 TECHNICIAN 1- �'_ PARAMEDIC — Hx: - DISPATCHER: (/n CHIEF COMPLAINT: A4 A-5 �� DRY RUN: ❑ YES � NO REASON.FOR DRY RUN AUTHORIZATION FIR DRY RUN(EMS USE ONLY) C!b 3 iI. PATIENT REFUSED.SERVICES: (SIGNATURE) X L!✓ MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: n S.S.N PRIVATE INS. CO.: BASE RATE: 1 0 4AISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X 1 �-0 P?50 MEDICARE N: ' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO OYES ❑ NO NIGHT: (19:00-07:00) CCH PH N:'` Z�'7 Z- EMERGENCY RUN: � C� I-CAL N CODE 2,,/3 HER: OXYGEN: (PEA 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:'1-bL b WLLt74I RELATIONSHIP: 1) E.O.A.: (IF NOT REPLACED) ADDRESS: AV 1= ORAL AIRWAY: (IF NOT REPLACED) "CITY: IC 1+ STATE—_ZIP: C-COLLAR:.(IF NOT REPLACED) PHONE: 2 `9 D'�a WORK PHONE: DRY RUN: (AUTHORIZED) —EMPLOYER: tt1 li ` OCCUPATION: OTHER: ADDRESS: CITY: STATE• ZIP: --'COMMENTS:- - - 4 TOTAL" / J I ____ _ PATIENT RECEIVED BY X. Z&��' X tc C_ I CC1N1►1A COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT [Fj] AUTHORIZATION k CHECK 0(1 FILL IN APPI10MATE SPACES c DATE: �T-SIE: PATIENT'S NAME___ ____ - __ !7_L�. $Y M ❑ F COMPANY N ADDRESS _7 ?)Gl��_ I=�N �Lh_ I AGE 1? 1 �c U CITY I C l�IV1C� STATE_ ` _ ZIP 9Y DOGS c 11 S. LYM ❑ T El ❑Th ❑ F ❑S :DRIVER'S LICENSE a ___.___ . PHONE e2a3.g� NATURE OF DIS/PATCH -- TYPE OF TRANSPORT: AMBULANCE OTHER❑ ___ STATION 1(A)^2(Bl_3(CI_4(D)_.5(E)_- I CIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME-(24 HOUR C OCC)/ TO SCENE S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION FROM SCENE13FIRE TIME 10-97 �- ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 r I END r,,:5 , ( TIME 10-98 DOCTOR � PMD/ER START C.} TIME 10.22 HOW CHOSEN: TOTAL 1 STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHERj CALL BACK a: AMBULANCE COMPANY I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ;lam' RESPONSE ZONE ` ' ❑ YES -O,NO ❑ WAL'CED UGUERNEY ❑ OTHER -5-r nn� { PATIENT CONDITION: DRIVER -' /�'�. C` EMT-1A I - i TECHNICIAN j DIC l i. Hx: c V6 gLITC) DISPATCHER: I I CHIEF COMPLAINT: �DRY RUN: 0 �� NO REASON FOR DRY RUN 1 + AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ICAL COVERAGE: INDUSTRIAL ❑ YES jgs10 NO. OF PATIENTS: ZS.S RIVATE INS.CO.: SCC/ tiTlq L BASE RATE: I/D•LP� �I KAISER a: ' I MULTIPLE PTS. BASE RATE r0 BLUE CROSS a:' TOTAL MILES: X Z10 ` MEDICARE a; E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO i. ❑ YES ❑ NO NIGHT: (19:00-07.00) CCHP/PPRP a: EMERGENCY RUN- "n 1 MED1-CAL a: CODE 2{3 OTHER: OXYGEN: (PER TANK) 1s'd�LCv G' I� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) i 111 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 75 NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X i DRUGS: (PER ADMIN.) X V NAME: FLf� �t RELATIONSHIP: M!"'_L E.O.A.: (IF NOT REPLACED) i' ADDRESS: 3-u r-12?)/L-) ORAL AIRWAY: (IF NOT REPLACED) {J CITY: �<< rLtt<<!N STATE- '`ZIP: C-COLLAR: (IF NOT REPLACED) PHONE 3���')-?-WORKP.HONE:'I ' ' DRY RUN: (AUTHORIZED) i v EMPLOYER:(�ti<�CLL�L7 OCCUPATION:- I!I G OCCUPATION: OTHER: ' LADDRESS: C)gtvk RC k, , V®5 5lo•yp i Ii CITY: _'At� `� U STATE:_f_h_-ZIP: c11��> _ L�•�A �C' —0, F COMMENTS: S i,—> PGv'-I PLV -C/ l� ��f�I >/. tY•� �� 17 cz) --sS TOTAL: c7 �U I 67, PATIENT RECEIVED BY: (SIGNATURE) Provider retain White .rd P:.; cetut•n Yr",- y . P - t" Fv� �•h.a !;i";gyp EMS-) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION.33(4 , Vii.? Z 2 CHECK OR EIEC INAPPROPRIATE SPACES T - DATE: PATIENTS NAME1.�7L►►j��0 -'�CTiRT1C, > !Q,{vt O F COMPANY N ADDRESS 7 AGEA0 13 q i CITY 1 STATE ZIP DOB Lt. ❑ SnM O T O W O Th O F O$ - ;. DRIVER'S LICENSE 0 (- PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ STATION 1(A) 2(8)._3(C)_41D)_5(E)_ 1 INCIDENT LOCATION - ; RESPONSE CODE: RE ESTED BY: TIME-- (24 HOUR CLOPK) 1 TO SCENE- 3O. CALL RECEIVED •c Y 7 �- _. ❑ 5p 1 D. TIME 10-8 PATIENT DESTINATION:- FROM SCENE- �2 ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 !! ' 7 MILEAGE: C`� Z ❑ OTHER/PVT TIME 10-7 l - . . END ` ' TIME 10-98 :L Z Z 0CTORT ^M I t�u P /E START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME I VAREST: 13FAMILY ❑ TRANSFER WAIT TIME TIENT O DIRECT O OTHER 3 CALL BACK M: AM U CE COMPANY: P AMBULATORY? PATIENT T E TO AMBULANCE: RESPONSE ZONE YES ❑ NO O WALKED G ERNEY ❑ OTHER i 2t` rv5 /` j PATIENT CONDITION: DRIVER �_ EMT-1A TECHNICIAN �^ ��- �1 PARAMEDIC Hx: DISPATCHER: l CHIEF COMPLAINT: DRY RUN: ❑ YES O REASON FOR DRY RUN /G( lQ +AQ i-N AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ! PATIENT REFUSED SERVICES: (SIGNATURE) X J 1 MEDICAL COVI.RAOE: IAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.» IeP PRIVATE INS.CO.: BASE RATE: KAISER 1<: MULTIPLE PTS.BASE RATE BLUE CROSS K: TOTAL MILES: X -`ted •✓� DICARE M:' I E.O.B. ATT. ROUND TRIP: OYES ❑ NO 1 _ _ ❑ YES ❑ NO NIGHT: (19:00-07:00) 'jT H PPHP N:": � EMERGENCY RUN: 1cS LseL(-•('� V� 4 - ALM: ` ' ' CODE /3 r ' HEROXYGEN: (PER-TANK) P.O. 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: ELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_r ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) "-EMPLOYER: OCCUPATION: OTHER: ADDRESS: —CITY: STATE: ZIP: ' COMMENTS: ob TOTAL SQ �--- PATIENT RECEIVEn BY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M X31'4 3Sg CHECK OR FILL IN APPROPRIATE SPACES DATE bzdF 3 PATIENT'S NAME i 11� 1�.G ��-�J p.dll ❑ F COMPANY N ADDRESS =tea 5 Elf /AGE CITY � STATE CA 21P 5 30 DOB— os" ❑ T O W ❑ Th ❑ F C]S 1 DRIVER'S LICENSE'# _ A PHONE N TJF OF DI PATO �- .7s- ' orte— I TYPE,OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: ' RESPONSE CODE: UESTED BY: TIME– (24 HOUR C CK) / 1 �CJ TO SCENE- S.O. CALL RECEIVED P.U. TIME 10-8 02� r��- i PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 �A ( ❑ PSAP TIME 10-49 MILEAGE 13OTHER/PVT TIME 10-7 _ 0 END �13 TIME 10 98 DOCTOR ))" ILIC 2- PM STARTA TIME 10-22 HOW CHOSEN: I TOTAL STANDBY TIME 2'T'.. ❑ NEAREST' , ❑ FAMILY (a TRANSFER L WAIT TIME ❑ PATIENT , ❑ DIRECT ❑ OTHER W CALL BACK C AMBI} Tt COMPANY: [C] T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _�U RESPONSE ZONE a YES ❑ NO ❑ WALKED ❑ GUERNEY D OTHER PATIENT,CONDITION., DRIVER A I N� �! EMT-1A TECHNICIAN 4J+�� 7(11 PARAMEDIC 0-1x: D PATCHER: CHIEF COMPLAINT: ' PZRY RUN: ❑ YES NO REASON FOR DRY RUN n c" - AUTHORIZATIO OR DRY RUN(EMS USE ONLY) 1 I PATIENT REFUSED SERVICES: (SIGNATURE) X X52 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.M . ' PRIVATE INS. CO.: BASE RATE: t w ' KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: X 61.50 J1,6 MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO C) YES D NO NIGHT: (19:00-07:00) CC /PPRP M: j ) EMERGENCY RUN: I MED CALM: CODE 2/ 1 OTH R: C At��- I AL1 OXYGEN: (PEWT'ANK) P.O . STICKER ❑ YES ❑ NO fUe C�A2p NEONATAL: (INCUBATOR) TES 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: (1F NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: ` CITY: STATE: ZIP-. - COMMENTS: _ TOTAL:.2vL.012. PATIENT RECEIVED BY X ---� ISICNA71 rT ONTRA COSTA-COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITrl`j 1 AUTHORIZATION a Ir CHECK OR FILL INAPPROPRIATE SPACES - DATE: PATIENT'S NAMEir ❑ M OF COMPANY# ADDRESS AGE— CITY— CITY STATE ZIP DOB ❑ Sn M ❑ T ❑ W ❑ Th ❑ F ❑ S- I DRIVER'S LICENSE# _ _ PHONE NATURE OF'DISPATCH A TYPE OF TRANSPORT: AMBULANCE THER❑ INCIDENT LOCATION: I C/i RESPONSE CODE: YEOlU'ESTED BY: TIME— (24 HOUR �CK) TO SCENE- S.O. CALL RECEIVED Al QV V/C �i�� V��/ �_ ❑ P.D. TIME 10-8 o'- PATIENT DESTINATION: FRO SCENE- ❑ FIRE TIME 10-97 �(I j ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 � I END TIME 10-98 DOCTOR `)' PMD/ER START TIME 10-22 > L- HOW CHOSEN: TOTAL STANDBY TIME ;1..:. ❑ NEAREST '' ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COtMY- s PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: L' RESPONSE ZONE �1 O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER �I PATIENT CONDITION: DRIVER ` ' EMT-1A TECHNICIAN _ _ PARAMEDIC Hx: DISPATCH E r '� I CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) `I PATIENT REFUSED SERVICES: (SIGNATURE) X _ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: 7 I S.S. # PRIVATE INS. CO.: BASE RATE: E KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) r CCHP/PPRP#: 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) E ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP; C-COLLAR: (IF NOT REPLACED) _Ls 1w PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: 1 CITY: STATE: ZIP: COMMENTS: 0 n 5!Q O TOTAL: PATIENT RECEIVED BY: X �y !� ••�.+�,• --• ••. :•,:• (SIGNATURE) rte, CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION OFF.�-� 4Z ~ CHECK OR FILL IN APPROPRIAtE SPACES DATE:.—s—1— K-1 r � aY PATIENTS NAME - O M ❑ F COMPANY# _/l ADDRESS*- . ( AGE 12 a :g v CITY STATE ZIP DOB ❑ Sn �'M OT OW O Th OF OS [)RIVER'S LICENSE# ._ PHONE ATURE OF pISPATCHIA OQ30 ICA LS TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ 'INCIDENT LOCATIONd f. .0 ' RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C�.�CK) . ?? �/ TO SCENE- S.O. CALL RECEIVED 1 ¢ 7 .}l- �U M�1 �- ❑ P.D. TIME 10 8 'PATIENT DESTINATION: FRO SCENE- 13 FIRE TIME 10.97 FL012 ❑ PSAP TIME 10-49i MILEAG ❑ OTHER/PVT TIME 10-7 _ I END TIME 10-98 �OOCTOR , PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME z w j 0 L NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: ail PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE s — 0 YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ;L�_ EMT-IA t. TECHNICIAN PARAMEDIC Hx:___ ___ + P DISPATCHER: - �,� CHIEF COMPLAINT: I DRY N: YES NO REASON FOR DRY RUKr-, n S t—, AUT I EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X-_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS:' S.S.# • - I PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS, BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#:' E.O.B. ATT. ROUND TRIP: O YES ❑ NO ±) ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL k: 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: IP:COMMENTS: TOTAL' Ju liCB. , Y v PATIENT RECEIVED BY: X (SIGNATURE) [h5-I Pr+'+vi dor roh .r'r, kiln .,.,f Pira .,��� Nrti.rn Yr', , f "V7 Whoa Ii1'inJ . I i CONTRA COSTA COUNTY AMBULANCE P E-HOSPITAL CARE FORM I UNIT AUTHORIZATION =3"-/ CHECK OR Flll INAPPROPRIATE SPACES DATE: - n PATIENT'S NAME—__ _ -- _ _ ❑ M ❑ F COMPANYa ,A r__J � t: � ADDRESS __ - AGE CITY - STATE -_- ZIP-__-__- __ DOB____- -- ❑ Sn OMOT OW ❑ Th ❑ F ❑ S DRIVER'S LICENSE q __-__ -------- PHONE ___._._ _-.- .____ NATURE OF DISPATCH-KI I[Y1V71 )LSS TYPE OF TRANSPORT: AMBULANCE❑ OT/HER❑ INCIDENT LOCATION: ��f 1-l"( RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CI,�OCfK) y TO SCENE �S�O. -_._.-_-_._- CALL RECEIVED -_ `J --- ____ ❑ P.D. __-_. TIME 10-8 ; PATIENT DESTINATION: FROM SCENE- ❑ FIRE -__- TIME 10-97 ❑ PSAP TIME 10-49 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 O'PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COM/PAY:. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ) ❑ YES ❑ NO ❑ WAL':ED ❑ GUERNEY ❑ OTHER -__---_ __-___ I PATIENT CONDITION. DRIVER.-I-41 EMT-1A x TECHNICIAN .�' PARAMEDIC Hx: _ DISPATCHER:.-L11 l-' f CHIEF COMPLAINT: --_ DRY RUN: •b<YES ❑ NO REASON FOR DRY RUN T ) A A THORIZATION F R Q UN�USE'ONLY) l f(/t, PATIENT REFUSED SERVICES: (SIGNATURE) X �I �). MEDICAL COVERAGE INDUSTRIAL A YES ❑ NO NO. OF PATIENTS: or S.S. a — — -- r PRIVATE INS. CO.: _____._ -- BASE RATE: KAISER#: —_ — MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X — MEDICARE x: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-0700) CCHP/PPRP 4: EMERGENCY RUN: MEDI-CAL q: __ 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 --- - -------.--.-_-__-- -._-- .--._._-.__-- PATIENT RECEIVED BY: X -__!-_- �•,. ..:,. .. (SIGNATURE) t CONTRA COSTA COUNTY l AMBULANCE PRE-HOSPITAL CARE FOR I UNIT AUTHORIZATION 0 'A s �`1 2 7 3 I, 6 CHECK OR FILL IN APPROPRIATE SPACES DATE: Q- ;E 1 " Y; 'PATIENT'S NAME�1—�+• .�+ �� ' F + .�tt� ® M O F COMPANY M ADDRESS _:J n 7_6z1 A n if- 1 3 1 _ AGE� J 9 � U�� ( C•I Li CITY- L r STATE K- ZIP DOB ❑ Sn O M ® T ❑W O Th O F ❑S DRIVER'S LICENSE M _ PHONE 19 q_!U LJ__ NATURE OF DISPATCH f?I c r cl-—!g, TYPE OF TRANSPORT: AM13ULANCCE 0 OTHER❑ — STATION i(A)_2(B)_,•3(C)_.4(D)_5(E)! INCIDENT LOCATION:` y� ' ✓ 1 RESPONSE CODE' REOUESTED BY: TIME—(24 HOUR CLOCK) 4T P Q TO SCENE- 12S.O. CALL RECEIVED J _ __1076 c��o If I /; 3• ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE __ TIME 10-97 077 4-12 Q ❑ PSAP TIME 10-49 j MILEAGE: ❑ OTHER/PVT TIME 10-7 -• END TIME 10-98 , DOCTOR PMD/ER START TIME 10-22 r' HOW CHOSEN: _ _ .. I TOTAL STANDBY TIME 1; C3 NEAREST..,,. O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: c- A5 PT. AMBULATORY? PATIENT TAKEN TCE: } RESPONSE ZONE S O YES �d�70'�� ❑ WALKED ❑ GUERNEY ❑ OTH PATIENT CONDITION: DRIVER RC•t. 1 A 1=� 1 EMT-1A i TECHNICIAN_s: L/ t �� PARAMEDIC X (�� Hx. - DISPATCHER: T �? 7 ,/ CHIEF COMPLAINT: d S S DRY RUN: 9t YES 13N J REASON FOR DRY RUN 10 �y7 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 9.5,L1 i . : PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE; - INDUSTRIAL ❑ YES ❑ NO NO. OF ATIENTS: S.S. PRIVA INS.CO.: BASE RATE: KAISER C ` MULTIPLE PTS. ASE RATE BLUE CROS K: I{ TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: O YE ❑ NO ❑ YES .O NO NIGHT:(19:00-07:00) CCHP/PPHP 0.. r EMERGENCY RUN. MEDT-CAL N: CODE 2/3 OTHER: - r OXYGEN:. (PER TANK) P.O.E. STICKER ❑ YESO 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 "NAME: REL IONSHIP: 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: � �• . i ;•I PATIENT RECEIVED BY:X I Pmuider mtalr, white ,.nd t'i•;1 ,•.I� 'vtw+ Y:' (SIGNATURE) ah Iti.-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES- DATE: PATIENT'S NAME------ fir_.=.'-/ ..--J��fl�/- ---------_ ..------- ❑ M ❑ F COMPANY p ADDRESS / - - -- — - - - -----._. AGE CITY.._____;—_ ----....--- STATE - --._ ZIP DOB _ - . ❑ Sn ❑ M T ❑ W O Th OF ❑ S , DRIVER'S LICENSE a __. _.. . ._- PHONE NAI URE OF DISPAI CH/L Ly LL`2. /ti�dI D)t�.`& TYPEOFTRANSPORT: AMBULANCEV( OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) DF TO SCENE- S.O. ____.____. CALL RECEIVED --------------- ❑ P.D._------ TIME 10-8 1 PATIENT DESTINATION: FROM SCENE`- - ❑ FIRE __-___ TIME 10-97 j ❑ 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 O TRANSFER WAIT TIME -- ❑ PATIENT O DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE. �_J RESPONSE ZONE 2 El YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER - --_ PATIENT CONDITION: DRIVEtom___ �,- - � (•-C ��_ ) EMT-1A �] r TECHNICIAN�` �'�1ZEV / ) _ PARAMEDIC DISPATCHER: _J_rr — CHIEF COMPLAINT: __ DRY RUN:;8�YES ❑ NO'j REASON FORDRYRUN/Q7ZSC�'�a 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 R: _. MULTIPLE PTS BASE RATE BLUE CROSS# _ _ TOTAL MILES:.--_ — X MEDICARE p:_ _ — E.O.B. ATT. ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT. (19:00-07:00) CCHP/PPHP#: — EMERGENCY RUN:MEDI-CAL q: _ __ 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:--.---- COMM E IP:-----COMME -- -- --- ------- --- 701AI fl 05 ..2 PAIIENI HLCEIVLI) HY X , `J CONTRA COSTA COUNTY AMBULA CE PRE-HOSPITAL CARE FORM I UNIT r AUTHORIZATION a CHECK OR FILL INAPPROPRIATE SPACES DATE:._—.� `J PATIENTS NAME ❑ M ❑ F COMPANY ADDRESS AGE CITY fsVA E .--- IP_—___—.__ DOB__—,_._ ❑ Sn ❑ 'Y" � ❑ W ❑ Th O F ❑ S DRIVER'S LICENSE p __—.___.__..______ ..._..__-. PHONE_.____ ___. -__--_.— NATURE OF DISPATCH- TYPE,OF TRANSPORT: AMBULANCE❑ OTHER❑ __ ___._-.__- __. INCIDENT LOCATION: RESPONSE COEOUESTED BY: TIME— (24 HOUR(',LACK) - ) TO SCENE S.O. _-___.___- CALL RECEIVED S`--- �L1 ?� � _L ❑ P.U. — TIME 10.81 I PAJIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 l w ❑ PSAP TIME 10-49 PAILEAG' — ❑ OTHER/PVT TIME 10-7 U EN TIME 10-98 DOCTOR PMD/ER START— TIME 10-22 L HOW CHOSEN: TOTAL X STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COM� �V�' PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'(ED ❑ GUERNEY ❑ OTHER -- f PATIENT GOND TION: DRIVER_ Y e _ _ EMT-1A — TECHNICIAN _� ✓ J -�_..�t ' /�L PARAMEDIC V —_—. _ DISPATC Hx: HER: LI(.�. CHIEF COMPLAIN : — _ DRY RUN: ,YES ❑ NO REASON FOR DRY RUN 11 I__- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ✓ (?— /V ��('lI PATIENT RE USED SERVICES: (SIGNATURE) X—__— ._.__--__---.—_—__.____ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: --- , S.S. # PRIVATE INS. CO.:..—_ ___--_--_._—_ BASE RATE: KAISER+i: MULTIPLE PTS. ATE _— BLUE CROSS#:__— - _-. _ TOTAL MILES: X MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN'. (R# a: CODE 2/3 -. —__ OXYGEN (PER TANK) CKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �1 LED: STANDBY: (OVER 15 ) E.K.G.: (PER EPIS E) RELATIVE/RESPONSIBLE PARTY: I.V.: (PER AD )_ _ X DRUGS: IP R ADMIN.)__— —.X _ RELATIONSHIP: E O.A.: ( NOT REPLACED) : - ORAL IRWAY: (IF NOT REPLACED) STATE--ZIP: C-COLE R: (IF NOT REPLACED)WORK PHONE:___._______._.- DRY RUN: AUTHORIZED): _--_..- OCCUPATION. --- -- --- OTHER: ADDRESS..---- ... --- - ---- - -- - -._.. -- -- --- - - --- ----- — CITY: --- ,STATE:--ZIP:-- COMMENTS: IP:_COMMENTS: TOTAL - - ---- - -- -- ---- - .. __ PATIENT RLCEIVT.0 BY: X SIGNA - ----D fJtZ . ITURF) IN I 1'nrilrr rv'RIiL'kit. . I ) CONTRA COSTA COUNTY AMBULANCE C PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME__`�._1 tla k_k`�a `� V_��ck [I'm LIF COMPANY M ADDRESS n---- LrO�,------- --"--�--/ CITY.__`�_\ ._=_ STATE___C_rlfj� .'___ ZIP 'S -7i _ DOB US jl.7���I ❑ Sri ❑ M T ❑ W ClTh ❑ F ❑ S DRIVER'S LICENSE q _._N._�' 1' PHONE r� V. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE TVOTHERO INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE ❑ S O. __.. ___ .__ CALL RECEIVED ❑ P D. _---- TIME 10-8 PATIENT DESTINATION /1/-'f, n a f80M SCENE - ❑ FIRE ___-____ TIME 1097 -1 v"""4� u.TJ ❑ PP TIME 10-49 G �' V — 4 MILEAGE: aj'OTHERiPVT TIME 10-7 END__U_ • _ TIME 10-98 DOCTOR ��. �_ r 5 PP_M R START � _ ___ TIME 10-22HOW CHOSEN" TOTAL I jJ ' STANDBY TIME❑ NEARESTFAMILY ER -- WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER I - CALL BACK #: AMBULANCE COMPANY: PT AMBVORY7 PATIENT TAKEN O AMBUL'AN RESPONSE ZONE �-- ❑ YES NO ❑ WAL':ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER—_�''Z r�(�s-D _r-_1_ �__.`_ EMT-1 TECHNICIAN .__._�_._a..I _.___�-+.__;_[�_ PARAMEDIC Hx: . ��.. j DISPATCHER: CHIEF CO 1PLAINT:�QQ `NJ-_�__t_r�il_S.!C.� DRY RUN ❑ YES i+ NO REASON FOR DRY RUN L� '� �� (` zs. _• 4_C - LLY�__ _ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL�,D��AG Q� IIyQUSTRIAL ❑ YES O NO. OF PATIENTS S. JJ PRIVATE INS CO �� 2f1 —� 1 - i� BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE _ BLUE CROSS#: TOTAL MILES:- _ I X r 'U MEDICARE#: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MED[-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.: IPER ADMIN.)_— X _ DRUGS: (PER ADMIN.)___, X NAME: L09N 1- M���_t SL��. RELATIONSHIP .1'._ E.O.A.: (IF NOT REPLACED) ADDRESS:j� __..— _ --________ ORAL AIRWAY: (IF NOT REPLACED) CITY:.�Q1��"` `�t{rU STATE ZIP:..-- C-COLLAR: (IF NOT REPLACED) PHONE: C=t=' �� � HONE: �.— ,, DRY RUN: (AUTHORIZED) EMPLOYER: w'- OC,U•gqATION: e TY`-h• OTHER: ADDRES }" N w-c-k ---------- - -- - CITY: A r STAT : 1&2 ZIP:_qjb_�1- 0 14 COMMENTS: ----- --------- —� PATIENT RECEIVED BY X��;�•� Jsi NATinlr�- - - IM+ni.lrt rr hti.. 19;i r. �;.j I rr:. � 1 f r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT _ AUTHORIZATION«- / CHECK OR FILL INAPPROPRIATE SPACES - DATE: -- ~ 93 ', L. './'7) `PATIENTS NAMEc� M ❑ F COMPANY« . 1 ADDRESS AGE d— /"1 / r� CITY STATE 4% ZIP DOB�L-( '' ❑ Sn O M' kf T OW O Th OF OS. DRIVER'S LICENSE« _ _ PHONE " MATURE OF DISPATCH 11d FAIC,4c TYPE OF TRANSPORT: AMBULANCE OTHER❑ -- STATION 1(A)_2(B)_3(C)_4(D)_,5(E)_f_ INCIDENT LOCATION: RESPONSE CODE: F)EOUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- 3 J S.O. _ CALL RECEIVED / //-.3L✓C/ 1 Ro_ t L� T--l-, ❑ P.D. TIME 10-8 =, PATIENT DESTINATION: FROM SCENE 3 ❑ FIRE TIME 10-97 ❑ TIME 10-49 L�• JcoV MILEAG 11OTH OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR PM ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 0 NEAREST O FAMILY ❑ TRANSFERl I WAIT TIME O PATIENT O DIRECT ❑ OTHER /', 1 CALL BACK«: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE } RESPONSE ZONE-� ❑ YES XNO O WALKED bl,/GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J i L(./AN1 EMT-lA_ ( � TECHNICIAN L^�I/GIjIAM -5JAI I(� �PARAM Hz: %I� ��dl Jr � DISPATCHER: z( '/-2 I(a CHIT COMPLAINJ: . I. Ly-c - DRY RUN: ❑ YES NO REASON FOR DRY RUN J I. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 4.1 S.S. « '�K 3 -�U=Z,. v a PRIVATE INS,CO.: BASE RATE: KAISER«: MULTIPLE PTS. BASE RATE T_.I BLUE CROSS«: TOTAL MILES: X t/r MEDICARE.«: -'•< i• / E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ITS/f �"t: rt �❑ YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN: 1 MEDT-CAL«: CODE 2/,3 I (1OTHER: OXYGEN: (PER TANK) C / 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.) 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: Y RUN: (AUTHORIZED) EMPLOYER: OCCUPATION ICER: ADDRESS: - - - CITY: STATE: ZIP: COMMENTS: fj ---- TOTAL -- PATIENT RECEIVED BY X -- u ISirrjJkTuaF► CONTRA COSTA COUNTY AMRULANCE. PRE-HOSPITAL CARE FORM I UNIT ,7 AUTHORIZATION M �v CHECK OR FILL IN APPROPRIA7E SPACES DATE: - Z LlPATIENT'S NAME___ �.� "r, !—' !�_ h.�'L'f?'J �� _ N"M 11❑ Fes] COMPANY# ADDRESS �� ?� /I �/ e �L. AGE `' `'1 CITY___ kv/ STATE_C ZIP------- DOB r 2_11cVJ`!6❑ Sn ❑ M ❑ TAW ❑ Th ❑ F O S DRIVERS LICENSE p _ _ -- _. : PHONE__ -,- NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER❑ Y ' INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR LOCK) a. TO SCENE- ❑ S.O. CALL RECEIVED ❑ P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE ❑ FIRE - TIME 10.97 �(�(,- � __— ___ ❑ PSAP TIME 10.49 i I y�'—_ MILEAGE: OTHER/PVT TIME 10-7 ^�^^^ /� END�� �,��� TIME 14-98 00- DOCTOR 1�--'I_� - PMD RSTART, �' LIC l GX TIME 14.22 _I HOW CHOSEN: �/ TOTAL J — STANDBY TIME 'NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ?� CALL BACK#: AMBUL C PANY: PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: Dy r RESPONSE ZONE YES ❑ NO V`AL'tED ❑ GUERNEY 13OTHERn 1�C� j PATIENT CONDITION: DRIVER_9��1— t 8 EMT-tA J� TECHNICIAN�1� �.-1 G PARAMEDIC Hx: ._.. � � J`.S- 1DISPATCHER: CHIEF COMPLAINT: _LA _._.- c�``�- _ DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �))`,1 PATIENT REFUSED SERVICES. (SIGNATURE) --___-.—_— +r' MEDICAL COVERAGE � 2INDUSTRIAL ❑ YES NO NO OF PATIENTS: -- ` S.S. m —_ - --- v 1-4--- -7- ` ----- -- PRIVATE INS. CO.'.-LJ>J.{ -__--_ —�- _� BASE RATE: LsLfO_"`!. KAISER a: __ _-_____ _ MULTIPLE PTS. BASE RATE ,�r'''' /R ''msns', BLUE CROSS q' _____- _ TOTAL MILES Cl X 1 MEDICARE E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO i ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPHP q:_ EMERGENCY RUN: MEDI-CAL N: -- ---__--` CODE 2/3 OTHER: -_- -_- OXYGEN: (PER TANK) IP.O.E. STICKER ❑ YES13NO - NEONATAL: (INCUBATOR) t DATES BILLED: STANDBY: (OVER 15 MIN.) 1 I J E.K.G.: (PER EPISODE) NEAREST RELATIVE/RE PONSIBLE PARTY: LV.: (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: - _ WMMENTS ---- ---- - - -- -------- TOTAL' .�fJ PATIENT RECEIVED BY:X (SIGNATURE) . •.'' .re .. - ,_ Rid 4•hrn Ec I ino [715-1 CONTRA COSTA COUNTY AMBULANCE ) CPRE-HOSPITAL CARE FORM l UNIT AUTHORIZATION It P 3' CHECK ON FILL IN PPROPRIATE SPACES DATE. '� - y, PATIENTS NAME �' ❑ M JU F COMPANY ADDRESS - -- AGE CITY (• STATE C41 ZIP _ DOB E 'bQ Sn ❑ M ❑ T W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M _ __ PHONE NATURE OF DISPATCHuTa TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ — STATION 1(A)_2(B)_3(C)_41D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) L-302 �� RuE" sy TO SCENE - gS.O. CALL RECEIVED � _ 3 _i P.D. TIME 10-8 PATIENT DESTINATION: lquU' FROM SCENE- ❑ FIRE -- TIME 10-97 U" :1 ? ,r �J z ❑ PSAP TIME 10-49 — NMILEAGE: ❑ OTHER/PVT TIME 10-7END (, ' � PMD START �'`j TIME 10 98 ' DOGTOR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ANEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME Q PATIENT ❑ DIRECT ❑ OTHER C—). CALL BACK k: AMBULANCE C `MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WALKED AGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 44,41611XIV 5-y c) EMT-1A ii. 1/ y ✓ � TECHNICIAN � PARAMEDIC Hx: Uri � DISPATCHER: —�,L✓r Ir_, 1�` 13 D CHIEF COMPL ) T: DRY RUN: ❑ YES N NO REASON FOR DRY RUN f2UV 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: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS N TOTAL MILES: X Lo MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO tQIGHT: (19.00-07:00) / CCHP/PPRP N: EMERGENCY RUN: MEVI-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: 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: - �� Lp C TOTAL:--;�� )— -------- -- — PATIENT RECEIVED BY: X 1'r gni Inr r�t•r% 10,.�, _ ISIGNAT JnE) rr+c_1 c _ 1 I CONTRA COSTA COUNTY AMBULANCE I. p� e PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION#p'a CHECK OR FILL IN APPROPRIATE SPACFS DATE: PATIFNT'S NAME- ��/V_`:1 ��"� ��/ is -------._ ❑ M •WF COMPANY it. I � � 1 L' AM ADDRESS -- -" -- - - ------- AGE CITY STATE___; _ ZIP __ __ DOB___^_ ❑ Sn ❑ M ❑ T>gWn❑ m OF OS DRIVER'S LICENSE -.-. PHONE__. .-. __.__ -__-_ NATURE OF DISPATCH �' ✓, . TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT _OCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- r' S.O.-_--_ CALL RECEIVED �... _. "�.1'r�__ -- ---- - -- - - ❑ P.D._ TIME 10-8 .l1 : PATIENT DESTINATION] FROM SCENE Cl 'SFIRE TIME 10-97 � 0 1 1 ❑ PSAP TIME 10-49 v -_.__ MILEAGE: ❑ OTHER/PVT TIME 10-7 END -. TIME 10-98 //� DOCTOR _ PMD/ER START__ TIME 10-22 L :1 HOW CHOSEN: TOTAL -__ _. __ _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �- ❑ PATIENT ❑ DIRECT C7 OTHER CALL BACK#: AMB C COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: C�U RESPONSE ZONE ❑ YES ❑ NO ❑ WAL',ED ❑ GUERNEY ❑ OTHER p PATIENT CONDITION: DRIVEU�LV:)��l .(YNMI-Lf 8L EMT-IA TECHNICTA�1TjYPARAMEDIC 1 1 '1 r� S �n'L _ DISPATCHER: �- L CHIEF COMPLAINT: _..-_. ___- -- .. _-._... __ DRY RUN:'>�ES ❑ NO REASON FOR DRY RUN AUT RI ATION F Y RUN(E USE ONLY) PATIENT REFUSED SERVICES (SIGNATURE) X_ _ �L/FdL,I a MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS: 1 S.S. it - -------- -- -- PRIVATE INS. CO.:._- __- -_-_ -_ BASE RATE: .KAISER »�_ MULTIPLE PTS. BASE RATE BLUE CROSS+1 _ _ _ - TOTAL MILES: X MEDICARE #:�__�- ____._____ E O B. ATT. ROUND TRIP Cl YES ❑ NO ❑ YES ❑ NO NIGHT: (19 00-07:00) CCHP,'PPHP -- - - EMERGENCY RUN: MEDI-CAL a:-- CODE 2 1 3 ��£cf 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; RELATIONSHIP: 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:--- - - --- --_-- - - - CITY: .-------------------- STATE:-_-ZIP:_- COMMENTSJ--L- E,.- --- - TOTAL:_ --- --- ------...--_-_- ------.--------.._..--_._ PATIENT RECEIVED BY X 5C )h•.•nr 7rr - fSIGNATLIREI . r CON IIIIA COS I A COUN I Y AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME _ _U�_rC- ST `'f O_M N-F COMPANY w 12-7 -7 '5 ADDRESS �Zc Z 1\ y� C_1 C� C lJ G%LAE I^ 0 _��I•'7 S ). �+ CIT C'i _ STATE e h F vcy�( y DOBI -►=y 6 O Sn O M O T Pw 13 Th OF OS DRIVER'S LICENSE ___ P ONS IE—Z_SL NATURE OF DISPATCH ~TYPE OF TRANSPORT: AMBULANCE OTHER❑ — _- STATION I(A)_2(B)_3(C1,&'-l1D)_5(E)� -�---� C ` INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CK) I 7 � , TO SCENE- KS.O. CALL RECEIVED S I'1 E Cif / ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-z- 11FIRE TIME 10-97 l ��. 1 .7O PSAP TIME 10-49 � $— !'�� MILEAG O OTHER/PVT TIME 10.7 END d TIME 10-98 DOCTOR PM PM R START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME t O NEAREST ❑ FAMILY O TRANSFER WAIT TIME ,$'PATIENT ❑ DIRECT ❑ OTHER 2 CALL BACK N: A M B14 N 2q CpM�Vyr�^-~.. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE J� 'T��''p i YES 11 NO O WAL CED )F GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVE/S-20 on 600 ��'0 EMT-lA � TECHNICIAN "-"1-7S0 n T 1 cS✓` S?%RAMEDIC ' Hx: _��CL DISPATCHER- f L - CHIEF COMPLAINT: `Z 4- 14 JQ4� DRY RUN: ❑ YES C O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X_ i i MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ( S.S. a t)vl K PRIVATE INS. CO.: BASE RATE: 61L_"Y KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: G� X i'Z-=-v x�OF.),- MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO O YES ONO NIGHT: (19:00-07:00) Ok CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL N: _ CODE 2/3 OTHER. yl t/E bl T -r-v EEyIPlo_ 4T C OXYGEN: (PER TANK) -. P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) j DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST]Ritl�7�ELR SPOIJ_SIBLE PARTY.. I.V.: (PER ADMIN.) X W I ` ( rvx u f('C��{ r� DRUGS: (PER ADMIN.) X NAME:S A I r b I c lELATIONSHIP: Yll 0 E.O.A.:(IF NOT REPLACED) ADDRESS: S P l ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER�NC������ ��S"��OCCUPATIONS LIIVi3Q�' OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: WE 1 .4 — ` PATIENT RECEIVED BY:X se Fmuider raccer, whit.- , _rd r:,: _,l, ��•:•+ Pr ;,•c• - r..- ••�.. (SIGNATURE) Oaf-1 CONTRA COSTA COUNTY AMBULANCE 43i� �bg PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N Q CHECK OR FILL IN APPROPRIATE SPACES DATE: ' _T 1-41 PATIENT'S NAME_ v` �� _ ► �o C.L IZ xM 2❑ F COMPANY ADDRESS �� la;n _ ( _ AGE . IeQ _ `J 13 CITY S,♦�. STATE GI ZIP 9`x3N- D0BQ<< qI ❑ Sn O M O T, O Th O F DS "} -0RIVER'S LICENSE# _._____ _..____._.._. _._ _ PHONE__ ;1-• �J E OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R UESTED BY: TIME– (24 HOUR CLgCK) TO SCENE- S O.—_ CALL RECEIVED J_Cc ❑.P.D. TIME 10.8 ' '4 PATIENT DESTINATION: FROM SCENE- Z ❑ FIRE TIME 10.97 ❑ PSAP TIME 10-49• MILEAGE: c ❑ OTHER/PVT TIME 10-7 'fir? END 55,b TIME 10.98 DOCTOR PM ER START___S�� TIME 10-22 HOW CHOSEN: TOTAL C3 STANDBY TIME ❑ EAREST ❑ FAMILY O TRANSFER WAIT TIME ATIENT O DIRECT O OTHER \-�> CALL BACK M: AMBULANCE COMPANY: rG-�- ' 7757 s- ,» T,)AMBULATORY? PATIENT TAKEN TO AMBULANCE: ^JO RESPONSE ZONE_. YES ❑ NO AL'<ED ❑ GUERNEY O OTHER �.._ PATIENT CONDITION: DRIVER��NG� 570 EMT-1A i 1 TECHNICIAN 1'V1 J>!�(LT�NSar.J 11,4 PARAMEDIC Hx: , C �'Tr �1 'b t`� DISPATCHER: ufLl CHIEF PLAINT: __.___ _ DRY RUN: O"YESPRDRY REASON FOR DRY RUN AUTHORIZATIO 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: G KAIRFR MULTIPLE PTS. BASE RATE BLUE CROSS Ill_ TOTAL MILES: o X G ,� f•--•� AE»: -' _ E.O.B. ATT. ROUND TRIP: 11YES ❑ NO i O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP# EMERGENCY RUN: O ct) 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 IT) 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 t4C0Z7 s ale PATIENT RECEIVED BY: X 5� (SIGNATURE) ppk 1R fl U CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IN fftROPRIATE SPACES DATE' I PATIENT'S NAME_ v — ❑ M ❑ F COMPANY#. ADDRESS _ AGE CITY_,•- STATE.____._.____.._ ZIP__.... . ....... .. DOB ._ ❑ Sn ❑ M ❑ TW GYTh ❑ F O S f DRIVER'S LICENSE a _ _. . - PHONE _ NATURE OF DISPATCH -�1L _.__—� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ \ INCIDENT LOCATION: RESPONSE CODE. REOUESTED BY: TIME — (24 HOUR C OCK) i `Al N _7_7 TO SCENE- __._.—_ CALL RECEIVED :� I 1 O P D. —_ TIME 10-8 -- — — — s PATIENT DESTINATION: �'j �' FROM SCENE - ❑ FIRE —_ TIME 10-97 j �J` T ❑ PSAP TIME 10-49 ' MILEAGE: O OTHER/PVT TIME 10-7 END. _ __ TIME 10-98 _ DOCTOR —_ PMD/ER START,/may — -- TIME 10-22 LL ��� • HOW CHOSEN: TOTAL — STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO O WALKED O GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER--Gu_l._LrS_� TECHNICIAN PARAMEDIC Hx: _Q22—i11�—_I�.r C__[`_Y—DISPATCHER _�',_� CHIEF COMPLAINT: _ ________.__—_— DRY RUN'. LS`KES ❑ NO REASON FOR DRY RUN 0 —Z AUTHORIZATION FOR DRY RUN(EMS USE UNLY� ` `� / PATIENT REFUSED SERVICES: (SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a - - --- -- ----- ` PRIVATE INS. CO..—_—_—__-.._._ —_..__----_—.------_--_— BASE RATE. — KAISER a: _.______._.. .._._____. _______ ._..______ MULTIPLE PTS. BASE RATE r BLUE CR a . _ TOTAL MILES:--_________--X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 11 YES O NO NIGHT: (19:00-07:00) CCHP/PPRP a: — EMERGENCY RUN: MEDT-CAL a:_ CODE 2/3 OTHER: __ OXYGEN: (PER TANK) �. P.O.E. STICKE OYES ❑ NO NEONATAL (INCUBATOR) _ DATES BILLED STANDBY: (OVER 15 MIN.) E K.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: T — ORAL AIRWAY: (IF NOT,REPLACED) CITY: \� — STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) L PHONE: WORK PHONE.— DRY RUN: (AUTHORIZED) S EMPLOYER: —J OCCUPATION:____-_._.._____ OTHER ADDRESS:---------------.. --- CITY: STATE'.___---ZIP: ,_----___--- ---- — COMMENTS: 5 qqD- ----------- --- 10TA1 - — ------- PA III ---- PAIII NI NI CEM II IIY X � CONTRA COSTA COUNTY AMBULANCE ) PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 y t CHECK OR FILL INAPPROPRIATE SPACES DATE:- 2-4 -s 1 -� I' Mcg z7y PATIENT'S NAME.- _ �.._ a9 M ❑ F COMPANY M �1 00 ADDRESS _ # 1- _I.- 2 AGE����J )/` # CITY�L ! STATE—CF�-- Zip DOB ❑ Sn ❑ M O T O Th ❑ F ❑ S' DRIVER'S LICENSE tt __._ __- _ _.__-----.____ PHONE�� _�.—_ NATURE OF DISPATCH C - TYPE OF TRANSPORT: AMBULANCE D OTHER D STATION 1(A)._2(8) (C)_4(D)_5(E)_. INCIDENT LOCATIO RESPONSE CODE: RE: STIED BY: TIME— (24 HOUR CLOCK) TO SCENE\- 2 S.O. CALL RECEIVED v� O P.D. TIME 10-8 �'^�^ PATIENT DESTINATION: �j �l, t-`! FROM SCENE - ❑ FIRE TIME 10-97 :31L 13PSAP TIME 10-49 ` llf' 1 Ay � — -f 1,(-L MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 "r ) DOCTOR ' PMD/ER START TIME 10-22 a�L,:v • .. HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST O A ❑ TRANSFER WAIT TIME r .I ❑ PATIENT ❑ T O OTHER CALL BACK C AMBUt E COMPANY: - PT ULATORY9 PATIENT TAKEN TO AMBULAN J J RESPONSE-ZONE ES 13 NO D WAL':EO ❑ GUERNEY OTHER PATIENT CONDITION: DRIV J\vA 7� EM .11A - TECHNICIAN PARAMEDIC Hx k DISPATCHER: - 3 �.J r CHIEF COMPLAINT:Wco� DRY RUN: YES ❑ NO REASON FOR DRY RUN UT INION{ 'DRY R (EMS USE ONLY) r� r� PATIENT REFUSED SERVICES: (SIGNATURE) X 1L�" R-- ('I r MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: .------- PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS q:— TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 ti CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 / OTHER: OXYGEN: (PER TANK) I L 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) EMPLOYER: __ OCCUPATION: OTHER: -- -- ADDRESS: CITY: STATE: ZIP: 1 v TOTAL: PATIENT RECEIVED BY:X J C Provider rota-r white r_rd !'i.; ; (SIGNATURE)•"1'h vt�r+ >'v'2�+a• ���,,t•� !M.S when Di1 inp OIS-1 ' CONTRA COSTA COUNTY AMBULANCE .� PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION M � 3 .~ 21 cf- CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME D M ❑ F COMPANY It ADDRESS AN2, I o cc, AGE CITY p�C STATE ZIP //, DOB 4_, I�❑ Sn D M ❑ T W /❑ Th ❑ F ❑ S DRIVER'S LICENSE R PHONO I_ _U �IATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE.'T OTHER CI __._�____ _ STATION 1(A)y2(B)_3(C)_41D)_51E)_ INCIDENT LOCATION: RESPONSE CODE: RE(; BASTED BY: TIME - (24 HOUR CLOCK) ���� ` I TO SCENE.- _� p'S.O ______ CALL RECEIVED t nC� v D P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- D FIRE TIME 10-972J � \ 2- D PSAP TIME 10-49 MILEAGE: !� D OTHER/PVT TIME 1D-7 END GA TIME 10-98 DOCTOR PM /ER START TIME 10-22 HOW CHOSEN: ` TOTAL STANDBY TIME ❑ NEAREST d FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 8: AMBULANCE C,, )MPANY: PT/MBULATORY? PATIENT TAKEt�VT0 AMBULANCE: RESPONSE ZONE ❑/YES 11NO ❑ WALKED 12 GUERNEY O OTHER PATIENT CONDITION: DRIVER ' EMT-tA, TECHNICIAN PARAMEDICS Hx: DISPATCHER: J f CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN I i AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M PRiV�IIiINS. C .: BASE RATE: )SER R: MULTIPLE PTS. BASE RATE OSS K: TOTAL MILES: 1 X MEDICARE p: E.O.B. ATT, ROUND TRIP: ❑ YES ❑ NO S ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL q: CODE 2 j 3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K-G.: (PER EPISODE) I P v NEAREST RELATIVE/RESPONSIBLE PARTY: I V . )PER ADMIN) X 1� DRUGS: (PER ADMIN.) X I NAM X1 ELATIONSHIP E.O.A.: (IF NOT REPLACED) ) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) , CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _ WORK PHQNE: A DRY RUN: (AUTHORIZED) EMPLOYER. OTHER: ` p ADD SS: CITY'"$ I STATE: ZIP: I I - _ I COMMENTS: W:nt- I. D23 la Z L' TOTAL 3� _ PATIENT RECEIVED BY. X Praluider )Mair Vhito nd PinKu (SIGNATURE) '' PY.• katurn Y.•: .�� •.,1» t � !,riC; uhdn bil'ind ENS-I I CONTRA COSTA COUNTY AMBULANT E PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OP FILL IN APPNOPRIATF SPACFS DATE PATIENT'S NAME A4�_� I 1 -1 ❑ M ❑ F COMPANY#_ 7777 ADDRESS - !.- - -_-----__-. _- AOtSILU AGE—__ CITY ❑Th DF S I DRIVER'S LICENSE # _. . _ __ P NE _ . _-_�_— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBITL.ANCE❑ OTHER EY X INCIDENT LOCATION: RESPONSE CODE: RE ESTED BY: TIME— (24 HOUR LQCK) TO SCENE- S.O. CALL RECEIVED lz v PD. _ TIME 10-81 _ PATTEN DESTINATION: FROM SCENE - ❑ FIRE __, TIME 10-97 v�� :� . r ❑ PSAP TIME 10.49 ' 1 ---------------_ tAILEAGE. ❑ OTHER/PVT TIME 10.7 END.--- ._ TIME 10-98 DOCTOR._______.__. ___ __. PMD/ER START_ __ TIME 10-22 of HOW CHOSEN. TOTAL — STANDBY TIME. ❑ NEAREST 5PA ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ OTHER CALL BACK#: AMBU N MPANY: PT BLILATORY� T TAKEN T 9ULANCE: ` RESPONSE ZONEES ❑ NO '(ED ❑ EY ❑ OTHER PATIENT CONDITION: DRIVEZ�),_) I. _ ?� &kEpEMT-1A TECHNICIAN _ RA MEDIC ( Hx: ._ _ DISPATCHER: . CHIEF 1PLAINT- ._. _Y_ p DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTRIZAT ON FOR DRY` I MS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) i2_(<f"N " f MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: S's PRIVATE INS. CO.:_— —__. --__—_. �— BASE RATE: KAISER x: ___—__-____-___ .__ .__—_--- MULTIPLE PTS. BASE RATE BLUE CROSS# TOTAL MILES: X MEDICARE #: _E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (1900- 07:00) CCHP/PPRP# __ _._�—____.___.�—. ___— EMERGENCY RUN. MEDT-CAL a:—_ _.._.-- CODE 2/3 OTHER _—._______..___.__._.. OXYGEN: (PER TANK) j P.O.E STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_ —_-__ STANDBY: (OVER 15 MIN.) / E.K.G.: (PER EPISODE) r NEAREST RELATIVE/RESPONSIBLE PARTY: I.V: (PER ADMIN.)` X DRUGS: (PER ADMIN.)_ X ri I NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:_. ORAL AIRWAY: (IF NOT REPLACED) CITY __:-_._--__._.------ _.. STATE.___—_ZIP:_--.-- . C-COLLAR: (IF NOT REPLACED) � PHONE: ;.__--__—.__.___ ___.__. WORK PHONE: DRY RUN:- (AUTHORIZED) �✓'`T/ EMPLOYER: ___ _. __ ._ OCCUPATION: OTHER: APPnF¢S CITY :._........ _ .. STATE.- ZIP:_ _ COMMENTg1__--pp ` TOTAL �JG s Cl(1.e:2 14-46-0 PATIENT RECEIVED BY: X �i�D. '.�. .r f..: .1:i•� .. o-• ..�,,. : (SIGNATUREI CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N If 3' <<�l i ,i. 2 5- CNFCK OR illi INAPPROPRIATE SPA CFS ^ ,�( ,/ DATE: - 'T 3 PATIENTS NAME�`� ' �`� t 1 �+ t 1� `�c-"I ❑•M ❑ F COMPANY N / ADDRESS AGE i ;� NA1. CITY STATE ZIP DOB " ❑ Sn 0 M 0 T ❑WPI Th ❑ F ❑S DRIVER'S LICENSE N ' PHONE —Y NATURE OF DISPATCH TYPE OF TRANSPORT:, AMBULANCE-P OTHER❑ _ -- STATION I(A),2(9)_3(C)_4(D)_5lE)_ INCIDENT LOCATION:' RESPONSE CODE: R OUESTED 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 : z 11 N 1 1 ❑ PSAP TIME 10-49 1 ' V MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR. . PMD/ER STAR TIME 10-22 l HOW CHOSEN: TOTAL STANDBY TIME .. ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- 0 PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: L/I 5 PT, AMBULA Y? PATIENT TAKEN MBULANCE: j ( j RESPONSE ZONE-S ❑ YES trNO ❑ WALKED 01GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �G t... I G�^G �1 C;�' EMT-1A TECHNICIAN d- I_ A PARAMEDIC -z!g Hx: DISPATCHER: I � ' ivt ".� 7 1 CHIEF COMPLAINT: DRY RUN: ;0 YES ❑ NO REASON FOR DRY RUN�� I A TRIZATION FOR DRY RUN(EMS USE ONLY) q5� + PATIENT REFUSED SERVICES: (SIGNATURE) X "� �7`G,�J -D0,::;7 L MEDICAL COVERAGE: . INDUSTRIAL ❑ YES-a 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 0 YES 0 NO NIGHT: (19:00-07:00) Y 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) =v EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: �/ G:C�'• - C PATIENT RECEIVED BY: X (SIGNATURE) r Y� PATIENT'S NAML: Muller,Kimberly ADDRESS: 196E Ardith dr_ Pleasant Hi11 .Ca. DATE OF SERVICE: 08-25=83 AUTHORIZATION NUMBER: 83-14506 AMOUNT DUE: $317.00 INCIDENT LOCATION: Contra Costa County Hospital .A Ward PATIENT DESTINATION: Alta Bates Hospital .Berkely 00526 TV 71 `l,j,' ;e' a• j� ! '+ :rid' '. ►. r♦!► i ...�! � ,��r-•�- t j � � � J�tl UG 25 1 � '� "" u� p!� X13 �3Auc Z5 s 14 AM 43. . : SO I'AP RF4 CAII RECEIVED I AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 CALLED BY-- r PATIENT INFORMATION C o I NAME --_. .{; =�•�v"d - -r------ 3 u0, AGE NC � r��+..�- ( C1..�r_..`.{JL7 Vl.�-._ i CUSTOMF 1 n(PT. 1): _ DOB, ----- - � IJ D !, .DEPT,FtOOR,'ROOM a, 1i17"� -- -'--' ` I 1C`m ber(Li Z -'------------ NAME: .._-�t�l_lLL{.eLC_-'- P1 CALLBACK a - -- L_ ,cJ —__— INS. TYPE: PVT MCAR KHP PHP VA AND CHAMPUS > vINCIDENT IOC: USJ-�:1�.��..._t�C' =r_tcZl_�1 IItZl,Z POUCY,MCAI Z tr: n �•� . J _ MCAR a: _ - m Z" ' m ( :CROSS STREET:* ---__. - -- ----- VERBAL PRIOf{ 19 1a-0-I_ o . - a JURIS. Gly. 1���1(1�Z-----_-/__-. DOCTOR: �AhA - 'DESTINATION: E'S.-,,. I Imo._-_ PT, a2 NAME: DOB: tlQ NATURE: -_-..-- CUST. a D I� :; _". ._ _ _ . _ - - ------ > •.I:, PT. 113 NAME: DOB: o TYPE OF CALL: EMG H N 11ME UNIT Is .__.--cE CUST. N z m t„ CREW: __— nd.ya1 _ye_ - WAIT TIME: YES NO REASON: Z O UNIT TYPE: ALS Le WC RESPONSE CODE: 0 1 © 3 4 A) REASON FOR 10-22: O `a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 102 3 4 CANCELLED BY: m �p + BY: __- END MILEAGE: t03 6 COMMENTS: �It�n/1J2 p ,�� • o N �[ TIME. BEG MILEAGE: 3( Y"i _v Q :2, co f D PAT HERR: MILES: r a XL'0( OI1d1S ld 3DNV1f19Wd 61-01 C-)NIN2iF113 V1F18WV 86-01 318d11VAd 3DNd1F19Wd L-01 1dlIdSOH!d 3DNd1f1BWd •r •;�' LE 01 5Z ��` E81 HV LE 01 5Z on Ego Hb 6001 5Z on ' b ' ,t n. 1, .tt` : '{ i 1!'F. .•i 7-"7!7 Ae 1.' t. .i , , •, gip: * . A `,�`���.'IS� .� , �i' �. [t. � •y,.K'. ..i� ••l,%,.'• 1 -V' C. " `b. .y mat � � 'e.♦ - '} :4 7 '` •i ti ".�' r �K�. ' � '�i��►k,'���T-i�- ,RRA Y �_.. 9 °..'►. •.��'. y.. _ ,F rr. �t•w ! � ?},vi�l�'i••��YNtr�.`t .. w�rf _ ��. A4. f� !, i ' .�� •�* ��i���l{°" -fit!' ��... F ►+,'��s. 1•i �ly�, :t. its i`.»'. d+rt;t':: _•$-'+; .r �. r -:,�+>`'!+. tiP��t; I.,' ''1 . Mil: 1.. ••.: i a CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT P 6 AUTHORIZATION M k 3- y S ! i • CHECK OR RLL W AoiROPR1A7E SPACES - DATE: 4S - S' y 3 , .' ATIENT'S-NAME'� - ❑t y 0 L—v% ) O M O F COMPANY N ADDRESS I ' AGES CITY STATE_�r, ZIP 008 O Sn O M OT D W IN Th O F O$ DRIVER'S LICENSE M 1 PHONE __ NATURE OF DISPATCH A &,,_f C, TYPEOFTRANSPORT:,AMBULANCE 0 OTHER t3 STATION 1(A)_2(8)_3(C)._4(D)_5(E)_ INCIDENT LOCATION:! i C. RESPONSE CODE: REQUESTED BY: •TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED c,�)1 _—317. ❑ P.D. TIME 10-8 1.L — PATIENT DESTINATION: ... . FROM SCENE- ❑ FIRE TIME 10-97 1L ' 156 ❑ PSAP TIME 10-49 MILER O OTHER/PVT TIME 10-7 _ END TIME 10-98 + PDOCTOR"T,. ,`�o ' 4 PMD/ER START TIME 10-22 HOW CHOSEN: ._ . _ + TOTAL STANDBY TIME ,O:NEAREST,, FAMILY ❑ TRANSFER WAIT TIME . ' O PATIENT O DIRECT O OTHER CALL BACK W AMBULANCE COMPANY: LAS PT. tJLATORY7 PATIENT�110MBULANCE: J.I�, [RESPONSE ZONE 5 ❑ YES ❑ WALKNEY O OTHER 1.37 PATIENT CONDITION:, DRIVER /`� C L� )��EMT-1A L �JS I C J s -• w'• TECHNICIAN 't-�- (� 2` U PARAMEDIC Hx: DISPATCHER: yin CHIEF COMPLAINT: DRY RUN:-Z YES O NO REASON FOR DRY RUN PU V l C/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qilr2 n, ,t PATIENT REFUSED SERVICES: (SIGNATURE) X — MEDICA OVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: �'Sel/ f S.S.M PRIVATE INS. BASE RATE: ) 1 KAISER>rh �' I MULTIPLE PT BASE RATE ( .= BLUE CROSS K: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O S ❑ NO O YES O NO NIGHT:(19:00-07:00 ' CCHP/PPRP#:r_ EMERGENCY RUN: MEDI-CAL 4: 1 CODE 2/3 OTHER: OXYGEN:1(PER TANK) c P.O.E. STICKER O YES O 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 OTAL:PATIENT RECEIVED BY. X h+.+niJir rita(n Vhit• - .! Pi+, (SIONAII)RE) .•.('p kot,..» 1. ' ., }r 7 IMS CONTRA COSTA COUNTY i AMBULANCE PRE-HOSPITAL CARE FORM I ` UNIT © AUTHORIZATION 0!&32 42--3 CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME O M E3 F COMPANY k ' ADDRESS AGE CITY :- W (- STATE ZIP _ DOBC4,1�1 ��` Sr, ❑ M O T O W Th OF O S NE/^ DRIVER'S LICENSE 0 _ PHO '�,�-�' IATURE OF DISPATCH TYPE:OE TRANSPORT: AMBULANCE a OTHER❑ _______. ___. ---- -•• STATION 11A1_21B1_31C1_41D1_5(E)_ INCIDENT,LOCATION: RESPONSE CODE: RSTED BY: TIME- (24 HOUR CLOCK)' TO SCENE- S.O. CALL RECEIVED ?i1��- � ❑ P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE- 13FIRE - TIME 10-97 �> 1 _v ❑ PSAP TIME 10-49 MILEAGE: / ❑ OTHER/PVT TIME 10-7 /�• /- END _ TIME 10-98 DOCTOR - ��� � PM ER START �D �/gin TIME 10-22 HOW CHOSEN: TOTAL :q��� STANDBY TIME ❑ eAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANU COMPANY: EYES BULATORY? PATIENT TAKEN3O AMBULANCE: ) : I• RESPONSE ZONE O NO ❑ WALKED ❑ GUERNEY ❑ OTHER i. PATIENT CONDITION: DRIVER ' 1_1 z- c 1•{ /�'-� EMT-1A TECHNICIAN '. ( PARAMEDIC HY DISPATCHER: (� Ll CHIEF COMPLAINT: 1-) S► 11 `r,��'� DRY RUN: O YES ONO REASONFORD14YRUN �'llci�f;til 1 _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 5 MEDICAL COVERAGE: I USTRIAL ❑ YES NO NO. OF PATIENTS: S.S. K _ PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE =� BLUE CROSS k: TOTAL MILES: X � '•��� ! MEDICARE R: E.O.B. ATT. ROUND TRIP: O YES O NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: INAEDI-CAL M: CODE 2/3 1 t OTHER: OXYGEN: (PER TANK) ' a P.O.E. STICKER. ❑ YES ❑ NO NEONATAL: (INCUBATOR) UI DATES BILLED:-, STANDBY: (OVER 15 MIN.) / E.K.G.: (PER EPISODE) `L f� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X (� DRUGS: (PER ADMIN.) i X :.i� 5J P�T NAME: RELATIONSHIr �O.A.: (IF NOT REPLACED) ADDRESS' ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) • PHONE: WO DR RUN: (AUTHORIZED) MPLOYER: 0tATION. ADDRESS: CITY: STATE: ZIP: COMMENTS: - - TOTAL:--- - - - a __. PATIENT RECEIVED BY: X • Pnroidor rvtair, White rd /'i,,; .•a1,F hutum Yr•:,. ,, ,, 9}l:: uh.n 1:1 i,:,l (SIGNATURE) tlts-I CONTRA COSTA COUNTY AMBU NC PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION it CHECK OR FILL IN An ROPRIATE SPACES DATE:. , ) a c PATIENT'S NAMEt_'�' -e--J _ O M F COMPANY p r _ ADDRESS '[�_ )�7!! ✓/7 AGE 13 4 ClTY._ , STATE___ _ ZIP_ DO _� Sn 11M O T ❑ W 13F S DRIVER'S LICENSE a t PHON� --- ATURE OF DISPATCH i TYPE OF TRANSPORT: AMBULAN OTHER❑ INCIJDENT LOC TION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) - /I TO SCENE- S.O.__— CALL RECEIVED �'- .� ❑ P.U. TIME 10-8 — I 3 PATIENT DESTINATION: r ) FROM SCENE Cl FIRE TIME 10-97 }� ; — --_— ❑ PSAP TIME 10-49 MILEAGT ❑ OTHER/PVT TIME 10.7 - t I END__ TIME 10-98 DOCTOR ._C ?, PMD, START�� . TIME 10-22 . HOW CHOSEN: TOTAL —CL_ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT O DIRECT Cl OTHER / CALL BACK a: AMBULANCE COMP ';q �S PT AMBULATORY PATIENT TAKEN TO AMBULANCE: 77, RESPONSE ZONE O YE�,S NO ❑ WAL`:Et��UERNEY ❑ OTHER — PATIENT CONDITION: DRIVER._ , JJLJV � �� EMT-1A TECHNICIA _Z V NC'_ D__10 PARAMEDIC ✓— r /j Hx 1 �, -- _-� _C��L t _-- _ DISPATCHER- --/f '�.CI CHIEFOMPLAIN __ C��Sz�� DRY RUN: O YESr�,0 REASON FOR DRY RUN _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ^,( PATIENT REFUSED SERVICES: (SIGNATURE) X �`. MEDICAL COVERAGE: INDUSTRIAL ❑ YE0�0 NO. OF PATIENTS: S.S. a PRIVATE INS. CO.:. ---- -- — — BASE RATE: KAISER #: _— MULTIPLE PTS. BASE RATE — BLUE CROSS#: _ TOTAL MILES: X � MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT (19:00-07:00) c� CCHP;PPHP a:_—__.__ EMERGENCY RUN: l r MEDT-CAL a' � —T— I���-�� CODE 2/3 ) OTHER: � �1i—i_! OXYGEN: (PER TANK P.O.E. STICKER O YES Cl NO NEONATAL: (INCUBATOR) DATES BILLED: ____ _ — STANDBY: (OVER 15 MIN.) E.K G.: (PER EPISODE) NEAREST RELATIVE/RES ONSIBLf PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NA ___ 1 ._._`�-�__ RELATIONSHIttS.— 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:__:_ ___—.___ __ na 0 / --— --- — - - - — - — TOTAL: S PATIENT RECEIVED BY:X Fmvidr rrf.. 4tii.. ^� c, �• rr^ t hor hi i (SIGNATURE) DIS iva -1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N v AJ."'? w• CNECK OR FILL IN APPROPRIATE SPACES - DATE: 7 PATIENTS NAM< OM OF COMPANY N ADDRESS,' —� — -- - - AGE i '� CITY STATE ZIP DOB ' O Sn O M O T OW O Th OF OS DRIVER'$LICE!NSE N - PHONE NATURE OF DISPATCH - 1 TYPE;OFTRANSPORT: AM13ULANCED OTHERO STATION IlA)`2(B)_3(C)_4(D),5(E)_.. INCIDENT I,OCATION: RESPONSE CODE: RESTED BY: TIME— (24 HOUR CLOCK) , 9 r� TO SCENE- S.O. CALL RECEIVED z �. j .Y� • ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 : } ❑ PSAP TIME 10-49, �` '• "�� L MILEAGE: ❑ OTHER/PVT TIME 10-7 -•-•-, END TIME 10-98 5.60cfoh I T'7 I PMD/ER START TIME 10 22 -L:c :,aq HOW CHOSEN: _ TOTAL STANDBY TIME - s NEAREST i;� O FAMILY O TRANSFER WAIT TIME I O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANT OMPANY-. �' I PT. BULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE r YES O NO,•_, O WALKED ❑ GUERNEY ❑ OTHER' PATIENT CONDITION:— DRIVER 21EMT-1A I TECHNICIAN Mr C�1-L-1 PARAMEDIC + Hx: DISPATCHER: CHEF COMPLAI T:` T DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN fL yUTHbr,lTIO�_T( DR t �U LY) 1 ;;)�_PATIENT REFUSED SERVICES: (SIGNATURE) (o11„�etnl je-�c,,,,l•� 1 r I '1'� � � MEDICAL COVERAGE: INDUSTRIAL ❑ ES O NO NO. OF PATIENTS: S.S.N PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE _ BLUE CROSS N: i TOTAL MILES: X c MEDICARE N:' E.O.B. ATT. ROUND TRIP: O YES ❑ NO 1 O YES ONO NIGHT:(19:00-07:00) CCHP/PPRP N:^ ( EMERGENCY RUN: MEDI-CAL N: CODE 2/3 )THER: "=s 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/RESPONSI PARTY: I.V.: (PER ADMIN.) X i 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- 01. IP:COMMENTS: n ri G i TOTAL • C`Zi •`J L PATIENT RECEIVED BY: X Pnwl,f.� r•rraia V1:it< ,r,,l �.� .-,.,, 4,,.... .. . .., (SIGNAIURE) f++5.1 #_ `trIr ' �'�••+ CONTRA COSTA COUNTY AMBULANCE I PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION 0 `' CHECK OR FILL INAPPROPRIATE SPACES ' DATE: PATIENT'S NAME/rI�._�_�CNS4t .�..o: .� ❑ M IV-* COMPANY a `ADDRESS AGES I /� CITY/' ' I�� - STATE�? ZIP---`=D9�! _ y ❑ Sn ❑ M O T "❑ W PlTh iD F `❑..5.... I GC S V 1 DRIVER'S LICENSE a _.__-.___.__-._._. _ _ PHONE�av-_--- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK)tl TO SCENE- ❑ S.O. CALL RECEIVED �\*`c cc ❑ P.D. TIME 10-8 "i.;'L1sE+ 1 _ t PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 ❑ PSAP TIME 10.49 �1 ` MILEAGE: OTHER/PVT TIME 10-7 j 1 ENO J f'� cC C TIME 10-98' DOCTOR _ PMD/ER START TIME 1D-22 HOW CHOSEN: TOTAL - STANDBY TIME', .ice ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME ` .r. O PATIENT 11DIRECT O OTHER CALL BACK 0: AMBULANCE COMPAN)2� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: G� RESPONSE ZON ❑ YES ISL NO ❑ WAL'-ED �k GUERNEY ❑ OTHER '�Q r PATIENT CONDITION. DRIVER�f"'� v ' 'EMT-1A�51�.1.�,..�' I LA/ L � TECHNICIA PARAMEDIC 52�/7Fix: DISPATCHER: l L .• 1 ".:._ .+ � CHIEF:COMPLAINT: _L�!"x— — DRY RUN: ❑ YES UI NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY). PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES�40 NO. OF PATIENTS: ! 'r S.S. a r, 3. PRIVATE INS. CO.: BASE RATE: I/�•��, KAISER a: MULTIPLE PTS. BASE RATE " `1 I! BLUE CROSS a: TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ���-�-77 �i,�❑ YES ❑ NO NIGHT: (19:00-07:00). CCH /PPHPa: "/6U,D �`�'�U[]r[_7 EMERGENCY RUN: MEDI-CAL a: CODE 2 13 I � OTHER: OXYGEN: (PER TANK) '("3.;`,T. P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) q DATES BILLED: STANDBY: (OVER 15 MIN.)- C2L_:'[_ C) E.K.G.: (PER EPISODE) s NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) Xj 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: �� !` I ADDRESS: LL CITY: r c ZIP:- COMMENTS: FEB 1198 - -- TOTAL:- I /G•U� --- - PATIENT RECEIVED BY:X Pr uidrr rrt,7r: Lhit, (SIaNATURE) ..'her t-I'iho off-1 CONTRA rt) LA COUNTY 1 AMRUTANCE PRE-HOSPITAL CARE FORM ! UNIT AUTHORIZATION M f� CHECK OR FILL INAPPROPRIATE SPACES DATE:"_ PATIENT'S NAME .. I L Q�I� ❑ F COMPANY - . _- �. . .y Lu ADDRESS AGE I .. l/'�'1 Z1 ❑ Sn O M ❑ T ❑ W t.Th ❑ F S ZIP__ DOB l�` DRIVER'S LICENSE If _._ _._ PHONE_.._ _.__—___..—__— NATURE OF DISPATCH TYPE,OF TRANSPORT AMBULANCE IK OTHER❑ INCIDENT LOCATION: RESPONSE CODE REQUESTED BY: TIME— (24 HOUR CLOCK) a �+ TO SCENE 9S.O.— CALL RECEIVED L— r P10-8 . Y y - --C -�L� SY ----- - - -- ----- .D. TIME L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 PSAP TIME 10-49 MILEAGE: / �1 OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _- - _ PMD/ER START_0' - TIME 10-22 HOW CHOSEN: TOTAL - -- STANDBY TIME 1 ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE CO PANY: ( -f ln, 3. PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ( ( I RESPONSE ZONE .r ❑ YES ❑ NO O WAL':ED ❑ GUERNEY O OTHER PATIENT CONDITION DRIVER-._z�(���rL�-_-_� -1A TECHNICIAN TECHNICIAN __qill�i PARAMEDIC GG . 1 H DISPATCHER: l�.F�,�1-S1� CHIEF COh1PLAINT: .1�/_lGc 6A—) DRY RUN: O YES NC REASON FOR DRY RUN AUTHORIZATION FOR D Y RUN(EMS USE ONLY) i PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL. COVERAGE: INDUSTRIAL ❑ YES NO NO, OF PATIENTS: SS r ' l PRIVATE INS. CO.:._ ____ BASE RATE: I KAISER #: MULTIPLE PTS. BASE RATE BLUE CROSS#:_- __. _ TOTAL MILES: X MEDICARE a: __-_-_ -___ E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO 1 1 ❑ YES ❑ NO NIGHT: (19:00-07.00) 1/ CCHP,'PPHP#) _- _ EMERGENCY RUN: _ a _MEDI- AL#: CODE 2/3 ! c OT �/,.._—_ __ OXYGEN. (PER TANK) P.O.E. STICKER ❑ YES ❑ NO - NEONATAL: (INCUBATOR) I' DATES BILLED:_ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: __ _ RELATIONSHIP -.._._._ _. E O.A.: (IF NOT REPLACED) ADDRESS: _-_... _ __ �_____ ORAL AIRWAY: (IF NOT REPLACED) CITY STATE ..____ZIP:___ C-COLLAR. (IF NOT REPLACED) PHONE: _____. WORK PHONE — - DRY RUN: '(AUTHORIZED) EMPLOYER: _-____._-- OCCUPATION: OTHER: ' ADDRESS: CITY ___-____-.__ STATE—_-ZIP: I COMMENTS:______--__ .- _ TOTAL:_ as L PATIENT RECEIVED BY: X �....:,,... ;,.:. *(SIGNAT p -30_g %� I~ CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM 1 UNIT AUTHORIZATION III. X/, _ CHECK OR FILL IN APPROPRIATE SPACESDATE: T PATIENT'S NAME _��17+/ /4�{LI P/ e ,8'M' ❑ F COMPANY N ADDRESS ��� _SO x/ Fm JQ(-d 2 99 '_ AGE Y CIT ?0.42(--O. STATE ZIP`I ? (G DOBIJ S f O Sn O M DIT,D]�N .PIT y DRIVER'S LICENSE N _, _ PHONE NATURE OF DISPATCH�� �a r► TYPE OF TRANSPORT: AMBULANCE OTHER 07 :1 - I STATION I(A)_�52(8)_._.3(C)_4(D)_6(E) INCIDENT LOCATION: S til �i RESPONSE CODE' REQUESTED BY: TIME-(24 HOU�1 CK) TO SCENE- 41'S.O. CALL RECEIVED (✓ A-i F a tia h"OIL,C r- � ❑ P.O. TIME 10-81T2, PATIENT DESTINATION: z3E Y-a,l, )4 FROM SCENE- ❑ FIRE TIME 10-97 •� J, ❑_PSAP 'IME-10-4 ►:.: I nQC.��� ���`'� MILEAGE: D OTHER/PVT TIME 10•7 ENO q 61 TIME 10-98. t DOCTOR PMD/ER START I ' TIME 10.42 A4 .HOW CHOSEN: TOTAL "' ? !STANDBY TIME W NEAREST n- FAMILYO TRANSFER WAIT TIME , ❑ PATIENT ❑ DIRECT ❑ OTHER CALLBACK N: AMBULANCE COMPA Y: i• PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: [ RESPONSE ZONE VrYES ❑ NO ❑ WALKED Z'GUERNEY 13 OTHER ^_- r ~�r PATIENT CONDITION: DRIVER�[' �'e�' �J�t1=MT�e�•. z r `' i '7 TECHNICIAN PARAMEDIC -T Hx: DISPATCHER: - CHIEF COMPLAINT: � ` L PQ L DRY RUN: ❑ YES i NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLJ.qa L>5� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDT AL COVER GE: 3 - INDUSTRIAL ❑ YES Ir NO NO.OF PATIENTS: P .I S.S. N RIVAT INS.CO.: BASE RATE: K ER MULTIPLE PTS.BASE RATE BLUE OSS k: TOTAL MILES.- X .. "1 MEDICARE N: i E.O.B. ATT. ROUND TRIP: ❑ YES D NO y T 2�q 12 a. ��d / P— ❑ YES ❑ NO NIGHT: (19:00-07:00) .� CCHP/PPRP M: EMERGENCY RUN: c7vlIajQ4� X �' r MEDI-CAL N: CODE 2/3 -"' ` OTHER:_ OXYGEN; (PER TANK) THi�Z3WVX.. P.O.E. STICK R ❑ YES ❑ NO NEONATAL!- (INCUBATOR) I� ATES BILLE STANDBY: (OVER 15 MIN.) �'t a' d�f E. 0,- (PER EPISODE) � NEAREST RELATIVE/RESPONSIBLE PARTY: I.V."(PER ADMIN.) "— S v DRUGS: (PER ADMIN.) X k ......r.�.rr r.x. �y� p '.•' NAME:�rt�; ��4 ••REILATIONSHIP: •E.O.A.-(IF NOT AEPLACE0f 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: PATIENT RECEIVED BY:X Ty.+ni,4rr tvt- - 7 r:• crr, (SIGNATURE) [. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION Q AX), CHECK OR FILL IN APPROPRIATE SPACES DATE: � Z ( 3 X PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE CITY STATE ZIP DOB--__ ' O Sn ❑ M OTOW OF OS DRIVER'S LICENSE NPHONE NATURE OF DISPATCH. TYPE,.OF TRANSPORT: AMBULANCE O OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLOCK) p C�= n Apo T CENE CALL RECEIVED 6 d �-1"y 1 D P.D. TIME 10-8 PATIENT DESTINATION: FFkQM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �`JJ MILEAGE: 13OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR I PMD/ER START TIME 10-22 o HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY D TRANSFER WAIT TIME -- `'' D PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO D WALKED ❑ GUERNEY D OTHER — r� 7, PATIENT CONDITION: DRIVER `� EMT-tA TECHNICIAN 1 -� PARAMEDIC Hx: _ DISPATCHER: `"1 4q CHIEF COMPLAINT: — 2 DRY RUN: YES ❑ NO REASON FOR DRY RUN QRZ 10 XZATION OR DRY R N( S USE ONLY) a /J PATIENT REFUSED SERVICES: (SIGNATURE) 't MEDICAL COVERAGE: INDUSTRIAL ❑ ES ❑ NO NO. OF PATIENTS: /�✓ �/ S.S. # PRIVATE INS.CO.: BASE RATE: KAI R#: MULTIPLE PTS. BASE RATE BLU CROSS#: TOTAL MILES: MEDI RE k: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ N ❑ YES ONO NIGHT: (19:00-07:00 CCHP/PPRP . EMERGENCY MEDI-CAL B: E 2/3 OTHER: XYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE P Y: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X --NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: AL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-C AR; (IF NOT REPLACED) PHONE: WORK PHONE: DRY.RU AUTHORIZED) �� EMPLOY OCCUPATION: OTHER: ADD SS: CITY: STATE: ZIP: COMMENTS: --- TOTAL ---------.__._.-- -- PATIENT RECEIVED BY X --_-- M1••tr/Jrr r�rn - .�. . r;.: _ • ISIGNAILIREI t 1 CONTRA COSTA COUNTY I f, AMBULANCE f% i ^' PRE-HOSPITAL CARE FORM I UNIT G' AUTHORIZATION N CHECK OR FILL IN APPROPRIA/E SPACES _� DATE:_L.�. �- PATIENTS NAME �� �'� �i' O M ❑ F COMPANY N ADDRESS AGE CITY STATE ZIP _ DOB ❑ Sn ❑ M O T O WJl] Th ❑ F ❑ S 11n ) DRIVER'S LICENSE N _____..__�-.__—__ PHONE-___ _ .--_- —_.._ NATURE OF DISPATCAJ k4 ,L— ,-jTYPEOF TRANSPORT: AMBULANCELI OTHER❑ _— STATION 1 fA)_2(B)_3(C),4fD)_5fE)_ INCIDENT LOCATION: 1`1� RESPONSE CODE: RE�ESTED BY: TIME (24 HOUR CLACK) 1 TO SCENE- �— S.O. CALL RECEIVED C 770 .s- ��T�-� O P.D. TIME 10-8 PATIENT DESTINATION: FRO SCENE ❑ FIRE TIME 10-97 D PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 T 4 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 O WAL`CED O GUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER `�- tom-- z�` _ EMT-1A TECHNICIAN.V /'i.> Ln3 ~.PARAMEDIC Il�lJ Hx: DISPATAH CHIEF COMPLAINT: DRY RUYES ❑ NO REASON FOR DRY RUN AUTHOON FOR DRY RUN(EMS U E ONLY) �.-. PATIENT REFUSED SERVICES: (SIGNATURE) X 1 ' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS, BASE RATE BLUE CROSS 0: 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) Y� P.O.E. STICKER O YES D NO NEONATAL: (INCUBATOR) 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: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) I ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: .(IF NOT REPLACED) cv PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:-"_ . .. - -- - - ---- —�� � — -_J_--- -.- ---. PATIENT RECEIVED BY: X.---. -----.... --_-- -- -..._ i, (SIGNA.-URE) r PmiiJor• rvtaic Lhiry ,.•.1 ... •r:. �.h, ,: r.. . r� I b CONTRA COSTA COUNTY ` AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION. S3 � �'3 0 — CHECK OR FILL IN APPROPRIATE SPACES DATE: o� ! PATIENT'S NAME� Q�C. CkM ❑ F COMPANY 406 (' ADDRESS AGE _ ) CITY `(AQ STATE ZIP yiSQ U DOB 2'Z4-tj ❑ Sn ❑ M ❑T ❑W ❑ Th f(F O 8 "DRIVER'S LICENSE# —�_— PHONE Z- �� NATURE OF DISPATCH i .,--TYPE OF TRANSPORT: AMBULANCE 19 OTHER❑ _ STATION 1(A)._2(B)_3(C)_4(D)_5(E)_ - C)DENT LOCATION: r RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CJQCK) - I "•" s#.., � TO SCENE- 3 S.O. CALL RECEIVED ,�•1 1.(eLlo1 4 �.�� twe S�cle-f— ❑ P.D. TIME 10-8 ' .. PATIENT DESTINATION: FROM SCENE- ❑ FIRE __ TIME 10-97 _ r ❑ PSAP TIME 10-49; l 4.�C _ D�c�t3rs MILEAGE: s 13OTHER/PVT TIME 10-7 ' J END TIME 10.98 , " ? DOCTOR DC l�w• Z- PMD/ START -3 TIME 1042 . HOW CHOSEN: TOTAL Z�_ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER �• ' 7 - WAIT TIME .PATIENT ❑ DIRECT ❑ OTHER CALL BACK.: AMBULANCE COMPANY: C.A s j PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ��Q. RESPONSE ZONE •,,,_ I JXYES ❑ NO ❑ WAL'<ED kGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 1613e EMT-1A TECHNICIAN S, a PARAMEDIC x Hz: � DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES Ql.N REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j PATIENT REFUSED SERVICES: (SIGNATURE)X I' ' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ,q NO NO.OF PATIENTS: +t KS.S. a !�_L I rl Y_ol 1!; >> L -- 1 RIVATE INS. CO: I i2�r'—SYS ([ SySACM A55 SY��I ASE RATE: 19ERw: -. / MULTIPLE PTS. BASE RATE �� ��'�� �BL E CROSS.: _ ' '7 '�)CF" -� TOTAL MILES: X [!5,50 MEDICARE.: S �� (T 61 9ell n Z E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO / ❑ YES -❑ NO NIGHT: (19:00-07:00) ff CCHP/PPHPM: EMERGENCY Rq : `I MEDT-CAL.: CODE 2 N3' OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) L t I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 1 y r 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: r N F'r Sl OCCUPATION: OTHER: ADDRESS: C' ( f c{ `c•v` Q.��t:SCC CITY: STATE' ZIP- COMMENTS: , TOTAL:- 9-5-0 n n c }s PATIENT RECEIVED BY:X a� d Pmuidar reto:r, Vhite trd Pini roph .Srturm Yt'i<n, mpy t ENS ukAn Di7 inp (SIGNATURE) CHS-1 .S• CONTRA COSTA COUNTY AMBULANCE O j PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# , f 1(• CHECK OR FILL IN APPROPRIATE SPACES DATE: ' X PATIENTS NAME ❑ M ❑ F COMPANY# ADDRESS AGE, 4' `- IA J i CITY STATE ZIP-- DOB— ❑ Sn O M 0 T O W 0 Th WF 0 S DRIVER'S LICENSE# — _ PHONE__—`__ NATURE OF DISPATCHLMCOki`,cam_ TYPE--OF TRANSPORT: AMBULANCE 0 OTHER 0 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) nn TO SCENE- O.,—_ CALL RECEIVED A9 : S3 ' u P.D.— 'TIME 10-8 _sly PATIENT DESTINATION: FROM SCENE- ❑ FIRE —_ TIME 10-97 0 PSAP TIME 10-49 MILEAGE: 0 OTHER/PVT TIME 10-7 END TIME 10-98 L— : e) i. DOCTOR PMD/ER' START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST 0 FAMILY O TRANSFER WAIT TIME (�... 0 PATIENT O DIRECT 0 OTHER CALL BACK#: AMBULANCE COMPANY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `� �; RESPONSE ZONE O YES ❑ NO ❑ WALKED O GUERNEY 0 OTHER PATIENT CONDITION: DRIVER CCI:i;:�1�.5 ;': _ EMT-1A 7)„4j S:' TECHNICIAN _ 9=0Lk7 A r' PARAMEDIC / HX: DISPATCHER: }�i�� �i r Lt(/ CHIEF COM HINT: — DRY RUN:/,eYES 0 NO REASON FOR DRY RUN/U 2 L £JJ(LG 44TT qqf AUTHORIZATION FOR DRY RUN(EMS USE ONLY) `� PATIENT REFUS D SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: I� S.S.# k- PRIVATE INS. CO.: BASE RATE: t KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO 0 YES 0 NO NIGHT: 119:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL#: 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) V 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) STATE—_ZIP: C-COLLAR:. (IF NOT REPLACED) /', PHONE: WORK PHONE: DRY.RUN: (AUTHORIZED) / Cf) _ EMPLOYER: _ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:4ALLC-LSLb CkVClATS 43V Ooc0 C_cj o J zKQL Cf _ TOTAL.. ------------,-.._-- PATIENT RECEIVED BY X ---- --.-- -.----------�-. _ hr t,l lrr rrra�. t.Ai .. , .. .. ISIGMAtl1RF) CONTRA COSTA COUNTY ' AMBULANCE 9 PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION# 0 3 wo CHECK OR FILL INAPPROPRIATE SPACES - ` /l DATE: ,PATIENT'S NAME OM ❑ F COMPANY If er ADDRESS ; AGE. CITY STATE 21P DOB O Sn OM OT OW 11O Th 4rF O S DRIVER'S LICENSE# _ PHONE _—__ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) (� /�r � TO SCENE- O P.D. TIME 0-8 EIVEO PATIENT DESTINATION: FROM SCENE- ❑ FIRE -- TIME 10-97 Ll— �[f ❑ PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST 13FAMILY O TRANSFER WAIT TIME -- ❑ PATIENT O DIRECT ❑ OTHER CALL BACK It: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE %.1-7 L: ❑ YES ,O NO, O WALKED O GUERNEY O OTHER �' l PATIENT CONDITION: DRIVER-AV-4y. `04 -_ ERAT-1A TECHNICIAN 17L PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: 9 YES Q NO REASON FOR DRY RUN i�k 15.0 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (�(y PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O 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: O YES ❑ NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP III:.' 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS:' IP:COMMENTS: 0- 0- 5-39 �(� (, TOTAL:``� �/- ------- —0- 0- 5-3 9 PATIENT RECEIVED BY- X CON IIIA CO'IA COUNIY ' AMIIIILANCE PRE-HOSPITAL CARE FORM I I\, UNIT / AUTHORIZATION N a3/ CHECK OR FILL IN APPROPRIATE SPACES DATE: - - - �n t PATIENT'S NAME /t/ '~G� �.� C _ %J4M ❑ F COMPANY N AlI� ADDRf.SS _- -_I,-.--__-- AGE CITY._+ I t 5 ' _ STATE1. ZIP �y �75�� DOB 12--.23 7 ❑ Sn ❑ M ❑ T ❑ W ❑Th VF O 3 DRIVER'S LICENSE a __._____..... _-.__ P O&E__f_�.-� NATURE OF DISPATCH Az TYPE OF TRANSPORT: AMBULANCE OTHER INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C CK) �_.,..,.-_.1 I r\� TO SCENE- ❑ S.O._ CALL RECEIVED - C H � j/)�� _� ❑ P.U. TIME 10-8 PATIENT DESTINATION: �q7 FROM SCENE- ❑ FIRE TIME 1D-97 n! �/ C 3� ❑ P TIME 10-49 1 ' l LLY �!!_• 1� MILEAGE: TIME 10-7 END TIME 10-98 r _ PMD START_ TIME 10-22 DOCTOR _ SJ d HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY XTRANSFER �h WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER / CALL BACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: L�L RESPONSE ZONE -- IRLyES ❑ NO ❑ WAL°,ED XGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER�`T .. TECHNICIAN w` O 4 '�'J 5 PARAMEDIC Hx: DISPATCHER: trn.pm�' CHIEF COMPLAINT: __ ___- DRY RUN: ❑ YES )&NO REASON FOR DRY RUN 1 1�'lQ _L,Cj_�_�_.- --_ S�1�A•ei� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I� PATIENT REFUSED SERVICES: (SIGNATURE) X__ �'•� f MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO.OF PATIENTS: T\ .SS.S. S 7� -W - 3 s PRIVATE INS. CO.: BASE RATE: A 1 KAISER R: MULTIPLE PTS.BASE RATE C ~~LUE CROSS �L 8 3 TOTAL MILES: 15 X 6.soO �- 98sK9 ► _.� / 7--E E.O.B. ATT: ROUND TRIP: ❑ YES ❑ NO t '46S ❑ YES ❑ NO NIGHT: (19:00-07:00) bCHP/ HP N: .�5 �a___ EMERGENCY-RUN: 1 �/ -- MEDT-CA4 N:_ �� ',.... �� ��,, COD 2%3 R OTHE --- �=z z!T� L I� sA•�t _ OXYGEN: (PER TANK) 1' P.O.E. STICKER ❑ YES 24-NO NEONATAL: (INCUBATOR) 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:- lA__v�tS8_Alc&zE RELATIONSHIP: 51 s E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY p( -__ ._ .. .._ STATE ZIP:--- C-COLLAR: (IF NOT REPLACED) PHONE: A -- -? S WORK PHONE. ___ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:LH E)4LST OTHER: ADDRESS: CITY: STATE: ZIP: - COMMENTS: PATIENT RECEIVED BY: Pr,ijidr+ rri.,. . :I,r .q r� M- TUBE) • ;+ !V: when 6iT'ing 016-1 yN CONTRA COSTA COUNTY �') t AMBULANCE PRE-HOSPITAL CARE FORM 1 }, UNIT AUTHORIZATIONS OPj t. �. f .+ P CHECK OR FILL IIV APPROPRIATE SPACESDATE: ©o ss f�oklor-{- 1 PATIENTS NAME�`�w� r� ® M ❑ F COMPANY L -;ADDRE//SS „,3��/'//� ST– AGE_1_ f CITY /Sr��L?o�� STATES ZIP DOB' 75/ 0 sn 0 M O.T,[]W,.13 Th.41 F Crl"711 DRIVER'S LICENSE p —_ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 --- _I STATION 1(AX2(B)_3(C)_4(D)_51E)�+.•.r•� ..ING_IDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLO K) TO SCENE- o -`- '�•- �•• t1V S.O. CALL RECEIVED l t� Sys/ ❑ P.D. TIME 10.8 t V3 PATIENT DESTINATION: FROM SCENE-2 0 FIRE TIME 10.97 J 0 PSAP TIME 10-491 A•.T ,,�, jl1'/0-�-” MILEAGE: 136TNER/PVT TIME 10.7 _•.J ENO TIME 10 98. rE_1e... DOCTOR if k,4-4 PMD/&) START TIME 1042 AE; HOW CHOSEN: TOTAL STANDBY JIME,• •' 0 NEAREST 0 FAMILY 0 TRANSFERWAIT TIME 0 PATIENT 17 DIRECT �O-OTHEROOKyr/ ,-�Mq� CALLBACK N: AMBULANCE COMPANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: »t RESPONSE ZON YES 0 NO 0 WALKED 0 GUERNEYU-OTHER <�ff�j-eJ 1 r PATIENT CONDITION: DRIVER 2AMEDIC TECH NICIAN a� Hz: _ A DISPATCHER: �l(7 t ,/ 'Q 1A r ^•• 1 n CHIEF COMPLAINT: ' C- DRY RUN: 0 YES ,b NO REASON FOR DRY RUN O e- i,�T AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X / MEDICAL COVERAGE: INDUSTRIAL ❑ YES 0 NO NO.OF PATIENTS: S.S. # C-. . . PRIVATE INS.CO.: BASE RATE: "- KAISER p: MULTIPLE PTS.BASE RATE BLUE CROSS S: TOTAL MILES: ��•t X� �_«•�y �� ` MEDICARE N: E.O.B. ATT. ROUND TRIP: OYES ❑ NO BROWN ROBE ❑ YES •0 NO NIGHT: (19:00_,07:00) CCHPPPHPM:_ 07380150483811 EMERGEN RUN: /� d // ' ..:. I D01.1aXA_h_=7 X I MEDICALB:rii 0883M79MN _ CO E2/9 R: ► -OXYGEN:-{FIER TANK) i H31 j W 37J T'?``" - P.O.E. STICKER 0 YES 0 NO NEONATAL: (INCUBATOR) --�..,.�.... DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.)' X� _,��•!'S" `. DRUGS: (PER ADMIN.) X A/'i Ll�- RELATIONSHIP•6� . E.O.A:(IF NOT REPLACEDr rf► 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: / _ •_ ` �' A PATIENT RECEIVED BY. Provider retain Aite xd Pink copy, . Return Yellow mpg t-, WS w etz (SIGNATURE) - . as tI /I I CONTRA COSTA COUNTY AMBULANCE , Jl PRE-HOSPITAL CARE FORM I , UNIT �/,� AUTHORIZATION K v CHECK OR FILL IN APPROPRIATE SPACES ( ►�(. DATE: PATIENT'S NAME I ❑ F COMPANY 0 /�' " 'ADOR S 131; W AGE 'V 1, I CITY 7 IL STATE % ZI DOB �—1) ❑ Sn. ❑ M ❑ T ❑ W ❑ F D S DRIVER'S LICENSE tt __^ _. PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE D OTHER❑ __ — STATION I 2(8)_3(C) 4(D)_5(E_- r INCIDENT LOCATION: ) RESPONSE CODE: QUESTED BY: TIME— (24 HOUR CLRCK) TO SCENE -� 0. CALL RECEIVED❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE -� ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �.•�Ii_' } �sl� MILEAGE: �� 13OTHER/PVT TIME 10-7 _ 1 ENO TIME 10.98 7 DOCTOR U i 1 PM ER START TIME 10-22 HWOSEN: TOTAL STANDBY TIME -+� NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: INJ rJ C' C_ J _ AMBULATORY? IENT TAKEN O AMBULANCE: I U RESPONSE ZONE ES 11NO ZAL': / , , CONTRA COSTA COUNTY 1 AMBULANCE PRE-HOSPITAL CARE FORM I I UNIT i AUTHORIZATION a .� (` '✓, CHECK OR FILL INAPPROPRIATE SPACES DATE: -. PATIENT'S NAM ( 5is-- LAVI_ _ M ❑ F COMPANY ADD SS D AGE// ^� CITY STATE ZIP 5A rJ _ DOB tS�. O Sn ❑ M ❑ T ❑ W ❑ T� ❑ S DRIVER'S LICENSE a 8 [- ~� ____ PHONE 4- 51 NATURE OF DISPATCH._L� 9 C'CT- 3��PE OF ANS FIT �M�BULANC OTHER❑ _ -_-___—____----__._ -_-_ DENT LFOCATIOINi�SA ku � RESPONSE CODE: R UESTED BY: TIME — (24 HOUR CLOCK) f: L,f �� .I .�' w ' TO SCENE S.O. CALL RECEIVED "� M ❑ P.b. — TIME 10-8 PATIENT DESTINATION: FROM SCENE - ^� ❑ FIRE —_._--_ TIME 10-97 _ ___ L 11PSAP TIME 10-49 2 C �) CCC MILEAGE:� � ❑ OTHER/PVT TIME 10-7 END TIME 10-98 T� DOCTOR A)AAAIeLPM ER START — TIME 10-22 HOW CHOSEN: TOTAL — — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ 7ANSFER I WAIT TIME _— ❑ PATIENT ❑ DIRECT OTHER t f CALL BACK #: AMBU�Ap1C MPANY: l� PT. MBULATORY? PATIENT TAKE O AMBULANCE: j C� RESPONSE ZONE YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ � 50 '.Z_L�± _ EMT-1A � 1 TECHNICIAN _ L �k r'.'x PARAMEDIC j Il Hx: h1 ��SL __ DISPATCHER: ;1'I I , ( C' i(f CHIEF COMPLAINT: —btu DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES PXNO NO. OF PATIENTS: r' S.S. # PRIVATE INS. CO.: BASE RATE: ) KAISER#: _ MULTIPLE PTS. BASE RATE / ) BLUE CROSS M:,5#:,5 -3,Z C-3 L ' q `? TOTAL MILES: ___lam X J MEDICARE#: 14 J L�O!f iL'O.Q. ]�S d0.8. ATT. ROUND TRIP: ❑ YES ❑ NO �h r�L( 4 f2 00 eA/ �-: ❑ YES ❑ NO NIGHT: (19:00-07:00) CeHP71PPFTP#tl L(S f 471.e/Vo" EMERGENCY RUN: ZE4 Yt h 6,-k- CODE 2/3 -N THER:C l M 7�FD 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:fG�S P�f,G`CISH V RELATIONSHIP:/ A ' E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY; STATE__ZIP:._.-- C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:_,� �Q DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: _ OTHER: ADDRESS: _ CITY: STATE: ZIP: . COMMENTS'' --- V I T A L c. —__.- ck, . _ .... ..____ _ PAI RECEIVFn BY X '• ''l` C,"` ',t�I i r.. .;L.., r.•r.r.'� ��.: . t$I(iNAllfiif 1 CONTRA COSTA COUNTY AMBULANCE t, PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION a '- !A^1(• CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME OM ❑ F COMPANY a 4 / ADDRESS AGE I CITY STATE ZIP DOB O Sn OM OT OW O ThF OS DRIVER'S LICENSE M _T PHONE NATURE OF DISPATCH �,Cjl AS�' TYPE OF TRANSPORT: AMBULANCE O OTHER O INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) / TO SCENE n S.O. CALL RECEIVED � .O (J � ❑ P.U. 10 8 � TIME :_Q_z PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 0 (1C. C ! �. n -�—'� O PSAP TIME 10-49 (�y� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 :1 L DOCTOR I PMD/ER START10 2 HOW CHOSEN: TOTAL DBY TIME 11 NEAREST O FAMILY ❑ TRANSFER WAIT TIME -- TJ PATIENT O DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: -� RESPONSE ZONE O YES ❑ NO ❑ WALKED O GUERNEY ❑ OTHER PATIENT CONDITION:. DRIVER ✓_l__ _ �' j EIdT-1A TECHNICIAN ��' C) PARAMEDIC L -- Hx: DISPATCHER: '�O Q CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN q� AUTHOR12ATION FOR DRY RUN(EMS USE ONLY) y yq� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: ✓ S.S.a /\ PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X MEDICARE r1: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHPIPPHP#: EMERGENCY RUN: MEOI-CAL k: CODE 2/3 C✓� 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: COM�ME TS: try A ILS' F_ _LF11y.&) ,(;cL J Z_ J7 ('1--2) — ag,4,-Jr, CAL{ ---+ " �✓�. fir/ TOTAL---- `-- - - PATIENT RECEIVED BY: X_ A. •ri.�rr rr... �Fi r. (SIGN.•TURE) [MS-) y 1 ) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ),{ 1 AUTHORIZATION N y t5C CNLCK OR PILL!M APPROPRIATE SPA CfS DATE: PAT.)ENrS NAME OM OF COMPANY N ADDRESS ' AGE- CITY GE CITY STATE_ ZIP T— DOB ❑ Sn O M O T O W 13 Th O F W5 j DRIVER'S LICENSE k PHONE NATURE OF DISPATCH t TYPE OF TRANSPORT: AMBULANCE OTHER _ - STATION 11A) (8)_3(C)_4(13)_5(E)_ INCIDENT LOCATION:! j RESPONSE CODE: RE STED BY: TIME-- (24 HOUR C+QCKy1 t P TO SCENE-� O S.O..D.— CALL TIME 0 8 EWEO GG a`- ) 11 PATIENT DESTINATION: F SCENE- ❑ FIRE TIME 10-97 ) ❑ PSAP TIME 10-49 i! MILEAGE: ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 'DOCTOR 1 I PMD/ER START TIME 10-22 �- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEARESTAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT oniRECT ❑ OTHER CALL BACK M: AMBUJ Ay,CE COMPANY: PT. AM NO PATIENT TAKEN T�g UULANCE: RESPONSE ZONE 4 O YE NO 13 WALKED ❑ G Y 13 OTHER I PATIENT CONDITION: DRIVE 3� =�'U EMT-lA_ :,Y11 TECHNICIAN PARAMEDIC Hx: DISPATCHER le : i +' i ' r qqy CHIEF COMP PINT: DRY RUN: ES ❑ O REASON FOR DRY RUN 77'j 11 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) n�/ PATIENT REFUSED SERVICES: (SIGNATURE) X / � MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M 1 PRIVATE INS.CO.: BASE RATE: KAISER c MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O YES ONO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C. EMERGENCY RUN: MEDI-CAL N: CODE 2/3 C OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ONO 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: 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:SO U0545' • PATIENT RECEIVED BY:X 11•ri.l.r r-r.,. t+; .. •I r:.: ..... +. ,.... .. .• i . . (SIGNATURE) f�c-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM IUNIT L AUTHORIZATION w - ,7 'I,,� CNECK OR/ILL/N APPROPRIATE SPACES DATE: f PATIENTS NAME O M O F COMPANY M ^ i ADDRESS-. AGE— CITY GE CITY STATE ZIP�_ DOB ❑ Sn ❑ M ❑ T O W 13 Th O F M/S i DRIVER'S LICItNSE 0 _ PHONE NATURE OF DISPATCH - TYPEOFTRANSPORT:, AMBULANCE W705THER 0 _ — STATION I(A)_2(B)-3(C)_4(D)_5(E)_ I INCIDENT LOCATION: I E +C RESPONSE CODE: D BY: TIME—(24 HOUR K) TO SCENE- � � Z.O.AIS SCALL RECEIVED ❑ P.D. TIME 10-8 ^„� PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 C12) - � n (� t ^ \ ❑ OTHER/PVT TIME 10-49 � (L `{lL +y MILEAGE: ❑ OTHER/PVT TIME 10-7 ' 1 END TIME 10-98 DOCTOR 1' _ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 2t, O NEAREST _, O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULAN MPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER /�'� ("�t� EMT-1A 1�, _ TECHNICIAN P RAMEDI Hx: DISPATCHER: n T' ( /o CHIEF COMPLAINT: DRY RUN: YES ❑ REASON FOR DRY RUN Vo 67 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) y)(C .' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE M: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL C CODE 2/3 cl OTHER: • ' OXYGEN: (PER TANK) P.O.E. STICKER OYES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (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: �0 ^L /I/?& /V�L /Nkj FO I i TOTAL: _o PATIENT RECEIVED BY: X f Prr+vidir retain whit, .mrd fink &,7p,, Return rs-i,�� •q,u t- "f! v6vll I it iry7 (SIGNATURE) tits-1 1 i 1' CONTRA COSTA COUNTY AMBUL CE PRE-HOSPITAL CARE FORM 1 UNITC AUTHORIZATION M I'LL 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: 'PATIENTS NAME1 " ❑ M ❑ F COMPANY N �� 1 ADDRESS A AGE ' k' ) CITY S TE ZI ` DOB— _. ❑ Sn ❑ M ❑ T ❑ W O Th DRIVER'S LICENSE M __ —_-- _ PHONE—__-.______.—__ NATURE OF DISPATCH —1T TYPEOF TRANSPORT: AMBULANCE D OTHER❑ TATION 1 ^2(8)_3(C)_4(D)_5(E)_ �.� INNCC..I.�DENT L CA I RESPONSE CODE: YQUESTED BY: TIME — (24 HOUR gl,OCK) TO SCENE S.0. CALL RECEIVED :_/L �� VJ ❑ P.D. — TIME 10-8 %O e PATIENT DESTINATION: FROM SCENE- ❑ FIRE -- TIME 10-97 (I f `' / ❑ PSAP TIME 10-49 '• MILE ❑ OTHEFLPVT TIME 10-7 ` 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 0: AMBULANCE C Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ! RESPONSE ZONE:� l ❑ YES 11NO 1) WAL'CED ❑ GUERNEY ❑ OTHER ( /�T_ i PATIENT CONDITION: DRIVER_ EMT-1A I TECHNICIAL �SIZY� ` PARAMEDIC Hz: DISPATCHER: 111111�yI\(I CHIEF COMPLAINT: DRY RUN ES ❑ NO REASON FOR DRY RUN Al AUT ORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED S VICES: (SIGNATURE) X_ — MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: z BASE RATE: KAISER R: MULTIPLE PTS.BASIf RAS BLUE CROSS M: TOTAL MILES: X I MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO s ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: ' i MEDT-CAL a: CODE 2/3 1 --� OTHER: OXYGEN: (PER TANK) P.O.E. ST KER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES LLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST LATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLA ) ADDRESS: ORAL AIRWAY: (IF T REPLACED) CITY: STATE—,ZIP: C-COLLAR: (IF N REPLACED) PHONE: WO PHONE: DRY RUN: (AUT ORIZED) 1 EMPLOYER: O CUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: --------- TOTALT004 6 A f�j -.--. -�_-- —.--_----.- -. PATIENT RECEIVE[) BY: X Pnwidnr roto. N,iI, ,.,.1 !•i. •I•� 1. „ , (SIGNATURE) fM. i 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION It CHECK OR FILL' IN APPROPRIATE SPACES DATE: PATIENTS NAME ❑ M O F COMPANY N ,/� Z 1 ADDRESS AGE I CITY STATE ZIP DOB___ ❑ Sn OM ❑ T OW O Th OF OS } DRIVER'S LICENSE N _ _— _ PHONE NATURE OF DISPATCH TYPEOFTRANSPORT: AMBULANCE D OTHER O __"__ -__ 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 ) (• r �� ' % / i�r �: f F%61/? _ ❑ P.U. TIME 10-8 / r _ - PATIENT DESTINATION: FROM SCENE - ❑ FIRE — TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: :, (' RESPONSE ZONE ❑ YES ❑ NO ❑.WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER J -' ? %` % - EMT-1A TECHNICIAN ! PARAMEDIC / Hx: DISPATCHER: - ^ 1 ' CHIEF COMPLAINT: DRY RUN: O YES ❑ NO REASON FOR DRY RUN r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X �) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: i S.S. N PRIVATE INS. CO.: 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 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) 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) A72 1 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ TOTAL7400548 PATIENT RECEIVED BY. X (SIGNAII)RE) I • CONTRA COSTA COUNTY AMBULANCE � -�,� 1Q h PRE-HOSPITAL CARE FORM I UNIT � AUTHORI TION M 8.3 1 U CHECK OR FILL IN APPROPRIATE SPACES DATE: z� 1 PATIENTS NAME l\J^ •FrJ �n �l SS ❑ F COMPANY N ^ ` ADDRESSp �4 l N �_I j� IAC �r� Am AGE CIT.Y� f STATE ZIP DOB j^ ❑ Sn ❑ M ❑ T ❑W O Th. ❑.F S� i DRIVER'c.I.ICENSE a _ PHONE 23- L671__ NATURE OF DISPATCH— TYPE OF TRANSPORT: AMBULANC OTHER❑ -- STATION 1(A) (el C)_4(D)_5(E)_ INCIDENT LOCATION: > > RESPONSE CODE: FIUESTED BY: TIME— (14 HOUR C K) TO SCENE S.O. CALL REEIVED D. TIME 10-8 . PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 ) MILEAGE ❑ OTHER/PVT TIME 10-7 Yom" ENDTIME 10-98 DOCTOR ( PMD/,C9START 05-7— 1L �5 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 1 TIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBI,I�AN�£COMPANY:11 55 Is r , &PT. MBULATORY? TIENT TAKEN TO AMBULANCE: ��� RESPONSE ZONE- S ❑ NO Al!"ED ❑ GUERNEY ❑ OTHER j �a PATIENT CONDITION: DRIVER '7'-22 EMT-IA +j TECHNICIAN PARAMEDIC - ' t Hx: DISPATCHER: m T• (1 CHIEF COMPLAINT: SLS aC -bn DRY RUN: ❑ YES N REASON FOR DRY RUN '1 / L l AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL 11Y O NO. OF PATIENTS: �O S.S.# I:l,.i 1 :.t y �I' r PRIVATE INS. CO.: BASE RATE: �S I KAISER K: MULTIPLE PTS. BASE RATE "' 1 ` f BLUE CROSS,,N. TOTAL MILES: l� X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) r�[g CCHP/PPRP 0: i EMERGENCY RUN: G �I MEDI-CAL R: 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 - -r� DRUGS: (PER ADMIN.) X NAME: yV�IJ `�l��J U RELATIONSHIP �r O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 1 I ► STATE— ZIP: C-COLLAR: (IF NOT REPLACED) ' PHONE: WORK PHONE: DRY RUN: '(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: -- ADDRESS: I CITY: STATE: ZIP: - COMMENTS: flCl54 TOTAL: J ox,-G 1 -- C PATIENT RECEIVED BY:X (SIGNATURE) r'rovidrr tvfof. Vltitr .•� r:.:. •, Sr :.r+: r • . r`." •..hrn lil•�t OIS-1 •J CONTRA COSTA COUNTY AMBULANCE �/ I PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 7 • CHECK OR BILI IN APPROPRIATE SPACES DATE: / 'PATIENTS NAME A ❑ M ❑ F COMPANY N ,. ADDRESS_ W Y;tl i CITY STATE ZIP DOB - ❑ Sn ❑ M ❑ T `❑w ❑ Th ❑ F �3 DRIVER'S LICENSE NI PHONE NATURE OF DISPATCHy TYPE-OF TRANSPORT: AMBULANCE 0 OTHER❑ _ — STATION 1(A)._2(B)_3(C)_4(D)._5(E)_ / INCIDENT LOCATION:! y RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) # TO SCENE- O. CALL RECEIVED . i J ��(3C� (� ��19� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM fFnlF- ❑ FIRE TIME 10.97 r r ,� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 \ END — DOCTOR' 1 PMD/ER START ?nFAE 10-22 _Z .Z HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ""J ) RESPONSE ZONE ,. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER C_ W L �. ` �. i PATIENT CONDITION: DRIVER � EMT-IA TECHNICIAN nC7 PARAMEDIC �- Hx: DISPATCHER: j=f Li CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN 40 2 t,3t2 AUTHO ZATION FOR DRY RUN (EMS USE ONLY) ry�� PATIENT REFUSED SERVICES: (SIGNATURE) X `'� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: /i:'. (_ �I S.S.N PRIVATE INS.CO.: BASE RATE: KAISER#. 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 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENT9�/4 AJCZ C-tl `pEq CF0 'ii�t7f T !tri CZ j� .. TOTAL: U©5 , PATIENT RECEIVED BY:X — R.,isClor r+t.ric Nits ,•.l 1•i•a .,.t.� 4,t.,,.. ,. ,. , (SIGNATURE) Thy-I �r CONTRA COTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT 1 9 AUTHORIZATION# / t �9 S CHECK OR FILL IN APPROPMAM SPACES DATE: - t l I PATIENTS NAME— _ OM ❑ F COMPANY# ADDRESS AGE CITY STATE ZIP DOB ❑ Sn OM OT OW O Th OF O S i ! DRIVER'S LICENSE# PHONE NATURE OF DISPATCH >7 TYPE,OF TRANSPORT: AMBULANCE 0 OTHER _ -- STATION i(A)_2(B),_3(C)e4(D)._6lE) INCIDENT LOCATION: CALL rzJ � ' RESPONSE CODE: RgE50 STED BY:' TIME—(24 HOUR C ?CK) 1 r' TO SCENE- ❑ P.D. TIME 0-8 RECEIVED r o PATIENT DESTINATION: FROM SCENE- ❑ FIRE _ TIME 10-97 ❑ PSAP TIME 10-49 j MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 >`DOCTOR PMD/ER START TIME 1D-22 HOW CHOSEN: TOTAL STANDBY TIME j' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �c' RESPONSE ZONE_-. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ! PATIENT CONDITION: DRIVER \ •E -1A TECHNICIAN 4, IV PARAMEDIC Hx: DISPATCHER: Of 0 / CHIEF COMPLAINT: DRY RUN: FS ❑ NO REASON FOR DRY RUN P V T PrU�I) (U J AUTHOR TION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1 95�_ MEDICAL COVERAGE: - INDUSTRIAL ❑ YES NO NO. OF PATIENTS: ( f S.S.# ( � PRIVATE INS.CO.: BASE RATE: } KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X f MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: 1 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) s EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 7, Q-Zv, TOTAL: =Z> 0 n 5 D ""- PATIENT RECEIVED BY:X (SIGNArURE) c ' Pmvidir ►Mair. Vhi t• rd Pi of onvk 4otw+ Y••' i.• ,".y,..: 1 r 7 !M5-I . I ice . CONTRA COSTA COUNTY AMBULANCE �J O PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 7 Q -• ` CHECK ON FILL IN APPAOPFIA 7E SPACES DATE: C �/r1l / r �T- PATIENT'S NAME r/l� " L� [ 1-15;x(l�( �f E}-M O F COMPANY N (�2Z( 2 t I ADDRESS 7 /�)((. IIC:� � f AGE CITY SA STATE ZIP�7 U DOB Z E '3 ❑ Sn ❑ M O T ❑ IN ❑ Th O F E3 S DRIVER'S LICENSE q __ _ PHONE Z�3`�O 3 G NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 7OTHER❑ __ — STATION 1(A)_2(B)_3(C)_4(D)_6(E)_. INCIDENT LOCATION: r ,r,, RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR%0 K I t ' ` C P TO SCENE- 2 O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 I ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10.7 —! END TIME 10.98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER WAIT TIME :_�__,•- ' ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY--,,r i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER ) PATIENT CONDITION: DRIVER TECHNIC IA � j d �� -� � /� [)IC L Hx: DISPATCHER: �/(I CHIEF COMPLAINT: DRY RUN4 YES ❑ NO REASON FOR DRY RUN j A�JTHORI7ATION OR DRY (EMS U ONLY) ' PATIENT REFUSED SERVICES: (SIGNATURE) X � ICAL COVERAGE: INDUSTRIAL ❑ YES/-NO NO. OF PATIENTS: 4 �ZVKTE . # � �' - y7 - �G �{"� INS. CO.: BASE RATE: _ V KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS N' TOTAL MILES: X (Y MEDICARE a: 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) _ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) .�y--G�•� ��y�. 0 �CZ:✓;1.n•F1��nY�. •'I- '�a SL'R�I I'�l� k ADDRESS. ORAL AIRWAY. (IF NOT REPLACED) CITY: __ STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) (�1 EMPLOYER: OCCUPATION: OTHER: - — -- ADDRESS: CITY: STATE: ^ 'ZIP: COMMENTS: IAJ - TOTAL: 2-- PATIENT RECEIVED BY:X 1 IGNATURE) F`ic:. rop} Fttar: )'e'::L• m;, t• m' ,he" !d1"inp CHS-1 CONTRA COSTA COUNTY AMBUA�NCE M � Q� � f r !1� PRE-HOSPITAL CARE FORM I UNIT CI ( AUTHORIZATION xU3 ff CHECK OR FILL INAPPROPRIATE SPACES - DATE:_ lk3i � c PATIENT'S NAME y� ❑ M ❑ F COMPANY N l/n�n/1`, 1) -7705 ADDRESS AGE , 7 CITY STATE ZIP DOB, '❑ Sn ❑ M ❑ T O W ❑ Th ❑ F S DRIVER'S LICENSE# _ PHONE------- NATURE OF DISPATCH V TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION:' RESPONSE CODE: R UESTED BY: TIME - (24 HOUR CLOCK)' TO SCENE S.O. , ' CALL RECEIVED � : A ❑ P.D. TIME 10-8 PATIENT DESTINATION: �- FROM SCENE- ❑ FIRE — TIME 10-97 �� : -S•� ❑ PSAP TIME 10-49 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 ❑ OTHER CALL BACK#: AMBULANC COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ` PATIENT CONDITION: DRIVER !/✓1�.��d U EMT-tA - t TECHNICIAN �.V PARAMEDIC _ Hx: _ DISPATCER: Yn- -j CHIEF COMPLAINT: DRY RUNYES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) yqq ' 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: O YES ❑ NO ❑ VES ❑ 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: i - - TOTAL:__ -�' PATIENT RECEIVED BY X —. Al CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N Y CHECK OR FILL IN APPROPRIATE SPACES DATE:_ PATIENTS NAME v O M O F COMPANY N ADDRESS AGE- CITY GECITY STATE ZIP DOB O Sn ❑ M OT Ow O Th O F O-S DRIVER'S LICENSE M PHONE NATURE OF DISPATCH 64 LC- TYPE OF TRANSPORT:, AMBULANCE OTHER O ___ - STATION 1(A)_2(B)_3(Ct ID)-5(E)- INCIDENT LOCATION:1 RESPONSE CODE: REQUESTED BY: TIME- (24 OUR(CLOCK) TO SCENE .D. TIME o-8 EIVED _ zo _ 111 lj (ti� I OF t VV\ 1 PATIENT DESTINATION: i FROM SCENE ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 ' MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 �- � DOCTOR I PMD/ER START TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME ❑ NEAREST, . ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK R: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �Gt7 RESPONSE ZONE �( COT O YES ❑ NO O WALKED O GUERNEY 13OTHER PATIENT CONDITION: DRIVER Acr ft, c) EMT-1A -,`I Y TECHNICIA t C� PARAMEDIC I Hx: DISPATCHER: I 8 CHIEF COMPLAINT: DRY RUN: " .YES ❑ NO REASON FOR DRY RUN ifo=z ws�vfl� (a l AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X I MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO.,OF PATIENTS: J 1 LI S.S. K PRIVATE INS. CO.: BASE RATE: KAISER 11: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE It: E.O.B. ATT. ROUND TRIP: O YES O NO O YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C'' EMERGENCY RUN: MEDI-CAL N: 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: I.V.: (PER ADMIN.) X cl 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'v EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP:- TS: TOTAL L PATIENT RECEIVED BY: X t.. ;!,•.. �. .�. i, . . (SIONA TURF) ... .. f' CONTRA COSTA COUNTY AMBULANCE 'I PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N � I Y LL CHECK OA,FILI INAPPROPRIATE SPACES GATE: Ir - f PATIENT'S NAME 1`- 1� �U� OM O F COMPANY M �L�,_r-7j /O i ADDRESS ` AGE /-� C) 1 CITY_ STATE ZIP DOB ❑ Sn ❑ M O T ❑ W ❑ Th O F 0rr S . - _ DRIVER'S LICENSE M PHONE NATURE OF DISPATCH 1P iSc�ceS 50\1° 1V1� TYPE OFTRANSPORT: AMBULANCE Q OTHER O _ — STATION 1(A)_..2(8)_3(C)_4(D).._5(E)._ INCIDENT LOCATION:. ( 1� RESPONSE CODE: REQUESTED BY: TIME-- (24 HOUR CLOCK) � TO SCENE-� KS.O. CALL RECEIVED I ❑ P.U. TIME 10-8 ,�- PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 O PSAP TIME 10-49 E: O OTHER/PVT TIME 10-7 1 ENO 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 M: AMBULANCE COMPANY: c. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZQNE ' ❑ YES 13 NO ❑ WALKED ❑ GUERNEY ❑ OTHER' I ' r' t � PATIENT CONDITION: DRIVER = J EMT-tA TECHNICIAN LD L PARAMEDIC Hx: y DISPATCHER: =-1 3 CHIEF COMPLAINT: DRY RUN:-$ YES NO REASON FOR DRY RUN Vy y AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O ❑ NO NO. OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER r<: MULTIPLE PTS. BASE RATE 1 BLUE CROSS k: TOTAL MILES: X MEDICARE 0: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ 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 ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) -EMPLOYER:EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: i Il Li 1 PATIENT RECEIVED BY:X (. Prnvl,d�r r.•,,:_ t ..i .. (SIGNATURE) .� , /. CON IIIA COSTA COUNTY AMBULANCE ,I PRE-HOSPITAL CARE FORM I UNIT AUT'ORIZATION CHECK ON FUL IN APPn OPRIA IF SPACES DATE:iF_ • . � p (( � 1 r 1•" ff 3(tPATIENT'S} NAME r,�r1C11� IC'.\--.--�._.— O-�IIJ qKf 1��1v1 ❑ F COMPANYN r' e� 1 [\ADDRESS)LL r ✓E('-��S\� C^_ CL_—/V AGE.�a— C� I�S 7O CITY"-. 1..� Com.__—_"_ STATE_6A ZIP Sn O M ❑ T ❑ W O Th O F �E3 S DRIVER'S LICENSE# .�-. .Z:_.� PHONE30 _ ATUR FIS ATCH(/�'� TYPE OF TRANSPORT: AMBULANCE 'k OTHER❑ INCIDENT LOCATION: `r , RESPONSE CODE: BY: TIME— (24 HOUR CLOCK))L TO SCENE- �EUESTED 0. CALL RECEIVED CPr =. _. D. TIME 10-8 _.. �{ PA ENT DES11TINATI/ON:�' / FROM SCENE.:., ❑ FIRE IME 10-9 / 419❑ PSAP TIME 10-49 f; _ MILEAGE: II'' SkSTHER/PVT TIME 10-7 END �L� TIME 10-98 Y DOCTOR �►J L PM /ER START TIME 14.22 _ HOW CHOSEN: TOTAL ^ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER i WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY) PATIENT TA�EN TO AMBULANCE: 00. RESPONSE ZONE_ ES ❑ NO ❑ WALKED MGUERNEY ❑ OTHER 1 PATIENT CONDITION. DRIVER_lA_Ak380 TECHNICIAN 6-15am ' 8•S PARAMEDIC _ DISPATCHER: ' !� C F�OMPLAINT: I&C.;-1L—[_�3��- DRY RUN: ❑ YO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X___.— —_ ' l� A MEDICAL COVERAGE: INDUSTRIAL ❑ YES M140 NO. OF PATIENTS: S S. # ��— lJ__2L1� PRIVATE INS. CO.: BASE RATE: . LLQ KAISER#: _— MULTIPLE PTS. BASE RATE BLUE CROSS# TOTAL MILES: �`3 X MEDICARE#: _E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) w CCHP/PPRP#: EMERGENCY RUN:Lo MEDI-CAL#: '` CODE 2/3 % ( OTHER. _Sa�G L� ' OXYGEN: (PER TANK) S CKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) \DATES B LLED: _ STANDBY: (OVER 15 MIN.) !` E.K.G.: (PER EPISODE) f. NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN-) X "- DRUGS: (PER ADMIN.) X ` l NAME JCCVAo.#L _` t�vlc�G__ RELATIONSHIP6tokVe O.A.:(IF NOT REPLACED) ADDRESS: —..___ ___-__."__—_- ORAL AIRWAY: (IF NOT REPLACED) CITY: --_ STATE__ZIP: C-COLLAR: (IF NOT REPLACED) lL..si PHONE: — WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: ---- -- _ /SctJ w CITY: _:._ STATE: ZIP: COMMENTS: 1l LL ��r P<<�_ TOTAL: PATIENT RECEIVED BY:X roti L Fr vid,•r rrraf.. ani• .rd "i.:7 .•.rp err:,!+ Ye':nt• •aPv r , FN." rhvn Filing (SI NATURE) Dts-1 CONTRA COSTA COUNTY AMBULANCE S� !y_ ` PRE-HOSPITAL CARE FORM I UNIT / / AUTHORIZATTION k 1p IM CHECK OR Flll INAPPROPRIATE SPACES DATE: .SPATIENT'S NAMELAL S< —___��______ �Q M ❑�F COMPANY M ' ADDRESS � /AGE�!�LZ_ CITY �o r G STATE (-A ZIP -r� D - OB J'/Zh 6� Sn ❑ M ❑ T OW O Th O CIS S DRIVER'S LICENSE v L173�—__ PHONE-3� _. ? NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER ._... :____ _ .._ __.._._ STATIONI(A)--2(B)-3(C)_4(D)_5(E).1c',- INCIDENT LOCATION: I ��� ` RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) r+ MT . -L�I A13LO Dt_✓C� TO SCENE-. S-O. __ CALL RECEIVED PJ_EAssw T— t�� S2t� EAbT of ❑ P.D.- TIME 1D-8 U L PATIENT DESTINATION: FROM SCENE - 3 ❑ FIRE ___.— TIME 10-97 ! v2- ❑ PSAP TIME 10-49 0 2 3 S � ;�_ _KwC E r2_ _ MILEAGE: ❑ OTHER/PVT TIME 10-7 02- 140 END )t0.3 TIME 10-98 DOCTOR CKl PMDtV!) START 13• o TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME 9+ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: 5 PT, AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE.ZONE ❑ YES Pi NO ❑ WALKED ;(GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I G A•Tf\ EMT-1A ( f0rM TECHNICIAN F 57Gp PARAMEDIC , r. Hx: � y5 Tr�� E� DISPATCHER: ( I✓ t' CHIEF COMPLAINT: llzl,_-- ORY RUN: OYES fiDNO REASON FOR DRY RUN A /nae7-iP4c /11ani�Zf (?A&mA AUTHORIZATION FOR DRY RUN(EMS USE ONLY). PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL C3YES NO NO. OF PATIENTS: , k^ S.S. M I PRIVATE INS. CO,: BASE RATE: `� - �\ KAISER p: f MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X (EL'✓... �•� MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES K NO �� d ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP B: EMERGENCY RUN: MEDI-CAL u: CODE 2 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES NO NEONA-TAt--(1NCUSATOR) DATES BILLED: E.K,G-=tPE_R-MSADE)_ NEAREST RELATIVE/RESPONSIBLE PARTY: I:.A(,1 Fes-ADMIN.) -;i` DRUGS: (PER ADMIN.). NAME: CARL RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: I ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_—ZIP:_ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) I • _ 1 EMPLOYER: OCCUPATION: OTHER: ADDRESS: : �, CITY: STATE: ZIP: �G Jo.dro COMMENTS: D Iov V lL ', _ ---- ----- — . e 4t, qu TOTAL: PATIENT RECEIVED BY: X.__ N /Cr ( .'"�` f A 9 Provider mai.. Viii lc .j..1 i'ir:: !iuturn Y. '.,c � (SIGNATIIRF.) /" � "I'N .p�.: L' ulirnfil rn;1 EM1-1 CONTRA COSTA COUNTY AMBULANCE _ 11 PRE-HOSPITAL CARE FORM ! uNlr © AU . ORIZATION .�•.1 CHECK OR FILL IN APPROPRIATE SPACES DATE: ✓x PATIENTS NAME ❑ M ❑ F COMPANY#� I 1� I ADDRESS AGE ` I CITY STATE ZIP DOB _ XSn O M ❑ TT OW it �❑ Th /❑ F ❑ S DRIVER'S LICENSE M PHONE ___.—_— NATURE OF DISPATCHI 7' �C,1L. CV 1 lU TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CL CK C Y7 _' 1 �� � TO SCENE- ") ❑ P — TIME o-8 CALL RECEIVED 1 / PATIENT DESTINATION: FROM SCENE000 ❑ FIRE TIME 10-97 y� ( , ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10-7 END TIME 10-138 ;T • DOCTOR PMD/ER START TIME 10-2222 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— IV ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER— W �N Ef, lA I' TECHNICIAN PARAMEDIC Hx: - DISPATCHER: 933 CHIEF COMPLAINT: DRY RUN:,ql�ES ❑ REASON FOR DRY RUN - AUTHORIZATION FOR DRY RUN (EMS USE ONL L/l�C/� PATIENT REFUSED SERVICES: (SIGNATURE) x. 51P. MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. # PRIVATE INS.CO.: BASE RATE: I KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: ` CITY: STATE: ZIP:— COMMENTS: a- 00 X``�'1 TOTAL: ---- - PATIENT RECEIVED BY: X iT,niarr rrr Stir,. .,, n:,•o- •nrl: �.I:.• r. i o,• r�' (SIGNATURE) 1 i.•4:•: inI EMS-1 r CON 1 AA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION III - y �yg CHECK OR FILL IN APPROPRIATE SPACES DATE: &/z'&f PATIENT'S NAME LAG ` �l x f 1 �_U[t �� n � ❑ M ❑/F COMPANY M ADDRESS . 30& I A" //!tt !/1 •C i � � C`S AGE L/ 3 ' ) CITY__ �ILv� rj(T� STATE._ _— ZIP—1_IS ' DOB_Z Iff Sn ❑ M ❑ T ❑ W O Th 0 F O S DRIVER'S LICENSE# - ----_-.-- — PHONE 9t V=' NATURE OF DISPATCH Uh C.tTAGC i TYPE OF TRANSPORT: AMBULAN OTHER❑ INCIDENT LOCATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- .0. CALL RECEIVED /0 �- J ❑ P.D. TIME 10-8 O PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE;, � ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMER START TIME 10-22 HOW CHOSEN: TOTAL = STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER I l WAIT TIME �� ~❑ PATIENT ❑ DIRECT ❑ OTHER y_J CALL BACK#: AMBULANCE COMPANY: PT. AMBULA '50 ORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES�NO ❑ WALKED, GUERNEY ❑ OTHER j PATIENT CONDITION: DRIVER U EMT-1A c� TECHNICIAN S 690 PARAMEDIC HK: -Am �St1tM, DISPATCHER: 4. too ~- / r CHIEF COMPLAINT: _ DRY RUN: ❑ YEe❑ NO REASON FOR DRY RUN _ a�1'71UTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE- ((� INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. # ��2 _ PRIVATE INS. CO.: rncl of 1 i BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE j BLUE CROSS#: TOTAL MILES: y X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1' ❑ YES ❑ NO NIGHT: (19:00-07:00) O 1i U CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 1 OTHER: OXYGEN: (PER TANK) T" 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. �,r �1 DRY RUN: (AUTHORIZED) EMPLOYERS r 1n`L>SCCUPATION:_[�l,ITt OTHER: ADDRE_S_S: . �� ., :•..�� ::5�� .TeZ CITY: STATE.:—,{ ZIP: A COMMENTS: c.L h S� /H TOTAL: 0 PATIENT RECEIVED BY: Provider retain. White I.nd Pink Topp . Retur+ Ye'Inw mpy to DNS when bi21i (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT b� AUTHORIZATIONM c, << ` CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME -�+it L I Ic I h ❑ M F COMPANY K ADDRESS I� Ci S Lw r�( Lh W AGE _ CITY..(�1'rc L,*)G4— STATE CCA- ZIP DOB �s'SL �Sn OM OT ❑ W O Th ❑ F Os . DRIVER'S LICENSE N _ PHONE �15/,�— NATURE OF DISPATCH S TYPE OFTRANSPORT: AMBULANCE 0 OTHER O _ -_ STATION 1(A),2_42(B)_3(C)_41D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL qCK) L� TO SCENE- 3 XS.O. CALL RECEIVED t•J'rJq �c�c Ilea& �erC__UIf 5 • . O P.D. TIME 108 ! PATIENT DESTINATION: FROM SCENE- 'L ❑ FIRE TIME 10-97 -LL -/ O PSAP TIME 10-49 7 �cS ifi)/ MILEAGE: ❑ OTHER/PVT TIME 10-7 END 0 TIME 10-98 /« :4 3 DOCTOR PMD/0) START C�3 TIME 10.22 HOW CHOSEN: TOTAL ' 4 STANDBY TIME ❑ NEAREST Q FAMILY ❑ TRANSFER WAIT TIME -- PATIENT O DIRECT ❑ OTHER S CALL BACK 0: AMBULANCE OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ('r RESPONSE ZONE ❑ YES M NO O WALKED �'GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER Li — EMT-1A TECHNICIAN `��� PARAMEDIC�— j Hx: D-ta DISPATCHER: ^ " CHIEF COM LAIN - �DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r n PATIENT REFUSED SERVICES:(SIGNATURE) X ;i�AEDICAL COVERAGE' ,7 INQUSTRIAL ❑ YES OLNO NO. OF PATIENTS: S.S. x J - ,'-7 PRIVATE INS.CO.: _ eA D BASE RATE: KA46ER N: T'-/ MULTIPLE PTS. BASE RATE BL-VeCR9S344 :2L"':71 TOTAL MILES: X ME0 CARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP 0: J EMERGENCY RUN: MEDI-CAL u: 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 RR Oji DRUGS: (PER ADMIN.) X NAME:UiEn NR t L E N RELATIONSHIP. E.O.A.: (IF NOT REPLACED) AODRESt S9°I S�-`�I� IC/[.moi ORAL AIRWAY: (IF NOT REPLACED) CITY. /1 17 c- STATE-1 ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: - ORK PHONE:rL:�� S�[9a DRY RUN: (AUTHORIZED) EMPLOYER: p }gW•� T. OCCUPATION:BnA"Ne C OTHER: ADDRESS:,' CITY: C STATE:ZIP: COMMENTS: TOTAL: NAI IENT RECEIVED BY X ___- ._ ._._ ---• � � o") CON IFIA COSTA COUNTY AMBULANCE c PRE-HOSPfTAL CARE FORM UNIT AUTHORIZATION N� CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME V.vW�l (�1 _ �CI — ❑ Mf COMPANY p - - /� ! r (� ADDRESS ?_ Y' f - (� '( - `�1_.Or. ._- AGE. - S-.7 CITYDH �f+lSTATE __-_ ZIP _ ..______//DOB�771�__ �S', ❑ M ❑ T 13W ❑ Th ❑ F ❑S DA-IVER'S LICENSE n ...._. . _._ . _ ..__.__ . .. _..__. PHONE��( LC r- IJ..._ NATURE OF DISPATCH�� - 1 - TYPE OF TRANSPORT: AMBULANC THER❑ INCIDENT LOCATION: RESPONSE CO REQUESTED BY: TIME- (24 HOUR CLO K) TO SCENE - _. CALL RECEIVED � :a� - -- -- ''- --- ----------= ❑ P.U. TIME 10-8 PATIENT DESTINATION: ' FROM SCENE - ❑ FIRE --_ TIME 10-97 y .- �• _ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 /d -----------^ - -- END.- _' - TIME 10-98 ; _ - �_ - TIME 10 22 DOCTOR - PMD/ER START �.___ HOW CHOSEN: ^,�N£� TOTAL --[I STANDBY TIME ❑ NEAREST LAMlLY ElTRANSFER WAIT TIME -- ❑ PATIENT Cl DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY/1 f r-- PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: ` RESPONSE ZONE�- ❑ YES KNO ❑ WAL':ED UERNEY ❑ OTHER PATIENT CONDITION. DRIVER TECHNICIA �/. � G�LLOC d PARAMEDIC Hr.: . ------- ----- - DISPATCHER: _ .�_1�-- f f,r, ( ( 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. �! PRIVATE INS. CO. �:� .�� BASE RATE: �` "' }FA46ER a: �. '�'-� ��_dz c MULTIPLE PTS. BASE RATE ` BLUE CROSS#:J 'Z' 1`7 0 TOTAL MILES: �`� X ev MEDICARE g; - -' - - lrO.B. ATT. ROUND TRIP: 11 YES ❑ NO - ��! r . ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP:PPHP k: EMERGENCY RUN: ���'aj d G MEDT-CAL :_ -- _- ___-_ CODE 2/3 CdI r OTHER _�1 Lit \���rrC __'�A�9 � DZ OXYGEN: (PER TANK) o7 C> P.O.E. STICKER ❑ YES ❑ NO u �� L, NEONATAL- (INCUBATOR) DATES BILLED: - STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 4// NEAREST RELATIVE/RESPONSIBLE PARTY: i IV.: (PER ADMIN.) X DRUGS (PER(PER ADMIN.) X ,� NAME�_ ___�_l1 �` - RELATIONSHIP/�-' E.O.A.: (IF NOT REPLACED) ADDRESS:---_ ORAL AIRWAY: (IF NOT REPLACED) STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: __ -.._ -_-_____ WORK IPHONE ._ DRY RUN: .(AUTHORIZED) EMPLOYER. rD6CAjOAT,ON-7,xlyr - OTHE 61 -',1r)_' L/ ! r,TiGJF.%moi ADDRESS._ STATE:L,_f ZIP: �/ /r7/' ✓�0 1 COMMENTS:_.- _- — --- ---- ---- TOTAL. --.__ - PATIENT RECEIVED BY:X SL 1'r-vi.�rr r•r,�„ +1;i'. r.•; r' .;- F�t:.r: Yr' (SIGNATURE) ^p Iry - nu ! 6T1^ r.+hrn 6:T'ins DIS-1 CONTRA COSTA COUNTY AMBULANCE �� L[ -7-70 � ,^ PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 j , CHECK OR FILL IN APPROPRIATE SPACES DATE:. PATIENTS NAMEA L'I'(77S O OM ❑ F COMPANY M-� --� ADDRESS � �V � fel/ AGE 33 U -94 O I CITY \ /`�L"7'j CATE� ZIP Q DOBE � �� � Sn ❑ M ❑ T ❑ W O Tn O I�oO"s 233 I 1 / DRIVER'S LICENSE a __ PHONE -72— NATURE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE CI OTHER❑ — STATION 1(A)�L2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: I ' RESPONSE CODE: REQUESTED BY: TIME— (24 HOURCIL K) TO SCENE S.O. CALL RECEIVED i.,c_ T ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE FIRE TIME 10-97 - 111Z {� ❑ PSAP TIME 10-49 �.r17 _ f MILEAGE: I ❑ OTHER/PVT TIME 10-7 r� �• l �� END TIME 10 98 DOCTOR �\COW I C / PMO E( R 1 START I TIME 10-22 - HOW CHOSEN: `/ TOTAL STANDBY TIME --' ... ❑ NEARESTAMILY 11 TRANSFER WAIT TIME _ ❑ PATIENT,-' ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE PT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL!"E?,,—PEERNEY ❑ OTHER PATIENT CONDITION: DRIVER �w ' ' 'W � '1 EMT-1A TECHNICIAN rf"� Y-r1 RAMEDIC Hx: � � ^ DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES,,E]'NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X / MEDICAL COVERAA_G " INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. a15 15--- :2 9 PRIVATE INS. CO.: BASE RATE: f KAISER R: MULTIPLE PTS.BASE RATE BLUE CROL S a: TOTAL MILES: �' X -�"J /,5:-. '•7 MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: T �• MEDI-CAL a: CODE 2/3 1 ' OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) I J E.K.G.: (PER EPISODE) -� Y NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X M DRUGS: .(PER ADMIN.) X ` NAME: L2 -1 UN t W/ 17 ""JRELATIONSHIP: AA 0 : (IF NOT REPLACED) ADDRESS:_4 n W 2�� �`� 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: f W11.1 TOTAL: PATIENT RECEIVED BY:X Provider rreai white and F1'ew ;rpp heturn Te'tuv rnpp t E?LS uhen biI:ing (SIGNATURE) [iMS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNITAUTHORIZATIO N N ® CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME r'" ( SLC//` "'jErM ❑ F COMPANY N r ADDRES� C t ) G�•7.� /� --- IAGE �.. ---� / CITY / ��//Y�-�f1/J STATE ' ZIP/a3_ �?ooe ���y 1t Sr, ❑ M ❑ T ❑ W ❑ Th 13 F A S ' y... DRIVER'S LICENSE tt __ _ PHONY _._ NATURE OF DISPATCH -; TYPE OF TRANSPORT: AMBULANC OTHER❑ _ — STATION 1(A)_2(B),31C1_4(D),5(E)_ 3- 'INCIDENT 'INCIDENT LOCATION/------) �- RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR Cr K) C / ji TO SCENE- S.O. CALL RECEIVED U ,1 C'C.'/� I ! (: /`/fyV 0/`J-P ❑ P.D. TIME 10-8 .1�..2 ..._ PATIENT DESTINATION:ON: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 - /�''� MILEAGE: ❑ OTHER/PVT TIME 10.7 ---�� / END - TIME 10.98 DOCTOR l_ I�� PMq)ER J START U TIME 14.22 - HOW CHOSEN: �/ TOTAL STANDBY TIME ,EfNEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBU rMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: `,R / RESPONSE ZONE YES ❑ NO ❑ WAL`<ED ElGUERNEY OTHER .. i PATIENT CONDITION: DRIVER EMT-1A _ TECHNICIAN 1DOrl/t 4p q PARAMEDIC Hx: _6L K DISPATCHER: /(-o Il C►�IEF COMPLAINT: F�.�1_L�( I DRY RUN: ❑ YES;RVNO REASON FOR DRY RUN c%' 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— s (( •, MEDICAL COYERAGT: INDUSTRIAL ❑ YES�NO NO. OF PATIENTS: ;2, O 2, M1 i K /v I / ( PRIV TE INS. CO.: BASE RATE: ����� \� KAISE R: ►'<<- ���1`-26''0 MULTIPLE PTS.BASE RATE Lam'7b / BLUE OSS#: TOTAL MILES: X MEDICARE x: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NQv C, C/C) . O YES 0 NO NIGHT: (19:00-07:00 ! ��,e"d CHP/PPHP\M: EMERGENCY RUN: cc' MEDI-Cal r ) i ',S$ r C' - CODE 2/3 OTHER: OXYGEN: (PER TANM P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBA WK-.1 DATES BILLED: STANDBY: (OVER 15 MIN.) / I� E.K.G.: (PER EPISODE) j` NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: 1PER ADMIN.) X- J�' r� DRUGS: (PER ADMIN.) X NAME: RELATIONSHIdpriV E.O.A.: (IF NOT REPLACED) ADDRE85 O� ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: •r WORK PHONE: DRY RUN: (AUTHORIZE( �\Q EMPLOYER: —�- OCCUPATION: OTHERS//iltrr ADDRESS: � L� _�1' •r'L�t 7)/ i CITY: STATE: ZIP:— COMMENTS: #o. TOTAL:L�Y 7� a 1�•'i�. Vii'c� ,^ PATIENT RECEIVED BY:X (SIGNATURE) Pmvi.:rr rttr: White ;rrt,; -.•r•!. Clrtir+e Yt",u .exp eyq ubv D{1"ivp ams-1 CC)rT!. CGUNI Y AIAf3ULANCE ' �S l ., , / CARIE F"021.1 I ONIT Ir AUTHORI2ATiON0 C;rECK Ot, .APPR(::'-IA7_ DATE: llo �3r PATIENT'S NA!.'E ❑ M ❑ F COMPANY a ADDRESS ., j-?y r3.1 AGE CITY___. _. STATE—__— ZIP—___ DOB—__ tSn O M O T ❑ W O Th ❑ F ❑S' DRIVER'S LICE°.SE it _. _—_ PHG:!F .. NATURE OF DISPATCH N f TYPE OF TRANSPORT: A1:BULANCEkl OTHER❑ _ —__ ._ STATION 1(A)_2(8)_3(C)_4(D)•_5(E)_.--•. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) (1� TO SCENE- C3S.O. CALL RECEIVED -/' -7 L !—-- - '.1 :. 'r— ---- ❑ P.U._ TIME 10-8 PATIENT DESTINATION: 7�� FROM SCENE - /� ❑ FIRE _ TIME 10-97 T •� ❑ PSAP TIME 10-49 1 �rJ ti :�J.f^ '_�'�� —7%r - }J• — MILEAGE. OTHER/PVT TIME 10-7 END— C' c f�. TIME 10-98 / _71--. DOCTOR __._ _ — PMD/ER START_ TIME 10-22 GT D HOW CHOSEN: TOTAL __ STANDBY TIME ❑ NEAREST ❑ FA!!`LY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIFECT ❑.OTHER CALL BACK k: AMBULANCE C9M�ANY: PT AMBULATORY% PATIE'JT TAKEN TO AMBULANCE: �' `I RESPONSE ZONE 2- 0 ❑ YES ❑ NO 2 V,'AL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDI7!ON: DRIVER— TECHNICIAN RIVER—TECHNICIA ^� PARAMEDIC Hr.: DISPATCHER: -- ' _ ! " •- CHIEF COMPLAIN�: DRY RUN. Lr'YES_VNO REASON FOR DRY RUN f'_J AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT rEFUSEC SERVICES: (SIGNATURE) X—_ MEDICAL COVERAGE: IN ❑ YEST.N0 NO OF PATIENTS: S.S- PRIVATE INS. CO..... BASE RATE: _ KA.ISEP. v: _— MULTIPLE PTS. BASE RATE BLUE CROSS TOTAL MILES: X MEDICARE a:— _ E.O.B. A`"T. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) I CCHPlPPHP#:__ ___— __ EMERGENCY RUN: L'�' NtED1• L+::_ ,------�-- CODE 2/3 OTHER __—.__---_ __._ OXYGEN (PER TANK) i r P O.E STICKER ❑ YES C NO NEONATAL. (INCUBATOR) DATES BILLED: _ STANDBY. (OVER 15 !AIN.) E.K G.: iPER EPISODE) NEAREST RELA.*'._;RELPG .:iLt PARITY: I V.: ;PER ADMIN.)___. X DRUGS: (PER ADMIN.) _X RELATIONSHIP: _ E O.A.: (IF NOT REPLACED) ADDRESS' ORAL AIRWAY. (IF NGT REPLACED) TO CITY:_ __. —_..____._ STATE—.ZIP:__ C-COLLAR: IF NOT REPLACED) _ PHONE: _ _ t':ORK PHONE: DRY RUN .tAUTHORIZED) --'� ENIPLOYER: __ —_ ___. OCCUPATION' _- OTHER: ADDRESS: CITY: _ _....___ STATE: ZIP:_-- CONIMENTS: TOTAL: -- -- 00564 _. PATIENT RECEIVED BY: X— _ :?ter,:...•r rrcai L;,i_, c_r.c. .r. �,. 5.: .�. ..•k. .. .. (` ..TURF) •-. i I CONTRA COSTA COUNTY AMBULANCE ?7 PRE-HOSPITAL CARE FORM I UNIT �� AUTIAORIZATION N Coll �3 �R r+.I CNECK OR FILL INAPPROPRIATE 50-ACESl ( 1 DATE: f G PATIENTS NAME ❑ M O F COMPANY N 1 ADDRESS AGE-. A A y I CITY_ STATE ZIP DOB P Sn ❑ M ❑ T ❑ W O Th ❑ F O S ) DRIVER'S LICENSE N _ PHONE _ - NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE 0 OTHER❑ - STATION 1(A)_2(B)_3(CI_4(D)_5(E)._ i INCIDENT LOCATION j RESPONSE CODE: REQUESTED BY: TIME-(24 HOURC} CK)l p 1 ' o TO SCENE- S.O. CALL RECEIVED O�> 'V ��2 �J9t L7j,�� 1�I GI{ P.D. TIME 10-8 ; PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10.49 MILEA ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME I ( ❑ NEAREST:. ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY* t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ' RESPONSE ZONE i t ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER j I ` EMT-lA TECHNICIAN 11L.-A. `/(� PARAMEDIC il r /oo Hx: DISPATCHER: !i'2`1 � CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN qqq 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: f KAISER C. MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X E MEDICARE 0 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES •❑ NO NIGHT: (19:00-07:00) /1J CCHP/PPRP M: EMERGENCY RUN: IMEDT-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: IP:COMMENTS: 2 tl Y1 TOTAL: ro 61 PATIENT RECEIVED BY:X Provider r•tnic Lhitn ..•I Pi. •i. (SIGNATURE) •� 0/, CONTRA COSTA COUNTY AMBULANCE I1 PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION# INAPPROPRIATE I riNECX OR FILL SPACES DATE: ✓ PATIENT'S NAME f_ /1 _—�_L_ ,(l_f1 � M OF COMPANY# ADDRESS �.1 �1 ! r r,- -s i B AGE (� CITY A-7) / !C, ( �/ _ STATE ZIP DOB ❑ M ❑ T ❑ W ❑ Th OF DIS DRIVER'S LICENSE ++ _______-_.._._ ._....__ ___ PHONE__(.L��i��___. NATURE OF DISPATCH— TYPE ISPATCH 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) A~ ^ 1 TO SCENE-!� ❑ S.O. CALL RECEIVED r N�-r ���G•� ��h < U _—_ O P.D. TIME 10-8 K ' 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 /� 1 }l) IlAill _I�^r'i'✓ MILEAGE: gel3 '§-0THER/PV TIME 10-7 END 0103 TIME 10-98 DOCTOR S r L' PMD/ER START L TIME 10-22 - HOW CHOSEN: (�,,_, �� STANDBY TIME ' ❑ NEAREST ❑ FAMILY \ddRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ``��OTHER �1 ^ `1 CALL BACK#: AMBULANCE COMA DAMBULATORY? PATIENT TAKEN TO AMBULANCE: 1444 RESPONSE ZONE I ES ❑ NO ,�WAL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN /1�f�y Z/ 0 PARAMEDIC Hx: 1_�1 l�(l j' r' f7/�'� DISPATCHER: CHIEF COMPLAINT. �' DRY RUN: ❑ YES NO REASON FOR PRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__ ' MEDICAL COVERAGE: INDUSTRIAL ❑ YES ANO NO. OF PATIENTS:S.S. # PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE ! �n BLUE CROSS#". TOTAL MILES: X Sc=fl-a l .•- MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO - I ❑ YES ❑ NO NIGHT: 119:00-07:00) CCHP/PPRP#: _ _ - ERGENCY'RUN: MEDT CAL#: . j'<< tr ` � - !.. CODE1243 I T}40r.. COieOXYGEN: (PER TANK) O.E. STICKER ❑ YENO NEONATAL: (INCUBATOR) DTES BILLED: STANDBY: (OVER 15 MIN.) \\ /j E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE'PARTY: I.V.: (PER ADMIN.) X — DRUGS: (PER ADMIN.) X NAME 1:2f�,�Z)N/,/' RELATIONSHIP:I;;�'t E.O.A.: (IF NOT REPLACED) ADDRESS: �,1 / ORAL AIRWAY: (IF NOT REPLACED) CITY: ��rLi%c-- ycL_—_ STAT�.G ZIP: C-COLLAR: (IF NOT REPLACED) PHONE WORK PHONE: DRY RUN: .(AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: ul;16 -- I COMMENTS: TOTAL: f1 -- PATIENT RECEIVED BY: X � /11V► Providrr "to-r Vhifr ,_r.a P:r% oopp prtur: Ir'e-,t• ,_ t• sTir ullry bill•W I$N: ATURE) DIS-1 S r� CONTRA COSTA COUNTY AMBULANCE l /� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONI e7 M a !a CNECK OR FILL IN APPROPRIATE SPACES DATE: �- PATIENTS NAME S„/I tl_\ I`cl . ❑ M tQ F COMPANY M - LI f ) ADDRE�ISS, AGE�o _� 2 CIN `� STATE DOB'�r 73 kSn ❑ M ❑ T ❑ W ❑/Th ❑ F ❑ S . DRIVER'S LICENSE N _ HP OIVE NATURE OF DISPATCH �V TYPE OF TRANSPORT: AMBULANCE ❑ -- STATION 1(A) 2(B)_3(C)_4(0)_5(E)_ INCIDENT,LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C �QCK) �n L TO SCENE- 0S.O. CALL RECEIVED I ❑ P.D. TIME 10-8 ` PATIENT DESTINATION: FROM SCENE Z ❑ FIRE TIME 10-97 ! ' �^ Q ❑ PSAP TIME 10-49 { d MILEAGE: ❑ OTHER/PVT TIME 10-7 EN TIME TIME 10-98 DOCTOR 1�1�1)W �� PMD/ER START / TIME 10-22 HOW CHOSEN: TOTAL'7 J STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT kr OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J 0 RESPONSE ZONE ❑ YES 0,NO ❑ WALKED kGUERNEY ❑ OTHER {��--- PATIENT CONDITION: DRIVER I(T1ae�: l�L��! t�—��.f����L'JC� EMT-IA TECHNICIAN PARAMEDIC / I Hx: A DISPATCHER: ?) CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) :I PATIENT REFUSED SERVICES: (SIGNATURE) X (_M EDICAL COVERAGE: INDUSTRIAL ❑ YES AUO NO.OF PATIENTS: �\S.s. �INSCO..: P�'A BASE RATE: KAISER C MULTIPLE PTS.BASE RATE BLUE CROSS M: TOTAL MILES: , X ?U f • y MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N; EMERGENCY RUN: MEDI-CAL M: j " CODE 2/3 �'- OTHER: C �� 9i=f. 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 .t 1 DRUGS: (PER ADMIN.) X NAM Ef;Sr, 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: 1 !� AA � TOTAL: PATIFNT RECEIVFr) 11Y X -,__ CONTRA COSTA COUNTY AMBULANCE �� 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIO N / Al-: T- - CHECK OR FILL IN APPROPRIATE SPACES DATE: � I PATIENT'S NAME O M 11F COMPANY K '� /7� ADDRESS AGE, c-- � `I w CITY STATE_ ZIP DOB '10 Sn O M O T ❑W O Th Cl F I DRIVER'S LICENSE 4 _ ' PHONE NATURE OF DISPATCH r �� TYPE OF TRANSPORT:- AMBULANCE 0 OTHER 0 _ — STATION I(A)_2(B)_3(C) 4(DI_5(E)_ INCIDENT LOCATION: RESPONSE CODE: RE ESTED BY: TIME— (24 HOUR CLOCK) C� iii A TO SCENE- S.O. CALL RECEIVED / (� va� 13P.D.—� TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 j 10 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10 22 : HOW CHOSEN: TOTAL STANDBY TIME 7n ;;� ❑ NEARESTPP, ❑ FAMILY ❑ TRANSFER WAIT TIME __ I ❑ PATIENT O DIRECT O OTHER CALL BACK K: AMBULANCE COMPANY• I i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: , RESPONSE ZONE ��- ❑ YES O NO ❑ WALKED ❑ GUERNEY 11 OTHER PATIENT CONDITION: DRIVER _ EMT-tA TECHNICIA64 PARAMEDIC=�! Hx: t DISPATCHER: ( L ! L'Q 0 CHIEF COMPLAINT: i DRY RUN: ES ❑ NO` REASON FOR DRY RUN AUTHORI TION FOR DRY RUN(EMS USE ONLY) r 7 // �J •. i' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: ._ INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: �Sy/ S.S.N PRIVATE INS. CO.: BASE RATE: " 1 KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X i MEDICARE C. E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N:' 1 EMERGENCY RUN: 1 MEDT-CAL It: I CODE 2/3 1/ OTHER: OXYGEN! (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) I "NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X `NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) " CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) —EMPLOYER, OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: Q COMMENTS:- `" TOTAL._ C' PATIENT RECEIVED BY: X Pmvf,lAr rot afm Vhit• err( I'i•iI ,••I.� 4•hr v,• (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: a r o PATIENT'S NAME (v%PI'S 0 tx V ' ',cl r, ❑ M 14 F COMPANY S_e"lA S '27177 ADDRESS ADDRESS�/-c S� `^r>,a F'!' S I 1 r AGE CITY U�U-C STATE C � ZIP DOBM"Sn ❑ M ❑ T ❑W ❑Th,O F 0 S DRIVER'S LICENSE M ___ .___._ PHONE���-.3_c� NATURE OF DISPATCH S co -� -_ TYPE OF TRANSPORT: AMBULANCE OTHER O STATION l(A)_2(8)_3(C)_Z4(D)_6(E)_- INCIDENT LOCATION: RESPONSE CODE: REf�UESTED BY: TIME— (24 HOUR CLOCK) ' TO SCENE- i S.O. CALL RECEIVED =:C i F 3 Det . V L 1�1 O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- 0 FIRE TIME%-97 / :�G, ,/� r � ❑ PSAP TIME 10-49 f� " MILEAG O OTHER/PVT TIME 10-7 TIME 10-98 3 � ; DOCTOR PMD/ER START R�k, TIME 10.22 - HOW CHOSEN: TOTAL !_,__=t_^� _ STANDBY TIME ❑ NEAREST 13 FAMILY O TRANSFER WAIT TIME ❑ PATIENT ja DIRECT ❑ OTHER 3 ) CALL BACK N: AMBULANCE MPP Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 50 RESPONSE ZONE _ 'YES ❑ NO ❑ WALKED XGUERNeY O OTHER (� PATIENT CONDITION: DRIVER_ r eri OK TECHNICIAN �iCJA i 0 t 41 PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: 'j m DRY RUN: ❑ YES 1(NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTPIAL ❑ YES (KNO NO. OF PATIENTS: S.S. N ' ' PRIVATE INS. CO.: ' BASE RATE: .. KAISER It: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X _ - MEDICARE N: 4 LG'C' ' 4�1 2 �" O.B.ATT. ROUND TRIP: O YES ❑ NO _ 3 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) �'aj S ! H-P/PPRP N"� - c)"�7 C.`-'�}C) — EMERGENCY RUN: d� MEDI-CALM: CODE 2/3 OTHER: OXYGEN: (PER TANK) -� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ✓?G - e Jv 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: (� STIIATE: t ZIP: COMMENTS: ���lnSe(11 Tc) TOTAL: PATIENT RECEIVED BY:X L.• Provider retair" Whit, rd 1•i•[% :•►.•- ! ?' �� UIS-1 .' CONTRA COSTA COUNTY AMBULANCE �� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# �f Jam} CHECK OR FILL IN APPROPRIATE SPACES DATE: L v O,tAd/¢ PUrn)k0 PATIENTS NAME0,t4,0,4. ❑ M �F COMPANY k �SO ADDRESS AGE/ — CITY-a 17 0 STATE Q ZIP D08?!S' S� ❑ Sn VIM O T ❑ W ❑ Th 0 F ❑ S' 2�7 2/.7® DRIVER'S LICENSE M ______..._ .__....__. .___ PHONE ...__..._...._ 3CNATURE OF DISPATCH �' D TYPEOFTRANSPORT: AMBULANCE OTHER n INCIDENT LOCATION: n RESPONSE CODE: R UESTED BY: TIME- (24 HOUR CLOCK) ` / 6�0� �� L ( ✓ �l�O TO SCENE - CALL RECEIVED _00 ❑ P.D. _— TIME 10-8 SL PATIENT DESTINATION: FROM SCENE- 2_ ❑ FIRE __ TIME 10-97 0 r ❑ PSAP TIME 10-49 ()�-1 MILEAGE: ❑ OTHER/PVT TIME 10-7 ALL -7 END 2 0 TIME 10-98 10 01 3_L DOCTOR � KQw 1 T-1 - PMD-A& START 2 _ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: A� COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: Q RESPONSE ZONE ❑ YES 'Z NO ❑ WAU',ED)d GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER -�,1 �L.L ,vq"Sn I OC�— EMT-tA— TECHNICIAN __ 12,61 PARAMEDICS_ • Hv M DISPATCHER: J CHIEF COMPLAINT: �� I�V1 �,/� DRY RUN: ❑ YES->R'NO REASON FOR DRY RUN ©. ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEr#: E: INDUSTRIAL ❑ YESNO NO. OF PATIENTS: _ S.S. PRfO.: BASE RATE: r\ KAI MULTIPLE PTS. BASE RATEBLU TOTAL MILES: X EDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ?\ CCHP/PPHP#: ❑ YES ❑ NO NIGHT: (19:00-07:00)EMERGENCY RUN: MEDT-CAL#: CODE 2/1'3 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 �1 I� DRUGS: (PER ADMIN.) X NAME: �� f4z 11 AA m RELATIONSHIP 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: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:_ ' _ — -- -- -- TOTAL. 'II NT rif rI 1 I, IIV x CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM IUNIT AUTHORIZATION N� A CHECK OR frill IN AIVROMIATf 3►ACf3 DATE: PATIENTS NAME OM OF COMPANY N ADDRESS AGE— CITY GE CITY STATE ZIP DOB O Sn 0M O T OW O Th OF OS � DRIVER'S LICENSE M _ PHONE _ — NATURE OF DISPATCH - TYPE;OFTRANSPORT: AMBULANCE �^OTHERF_ — STATION 11A)_X2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:; S' "^ RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) I� `) TO SCENE- S.O. CALL RECEIVED C4 P.D. TIME 10-8 . - PATIENT DESTINATION: (,� �) FROM SCENE- 13 FIRE TIME 1D-97 ti -- rr� v R�/ ( ❑ PSAP TIME 10-49 'J ^� '- ' MILEAG O OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR ' PMD/ER START TIME 10-22 c� HOW.CHOSEN: TOTAL STANDBY TIME }, ❑ NEAREST O FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: Q I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ,t� RESPONSE ZONE JaQe ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER } PATIENT CONDITION: DRIVER ` z�`-I EMT-lA ' 1 TECHNICIAN Q z PARAMEDIC q // Hx: DISPATCHER: '7 1 ob CHIEF COMPLAINT: DRY RUN: g(YES ❑ 48 REASON FOR DRY RUN T ✓ A T RIZATION FpR pRY�MS USE ONLY) r PATIENT REFUSED SERVICES: (SIGNATURE) 2 MEDICAL COVERAGE; INDUSTRIAL ❑ YES ❑ NO NO.OF PA TENTS: S.S.# PRIVATE INS. CO.: BASE RATE: 1 KAISER K: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: O YES O NO ❑ YES ❑ NO NIGHT: (19:00-07.00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: n _ TOTAL: 1 ' PATIENT RECEIVED BY:X Pmuidi� rvru�. V4i r� ,.•I n; ,. .,. (SIGNATURE) PATILNT's r ,; �1;: - —kiunt,Lem ADDRESS: 3025 Qhin Ave Rich nn ,ra_ DATE 017 SERVICE: OA-29-�3 AUTHORIZATION NUMBER: 83-14f�12 AMOUNT DUE: INCIDENT LOCATION: Sleepy Hollow Ln.& Terry Ln. Orinda PATIENT DESTINATION: Kaiser Walnut Creek 00 572 1 r /1' , 127715; Auc 29 8H 5q I � 3 Auc 19 8 59 AM '83 Auc 19 -8 s9 ' s p/ SO NUMBEej J / CALL- RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE I" CALLED BY— PATIENT INFORMATION zs}. D C NAME: o AGENCY: CUSTOMER It(PT. 1): DOB: N _DEPT;FLOO/R�;�R/OOM a: —_ NAME: m CALLBACK 2o� �' PVT MCAR MCAL KH PHP VA rIND CHAMPUS Co w :INCIDENT LOC: '.__<!p_/('• �'r D/ wA POLICY/MCAL a; S.3O Od e v a —SI '/ MCAR p: m D CROSS STREET .— VERBAL PRIOR: q Z City: DOCTOR: v d - - cDESTINATION: -_- /�(/V_�.�._._-------.__--- PT. a2 NAME: DOB: RA'TURE: _ _ CUST. # -'A -,:- __ PT. #3 NAME: DOB: Z. o �1 Z TYPE OF CALL: E TR NS TIME UNIT a CUST. a n m ,., CREW: � _ _ -- _-- _ �'" WA1T TIME: YES NO REASON: m UNIT TYPE: ALS WC RES NSE CODE: 0 1 24 REASON FOR 10.22: 7O , a INCREASE ECREAS CODE: 3 10-49 CODE: 0 2 4 CANCELLED BY: m v BY: ,�-w A -- END MILEAGE: COMMENTS: p H W I a TIME: �1 BEG MILEAGE: 00573 3 a -i FDISPATCHER: TOTAL- MILES: a A 4cm XC'OL 1v 3DNvinBwv 6l'Ol ONINam Nvin9wv 86-OL 318VIIVAV 3DNvinewv L•Ol lV11dSOH LY 3DNVU19Wd w ---- Do HV 94 6 BZ 04 E8s WV LE 6 6l onV CONI FIA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT / J AUTHORIZATION M L .CHECK OR FILL rH APPROPRMA TE SPACES DATE: PATIENT'S NAME v /1(• ✓ f� IC G F U ���')5 CKM ❑ F COMPANY ADDRESS IC ! � y AGE 2' 13 .4 r ^~ CITY /Yy)•vJ}'✓1� �� lv STATE—�_ ZIP --o�—�— DOB !I� O Sn 05-M D T D W D Th Q F O$ DRIVER'S LICENSE a _.__, _. PHONE E : �� _/��`� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ _ -_ STATION 1(A)_2(B)_3(C)_4(D)_5(E)---, .� INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- V/S.O. CALL RECEIVED _ %P-D.J26A Md TIME 10-8 1ZL L -� PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME 10-97 21-,': lam C ❑ PSAP TIME 10-49 �1-•: IT C /7 f (•tom j�I�-C7 _ MILEAGE: ` r ❑ OTHER/PVT TIME 10-7 � : Z' 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 �Z3i CALL BACK a: AMBULANCE COMPANY: F-- Pg. AMBULATORY? PATIENT TAKEN TO AMBULANCE: (��/-� RESPONSE ZONE -J YES ❑ NO WAl' ED ❑ GUERNEY ❑ OTHER PVT PATIENT CONDITION: DRIVER y1_!1 (1 �-1 0 MT- // TECHNICIAN (1) ! PARAMEDIC > ' Hx: DISPATCHER: .`r'-QF– CHIEF COMPLAINT: /L.-Li--'' i-L�- DRY RUN: Cl YES gNO REASON FOR DRY RUN r t. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) { — PATIENT REFUSED SERVICES: (SIGNATURE) Xt r '1 - MEDICAL COVERAGE: INDUSTRIAL ❑ YESI<NO NO, OF PATIENTS: S.S. a \ ' 1 PRIVATE INS. CO.: BASE RATE: 1 •�–� I I KAISER a: MULTIPLE PTS. BASE RATE � ���� BLUE CROSS a: TOTAL MILES: X 520 MEDICARE a: E.O.B. ATT. ROUND TRIP:' ❑ YES ❑ NO •""`) ❑ VES ❑ NO NIGHT: (19:00-07:00) �L1iL11J QJ^ CCHP/PPRP a: EMERGENCY RUN: �( MEDI-CAL a: CODE 2/3 .�J OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME:••Sw h?Cw0! 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: �'/.�fJ///�.�1� IS,lA> 70 1 CITY: STATE: ZIP: COMMENTS: �D TOTAL*-- ' ---w-- ' PATIENT RECEIVED BY:X 4vv, - Pr,vidrr rrtair. Whitr .-r,i tY.: ne 4�r•,.� v� .�r- IG )' vh'a ! l'iaa b13-1 CONTRA COSTA COUNTY ! '^r , AMBULANCE Q3 L/ i B�L/ FRE-HOSPITAL CARE FORM I UNIT �j AUTHORIZATION a uJ 7 D i CHECK OR FILL IN I(PPROPRIA fE SPACES DATE: 1-9 I 1-C_L PATIENT'S NAME 2 a` -i - Q-- ❑ F COMPANY a X Z ,ADDRESS -�� V`� `� L-�- --- ------ - AGE:-.1[(�t- CITY MT-Z • STATE— A ZIPDOB3� ❑ Sri W-M O T ❑ W ❑ Th ❑ F O S DRIVER'S LICENSE a .__.._1_" - PHONE NATURE OF DISPATCH.-_ �!rqrk TYPEOF TRANSPORT AMBULANCE T/HER❑ A INCIDENT LOCATION: 11 RESPONSE CODE: RE STED BY TIME- (24 HOUR CLOCK) IJU SIm TO SCENE- �l S.O. ..___..._ _. CALL RECEIVED L- IN p'� �• U __— ❑ P.U. _._._,_ TIME 10-8 PATIENT DESTINATION: FROM SCENE i ❑ FIRE -_-__. TIME 10-97 _ _ ❑ P`$AP TIME 10-49 :Z_ r�� c �( '� ' (c ( i u C MILEAGE E. -,-- QL THERiPVT TIME 10-7 • •2' r END_-��_^�__ TIME 10-98 DOCTOR ER START-4_�1.3 __.____---_- TIME 10-22 HOW CHOSEN � TOTAL —_ .7—_. ___—__ __.__ STANDBY TIME ,, ❑ NEAREST ❑ FAMILY TRANSFER _-_ WAIT TIME _- ❑ PATIENT ❑ DIRECT ❑ OTHER 1. `1� CALL BACK a: AMBULANCE COMPANY: C A1C PT Pr(0BULATORY? PATIENT TAKEN AMBULANCE: RESPONSE ZONE YES ❑ NO ❑ WAL',ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER-__.�_J' ._ -. MT-1 TECHNICIAN �1.�� _._�ali-_ PARAMEDIC __- Hx: _0L .� DISPATCHER: �' L7 C IEFCj O. MPLAINT: _S�S+- �Srt(Q �_._D .. DRY RUN. ❑ YES C,'- O REASON FOR DAY RUN \.eC U{D_ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. /IreSTRIAL 13 YES O NO. OF PATIENTS: .____-.. -__- S.S. a `� --5 PRIVATE INS. CO.:— —_ BASE RATE: r KAISER a: MULTIPLE PTS. BASE RAT L l� BL a: TOTAL MILES: EDICARE a _ a S fK E.O.B. ATT. ROUND TRIP ❑ YES Cl NO ++' ''��.���;L/ O YES ❑ NO NIGHT: (19.00-07:00) `N CCH 'PPHP _ `L � _ EMERGENCY RUN: ti MEDT-CAL a: — _ CODE 2/3 OTHER: __ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: _ STANDBY: (OVER 15 MIN.) PLl• fo d""�{Z` E.K G.: (PER EPISODE) —� NEAR ST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN )_- X C-10 ,til -_ D.L .e�t, AZw-�(•l DRUGS: (PER ADMIN.) X J NAME: Ne-IF RELATIONSHIP:SO" _ E O.A.: (IF NOT REPLACED) ADDRESS 674 5C o'a_ 'I -_/� ___..._.-._. ORAL AIRWAY: (IF NOT REPLACED) -- CITY: �/ �� . STATE`_ ZIP.-._.__ C-COLLAR: (IF NOT REPLACED) - '// �J!� X99,1 - WORK PHONE .___.___-._--.__- DRY RUN. (AUTHORIZED) PHONE.''ZZl-- -- EMPLOYER: OCCUPATION:_.__. OTHER: c J. ADDRESS: ------- - ------ -- 1. CITY: - STATE:---- ZIP:----._ . — _--_--- - -- - - - - - _--- -------- ...--- COMMENTS: 11C n n 5 75 f_i_!_ ...__�_ y TOTAL/1949 O1 I -�- `�-- PATIENT111r'rIVI-niJ _ �7 ( ' r I ,•,• u:.L r r,, u,:r. I_. r. (',I(INkrORE) G+s-1 I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 111 � `3 7 ' CHECK OR FILL IN APPROPRIATE SPACES DATE: s _d2 4 3 - 'PATIENT'S NAME-` �`- / ��JSP t O M. D F COMPANY N ADDRESS.. ` ` ' AGE, �> CITY STATE ZIP DOB ❑ Sn fS M 0T Ow O Th O F E3S DRIVER'SYICENSE N ,f PHONE __'NATURE OF DISPATCH T�i9N3��72 TYPE OF TRANSPORT:) AMBULANCM OTHER —. STATION 1(A)k2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATIONt -M / ;i�' RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C OCK) g �l TO SCENE- ❑ S.O. CALL RECEIVED C C N; — '1°�h'�j ❑ P.D. TIME 10-8 OATIENT DESTINATION:..___ ) FROM SCENE- ❑ FIRE TIME 10-97 SIU ❑ PSAP TIME 10-49 MILEAG 12 OTHER/PVT TIME 10-7 �� II� END TIME 10-98 yy�� / ';l(L S?'OOCTOR "' ? PMD/ERS START CCC TIME 10-22 42 :_t:F yb HOW CHOSEN: TOTAL STANDBY TIME D NEAREST.,-, D FAMILY JK TRANSFER WAIT TIME D PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANC�SMPANY: i PT. AMBULATORY? - PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: - --- . DRIVER a ,�7�tf6_t16-72 T �-' Ll li ��• CONTRA COSTA COUNTY AMBULANCE �3 PRE-HOSPITAL CARE FORM 1 UNIT j/ AUTHORIZATION 0�3 J o �z { CNECK OR FILL IN APPPPROPMATE SPACES DATE: PATIENTS NAME l ���« D XM Cl F COMPANY a DDRESS f 9n /PfIt / /L Q AGE. ! f Co I art r� CITY 'W r2— STATE �� ZIP DOB—7 ACM`7` j� ❑ Sn ❑ T 13W 13Th 13F O S DRIVER'S LICENSE M _ __ __ _ PHONE � SdJ NATURE OF DISPATCH_. TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION I(A)_2(6)_3(C)-4(D)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) , `AA Y TO SCENE- S.O. CALL RECEIVED AJ F ! 'U ,D ^_LI ❑ P.U. TIME 10-8 f (PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 10 l 44' MILEAGE: / OTHER/PVT TIME 10-7 ' `r 1 Tb� END /`S / 1 '= -'�' TIME 10-98 - DOCTOR �� /ER START_ TIME 10-22 HOW CHOSEN: TOTAL 3 •'t STANDBY TIME ❑ NEAREST ❑ FAMILYTRANSFER WAIT TIME ❑ PATIENT 11 DIRECT 13 OTHER I CALL BACK M: AMBULANCE COMPANY: PT. AMBU TORY? PATIENT TAKEN TO AMBULANCE: '1 RESPONSE ZONE 13 YES L1O ❑ WALKED GUERNEY ❑ OTHER If PATIENT CONDITION: DRIVER ��� — EMT_J6✓ TECHNICIAN r 1/i PARAMEDIC ' Hx: ` !. � '-'A i.L' .l.G. DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES 1110 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ i MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: r 1 S.S. FF 1/0 � ' PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS p: � TOTAL MILES: X 1; DICA 4: ' S 16 E-0 B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) j CCHP/PPRP R: EMERGENCY RUN: MEDT-CAL#: CODEr2/3 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/RESPONSIB�E PARTY: I.V.: (PER ADMIN.) X � ^ DRUGS: (PER ADMIN.) X 1 NAME: m L Ol��J�c 3 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ,` ADDRESS: v 1 -3 CSL`xl S ORAL AIRWAY: (IF NOT REPLACED) /CITY: / 77-s STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: =I_, �r-WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: — _ . TOTAL./x%,40 el' '' __-___... PATIENT RECEIVED BY: X 1 ISIGNA-UF1E) ( /Yui.fir r�rair, Yhit, r! r•:.: ..I y. .4.t .r,, � ...i.., r ... .. . r I ....._..._ .,_.-- --- t•MS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z 1 AUTHORIZATION# e3-143"-o-� 2 y-� CHECK OR fill IN APPROPRfAT[SPACES DATE: 5 PATIENT'S NAME I OM OF COMPANY it ADDRESS AGE— CITY GE CITY STATE 21PDOB O Sn >CM OT OW D Th OF OS ` DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH S V U A?o S TYPE OF TRANSPORT: AMBULANCE OTHER 0 STATION 1(A)X2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:' RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLO,CK), r // TO SCENE _�S.O. CALL RECEIVED , 5 0 1 7 ❑ P.D. TIME 10-8 . rO� PATIENT DESTINATION: FROM SCENFo ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10-7 END TIME 10-98 >�DOCTOR` I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCSCOM ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: f'1 1 0 RESPONSE ZONE OYES 13 NO 13 WALKED C-) GUERNEY O OTHER ~> PATIENT CONDITION: I DRIVER L 10,�,z !i Z�-, " f TECHNICIAN_� 9 /IS I Ol7 PARAMEDIC Hx: DISPATCHER: Ju/L jl�3 CHIEF COMPLAINT: Z ��� DRY RUN:AYES ONO REASON FOR DRY RUN e— �1_2 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: Al S.S.# PRIVATE INS. CO.: BASE RATE: KAISER 0: MULTIPLE PTS.BASE RATE f BLUE CROSS 0: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: D YES O NO D YES .❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 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) E EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -• - s TOTAL: SOL ' PATIENT RECEIVED BY:X `._.. Provider retain White rd Pink ropk keturn Yr.'I,t rnf, f /�� Whrn til'L,a (SIGNATJRE) EMS-1 CONTRA COSTA COUNTY AMBULANCE a PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION# 13Lj ! :5 ; - CHECK OR FILL 1 ROPRIATE SPACES DATE: ay PATIENT'S NAME '' �A v ❑ M OF COMPANY# C ADDRESS I AGE u. 1 f CITY r STATE ZIP DOB _ ❑ S I(M O T /O W O Th OF ❑ S DRIVER'S LICENSE 0 PHONE — NATURE OF DISPATCH TYPE OF TRANSPORT:, AMBULANCE OTHER 0 _ -- STATION I(A)_2(B)_3(C) 4(D)_5(E)_. INCIDENT LOCATION:i + ` RESPONSE CODE: RUESTED BY: TIME- (24 HOUR CLO K) elo / ' 1 TO SCENE- '-' S.O. CALL RECEIVED k_/06 d vin i O ) O O P.D. TIME 10-8 (J . /` PATIENT DESTINATION: FROM SCENE- ❑ FIRE _ TIME 10-97 L-/ Qv 1 11PSAP TIME 10-49 D'`� �r"�� I ' MILEAGE: ❑ OTHER/PVT TIME 10-7 T— END TIME 10-98 7D0CTOR " PMD/ER START TIME 10-22 HOW CHOSEN: __., TOTAL STANDBY TIME G. .,. O NEAREST ;' O AMILY ❑ TRANSFER WAIT TIME __ ! 13PATIENT Pr DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY- CA's Ot P NAYS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �'J RESPONSE ZONE- 0 ONE❑ YES ❑ NO, O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERCCdCZ7� EMT-IA_p� TECHNICIAN ►-� 5 �+�l° p�� PARAMEDIC Hx: DISPATCHER: 5nfkL -7t/ AUTHORIZATION //�6 CHIEF COMPLAINT: DRY RUN: WYES 13 NO REASON FOR DRY RUN ��- 1 Pu G D I C AUTHORIZATION FOR DRY RUN (EMS USE ONLY) Lfqr/ . _. 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 i BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO OYES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: I ( EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) cz-A P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X "NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR:. (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) -EMPLOYER: OCCUPATION: OTHER: ADDRESS: ' CITY: STATE: ZIP: -COMMENTS: f 1 r w TOTAL: PATIENT RECEIVED BY.X (SIGNA[URE) CONTRA COSTA COUNTY AMBULANCE ` PRS-HOSPITAL CARE FORM IX IUNIT AUTHORIZATIO N9 • , 9- CNECI(OR FILL INAPfROPRIArE SPICES DATE: PATIENTS NAME G` -7'-- '�/ _ O M .gel F COMPANY N 7 - ADDIRSOSS � � AGE/CITYSTATE ZIP DOB_! O Sn O T O W ❑ Th ❑ F O 6 6PAVER'S LICENSE N __ —_ — PHONE 3_-2 ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEP OTHER O -_ STATION I IA)_2(8)_3(C 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: R VESTED BY: TIME- (24 HOUR CLOS,K) i I n�'4 TO SCENE S.O.— CALL RECEIVED Z.:i_ J ��� / ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE. O FIRE TIME 10.97 3� o� PSAP TIME 10-49 MILEAGE ❑ OTHER/PVT TIME 10.7 1 rn END TIME 10-98 DOCTOR _ ii i'in gn, PMER START _ �2 TIME 10-22 ,.- HOW CHOSEN: TOTAL STANDBY TIME 1 EAREST FAMILY TRANSFER WAIT TIME _ ❑ 13 ❑PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE CO EoT AMBULA RY? PATIENT TAK�ENJO AMBULANCE: ��' RESPONSE ZYES NO O WAL ICED L,VGUERNEY O OTHER / _ `� PATIENT CONDITION: DRIVE , !P� ( EMT-IA TECHNICIA s PARAMEDIC Hx: DISPATCHER: I I C ti B�• �n CHIEF O PLA T: VV-eDRY RUN: O YES 13NO REASON FOR DRY RUN (m to avf 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.: BASE RATE: 1 sa uv KAISER N: �" �� MULTIPLE PTS. BASE RATE ' TOTAL MILES: BLUE DI ARE E.O.B. ATT. ROUND TRIP: O YE S O NO O YES ONO NIGHT: (19:00-07:00) I RP / REMERGENCY 1N: I � MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) ¢�[� P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) X- DATES BILLED: STANDBY: (OVER 15 MIN.) `� -��0'cz) E.K.G.: (PER EPISODE) SQ•(1ZJ q NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ad• x DRUGS: (PER ADMIN.) X ' NAME:Ae 60 C ar-1 ATINSHIP E.O.A.: (IF NOT REPLACED) 1 �' ADDRESS , n ORAL AIRWAY: (IF NOT REPLACED) CITY: , c STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE70ET3'7-,17RK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - ADDRESS: L'/9 is . ! ''L 40, CITY: STATE: ZIP:- COMMENTS:k /1 e / a _ !2i,54 T C` /� R TOTAL:.5.3v.-ad I PATIENT RECEIVED BY:X Provider reta:r. Nisi•,• rd 1•i c:. 'o ier, ), : r (SIGNATURE) PF r LIS-! T- CONTRA CJSTA COUNTY AMBULANCE PRE-HOSPITAL CARE/FORM I UNIT AUTHORIZATION# CHECK OR FILL IP—APPROPRUir.."ACUS DATE: � ��{ C�1 ,^•�•••, L..� PATIENT'S NAME i':, 1__1't-Y_:; . -_Sc..� It: .L:- DSM ❑ F COMPANY# U7 + r ADDRESS I AGE CITY \ „r 1l E' STATE ( Y� ZIP � DOB �' Z ❑ Sn 4-M ❑ T, ❑ W ❑ Th;❑ F P S DRIVER'S LICENSE p PHONt _U'6LC NATURE OF DISPATCH /14C'GC f✓C�1.S TYPE OF TRANSPORT: AMBULANCE E.;OTHER❑ _ _ –_ STATION 1(A)_2(B)_3(C)_4(D)_5(E) –; INCIDENT LOCATION: / RESPONSE CODE: REQUESTED BY: TIME– (24 HOUR�L�CK) ( � TO SCENE- -Z ❑ S.O. CALL RECEIVED � _ ❑ P.D. TIME PATIENT DESTINAT1 FROM SCENE 13 FIRE TIME 10-97 r i 7 ❑ PSAP TIME td 49•;. t Aeti,:.Lt' ' •` \-� \ �- "\ �l X _— MILEAGE. R OTHER/PVT TIME 10-7 ���'J:,jtj /� / END ��� TIME 10-98, DOCTOR ( ) >l� _ PMDrER START j TIME 10-22 ---' HOW CHOSEN: t� TOTAL STANDBY TIME _�- ❑ NEAREST ❑ FAMILY tkTRANSFER - WAIT TIME I _� ❑ PATIENT ❑ DIRECT ❑ OTHER �25� CALL BACK N: AMBULANC OMPANY: --- PT. AMBULATORY' PATIENT TAKEN TO AMBULANCE: P,/ RESPONSE ZONE YES ❑ NO ❑ ;VVAL"ED f GUERNEY ❑ OTHER � Y PATIENT CONDITION: DRIVER / 1 EMT-lA TECHNICIAN "�'1 rlcSC�t I a5 PARAMEDIC Hx: _ ^ ' _ _ DISPATCHER: CHIEF COMPLAINT: ;1rL'i 1 f–'�- E E� — DRY RUN: ❑ YES CR-NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X I I . If MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑t;NO NO. OF PATIENTS: U S.S. N SSV ; PRIVATE INS. CO.: BASE RATE: Vio. KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: S X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO '-`- �t ❑ YES ❑ NO NIGHT: (19:00-07:00) - -[ �CCHP/PPHP N:_. (\r%� - . / �1 V EMERGENCY RUN: MEDT:C-Al# _ COD(;2/3 ----- OTHER: _.- OXYGEN: (PER TANK) I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) �- DATES BILLED: STANDBY: (OVER 15 MIN.) 1� .f�Cf E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.' (PER ADMIN.) X'-' ' DRUGS: (PER ADMIN.) X NAMERELATIONSHIP: 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: J�� i r TOTAL: 7 ^. 5 Q\' ,. r r r- __... I (• L.. _�L� — PATIENT RECEIVED BY:X - (SIGNATURE) Yr•nidrr rrrar.. .%n• .. •I`t'p Aet�ry Yo'F•c n• ch•e tflin� LMS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M ..,.. . - 3 . CHECK OR FILL IN APPROPRIATE SPACES DATE: Q PATIENTS NAME ❑ M ❑ F COMPANY M �) ADDRESS z , ;; AGE N /V' L I " l� CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑W ❑ Th O F O.S DRIVER'$LICENSE N PHONE NATURE OF DISPATCH - A/ A « 1 N TYPE OF TRANSPORT: AMBULANCE D OTHER — - STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: L(J•�%� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �� D (br/ L 1 �i , TO SCENE dS.O. CALL RECEIVED 1 d 1, of ❑ P.D. TIME 10-8 :_/ PATIENT DESTINATION: . ... FROM SCENE - ❑ FIRE TIME 10-97 (1Q 11PSAP TIME 10-49 ►J„� 1'./fvi' i/921-fl.-• " MILEAGE: ❑ OTHER/PVT TIME 10-7 • • - � END ���- TIME 10-98 i DOCTOR' T'" ) PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK K: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: fj RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER '�� , 1 EMT-tA TECHNICIAN ��� �` G�l �' r:/ 5 1 PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: WYES ❑ NO REASON FOR DRY RUN 'V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �\ -• Ll/ S.S.N i PRIVATE INS.CO.: BASE RATE: KAISER R: ' 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 C', EMERGENCY RUN: MEDT-CAL 11: 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: STATE: ZIP: "COMMENTS: � _ �0 TOTAL: PATIENT RECEIVED BY: X �1 A CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION N � LI V-R CHECK OR FILL IN APPROPRIATE PAC[3� / DATE: )" O PATIENT S NAME LN\. ❑ M ❑ F COMPANY NMAW , ! ADDRESS AGE k 1 i lull CITY STATE ZIP DOB O Sn O M OT OW O Th OF O S ► DRIVER'S LICENSE N _ ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEV OTHERO —_ STATION I(A)j-_2(B)_3(C)-4(D),6(E)_ INCIDENT LOCATION:1 RESPONSE COD REQUESTED BY: TIME— (24 HOUR CLOCK) �Y( TO SCENE-COD REQUESTED CALL RECEIVED O P:D. TIME 1G-8 PATIENT DESTINATION: FROM SCENEO FIRE TIME 10-97 - P + ❑ PSAP TIME 10.49 -�' 1�. 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 ` END TIME 10-98 DOCTORL '' PMD/ER STARTS TIME 10-22 1 L 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: (, RESPONr ZONE E ri ❑ YES O NO O WALKED ❑ GUERNEY O OTHER 1 PATIENT CONDITION: DRIVER IA L1 - '`I' 5 EMT-IA 7 ` TECHNICIAN`'-l� Ue Y PARAMEDIC 17 Hx: rV Ij� DISPATCHER: <� +1 (f[J CHIEF COMPLAINT: DRY RUN: P(YES NO REASON FOR DRY RUN G_Lt 'C.\ L IJl 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) V � R` `v' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO. OF PATIENTS: i %7 S.S.N PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS Y TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO / ❑ YES O 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 O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) i E.K.G.: (PER EPISODE) i 'NEAREST RELATIVE/RESI IONSIBLE 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) j CITY: STATE— ZIP: C-COLLAR: .(IF NOT REPLACED) 11 0 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: M ADDRESS: CITY: STATE: ZIP: COMMENTS: 00583 TOTAL: PATIENT RECEIVED BY:X (SIGNATURE) �^ CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTWORIZATION • CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAM ❑ M �F COMPANY M y 1 L L ADDRESf/7-�`�^--_(--% ��✓!'/✓�l G/ '.P AGE CITY f (L -l•��YtO.n C'l gTATE 21P lel �� DOB //7- J./ 11Sn ❑ M OLT ❑ W ❑ Th`/❑ F S DRIVER'S LICENSE k /'r � `_� _._� G .ZSCt NATURE OF DISPATCH PHO 9 TYPE.OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: rsp ESTED BY: TIME- (24 HOUR CLOCK) ( TO SCENE . - CALL RECEIVED . TIME 10-8 7 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97CIPSAP TIME 9 MILEAGE- ❑ OTHER/PVT TIME 10.7 •�� t END- TIME 10-98 `! DOCTOR 'i l^/� PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL TZ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER , WAIT TIME PATIENT ❑ DIRECT ❑ OTHER `5 ; CALL BACK 4: AMBULANPE OMPANY: T. AMBULATORY? TIENT TAKEN TO AMBULANCE: 5'� RESPONSE ZONE t' /YES 0 NO WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ' '� �j IC,EMT-tA TECHN CIAN ' �-i--PARAMEDIC Hx: / DISPATCHER: C.- :� t (7nit CHIEF COMPLAI �L DRY RUN: ❑ YES O REAS N FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES InO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X G zJ MEDICARE t►: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C EMERGENCY RUN: MEDI-CAL u: CODE 2/3 11 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ElYES ❑ NO NEONATAL: (INCUBATOR) J 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�(a� �J�`� RELATIONSHIP: FAT E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) STATE— ZIP: C-COLLAR: (IF NOT REPLACED) O E: "i71 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP;— COMMENTS: IP:COMMENTS: — lJ t1 ar TOTAL: PAI IF NT RrrJ IVFn FIV X CONTRA COSTA COUNTY AMBULANCE d,I PRE-HOSPITAL CARE FORM I UNIT AU HORIZATION r CHECK OR Flll IN APPROPRIATE SPACfs DATE: l 1 VATIENTS NAM ` v OM OF COMPANY 4 `"Z ADDRESS .,l ' 'AGE CITY. STATE_,,, ZIP DOB Sn ❑ M ZT O W O Th O F O S ,. -� , :. DRIVER'S LICENSE M PHONE NATURE OF DISPATCH Mr� TYPE OF TRANSPORT: AMBULANCE LT OTHER❑ •_ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ t INCIDENT LOCATION* RESPONSE CODE: REQ? PESTEO BY: TIME– (24 HOUR CLOCK) TO SCEN - S.O. CALL RECEIVED ❑ P.D. TIME 10-8 1 , PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 p ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME TIME 10-98 :.DOCTOR: _- _ PMD/ER START� TIME*10-22 HOW CHOSEN: TOTAL STANDBY TIME �yj'-y„❑ NEARESTI:; O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK M: AMBUL2AnjCQMPANY. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S(> RESPONSE ZONE ! Q YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ( i ' PATIENT CONDITION: -' ' ) DRIVER ` Say EMT-1A i TECHNICIAN ��/.Cf u� ,9'L SIPARAMEDIC _../ y N y Hx: DISPATCHER: I ppQ CHIEF COMPLAINT:�C�"'?-`� 1 e.-N I DRY RUN: ❑ YES O NO REASON FOR DRY RUN d (�III AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X ,� MEDICAL COVERAGE: l INDUSTRIAL 0 YES 13 NO NO. OF PATIENTS: Jp �5 7/ S.S.M _ PRIVATE INS. CO.: BASE RATE: KAISER c MULTIPLE PTS.BASE RATE BLUE CROSS N: ' TOTAL MILES: X I MEDICARE 0, E.O.B.ATT. ROUND TRIP: O YES ONO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N I EMERGENCY RUN: MEDI-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:- -- REL TIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: - S TE– ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK HONE: DRY RUN: (AUTHORIZED) s.�=• EMPLOYER: O CUPATION: OTHER: ADDRESS: —CITY: STATE: ZIP:-----:-- COMMENTS— nz IP: :COMMENTS- 4, TOTAL: �•CeV LSC PATIENT RECEIVED BY:X P,r„i.lor rvtn!•. Vhit• ,nd N. (SIGNATURE)•pt�F Mot,,-, Y. 'I •.,pp f F%I! oh'.1 fil in,; (SIGNATURE) Lp1-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUfHORJZATION N 1 CHECK OR FILL INAPPROPRIATE SPACES DATE: "J PATIENT'S,NAME �> 1':L,1! r + Z z ❑ M f COMPAN`f N �1_�/ / ADDRESS _2 " rAGE CITY_ L 4. y STATE'-1ei— ZIP — DOB X1-15- J3 ❑ Sn ❑ M IDT OW O Th OF OS DRIVER'S LICENSE q __ ..__-._. .__._ PHONE_—_..--____-- NATURE OF DISPATCH 11 S. A 1 c., I- - TYPE OF TRANSPORT: AMBULANCE D OTHER❑ __ STATION 1(A)_20_31CI)L4(0)_5(E)� INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) � i tt TO SCENE- 19 S.O.— CALL RECEIVED P.U. TIME 10-8 ! � :.�� PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 .—�Ij I c 1-�_ _ MILEAGE: ❑ OTHER/PVT TIME 10-7 EN TIME 10-98 DOCTOR X11 A PMD/ER STAR TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT AMBULA Y? PATIENT TAKEN TO A• ANCE: U RESPONSE ZONE S ❑ YES PINO ❑ WAL'tED ❑ G NEY ❑ OTHER PATIENT CONDITION: DRIVER P-A c: 1 t_aLL, 5110 _ EMT-1A TECHNICIAN F c I ) �2� PARAMEDIC k - - Hx: _ / i1 ,/ r ^- DISPATCHER: C2 004 CHIEF COMPLAINT c�t.c c- . r DRY RUN: 9 YES ❑ NO REASON FOR DRY RUN PR S ACJ HORIZATION FOR RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) i MEDICAL COVERAGE: INDUSTRIAL ❑ YES M NO N OF PATIENTS: S.S. a PRIVATE INS. CO.: BASER TE: I KAISER a: MULTIPL PTS. BASE RATE BLUE CROSS N: TOTAL MIL S: X MEDICARE k: E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NO I ❑ YES ❑ NO NIGHT: (19:00- :00) �I 'STc CCHP/PPHP 4: EMERGENCY RU n MEDI-CAL#: CODE 2/3 I OTHER: OXYGEN: (PER TANK) - P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATO 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: e-il- n -0. .RELATIONSHIP: 011 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: S70 d PATIENT RECEIVED BY: X � �,..,:,.. _...:.. .. (SIGNATURE) �r= i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT �� AUTHORIZATION N lS C 77 CHECK OR FILL IN APPROPRIATE SPACES DATE: 13 / PATIENTS NAME OM ❑ F COMPANY N ADDRESS 1 AGE- CITY' GE CITY V STATE ZIP DOB O Sn OM OT Ow O Th O F OS l DRIVER'S LICENSE N _ PHONE _—_ NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ __ STATION 1(A)_21B)_3(C)_41D)._5(E)_ @NCIDENT LOCATION:, �L�rl RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) _ y 7TO SCENE- O'S.O. CALL RECEIVED `S 1 ��-a ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 E ❑ PSAP TIME 10-49 rte " MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 `DOCTOR �' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME << O NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J( J RESPONSE ZONE O YES O NO ❑ WALKED O GUERNEY O OTHER 11 PATIENT CONDITION: DRIVER 4��%L�C ✓a S_ EMT-tA ( TECHNICIAN �< < {t >7= ` �— PARAMEDIC / Hx: DISPATCHER: 3 f L F_ f L CHIEF COMPLAINT: DRY RUN: 0 YES ❑ NO REASON FOR LRY RUN Z" L' PATIENT REFUSED SERVICES: (SIGNATURE) X AUTHORIZATION FOR DRY RUN (EMS USE ONLY) :. rr '/ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N I PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE 1 BLUE CROSS It: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO /)1 O 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) 4 t DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: r c TOTAL: r PATIENT RECEIVED BY:X P......i,.. �... _ r�.:... ... r � � . • .. (SIGNATIME) ►r.-1 'i3r`193 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION N2 CHECK OR FILL IN APPROPRIATE SPACES DATE: �+ _ +' PATIENTS NAME j k O MG`V F COMPANY M ADDRESS 3 J© � �" EAGEc, r.r 01-h CITY L�`� STATE ZIP_ DOB Z ( �w 11S El 1XT 13W E3Th O F PS OR4VER'S LICENSE PHONE%5:5�1- 0_U_ NATURE OF DISPATCH Pm,5s S 11ZLIZ. TY• OF TRANSPORT: AMBULANCE OTHER❑ -_ us ------ - - --- STATION I(A)_2(B)_31C) 4(D)_.5(E)_- IIyNCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLO%K) TO SCENE- CALL RECEIVED o D TIME 4.8 �Q PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 4v K J l� Cl PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 f ,�G��e END TIME 10-98 DOCTOR �- 1 PM START TIME 10-22 HOW CHOSEN: ' TOTAL 1! STANDBY TIME ❑ NEAREST C]FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULAZ�CO�P _ I PT. AMBULA RY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON ❑ YES JV NO ❑ WALKED �UERNEY O OTHER j PATIENT CONDITION: DRIVER 1 650 EMT-1A TECHNICIAN Cd rr''�S d PARAMEDIC �- 1 Hx: r e V l V u5 C DISPATCHER: 'k")i - ) y CHIEF COMPLAINT: TT Li C 0 C DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (; PATIENT REFUSED SERVICES: (SIGNATURE) X_- MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER w: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: 7 X \ DIC N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO - 8 ❑ YES ❑ NO NIGHT: (19:00-07:00) . CCHP/PPRP N: .EMERGENCY RUN: _ 5a oj v6 fI/ MEDI-CAL N: CODE 2/3 j 11 v I OTHER: OXYGEN: (PER TANK) F7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) nen °f GATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ) r I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X U ' Q DRUGS: (PER ADMIN.) X NAME. T (_"""" 1 RELATIONSHIP5L5 E.O.A.: (IF NOT REPLACED) ADDRESS: S ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - - ADDRESS: CITY: STATE: ZIP: COMMENTS: C h S ct h e y pVC,6le 7C—P 0052 yl F=o TOTAL: We, _ PATIENT RECEIVED BY:X se nj p,•..,:�,_.. .�.. La.. . _., n:.: _ (SIGNATURE) od CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM.I UNIT AUTHORIZATION-N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME._. (r/i C,! Z_� 1r6./L DN M ❑ F COMPANYN ADDRESS /AGE �(_ n I CITY_ A-S / �t1�{Zr� STATE G ZIP DOB- _ ❑ Sn ❑ M/KT ❑ W ❑ Th ❑ F ❑S DFIVER'S LICENSE a ._ocf j._.. .._J._�__-____ PHONE_ __..-_.�.-_ NATURE OF DISPATCH IIII - TYPE OF TRANSPORT: AMBULANCE?Z OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR LOCK) (QA i Y. TO SCENE�� S.O. _ CALL RECEIVED � CL ` ❑ P.D. TIME 10-8 I PATIENT DESTINA ION. FROM SCENE-� ❑ FIRE TIME 10-97 �v ❑ PSAP TIME 10-49 'Y MILEAGE: �y ❑ OTHER/PVT TIME 10-7 // ENDL��. TIME 10-98 DOCTOR PMD/® START TIME 10-22 HOW CHOSEN: TOTAL - �- STANDBY TIME I NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- PATIENT ❑ DIRECT ❑ OTHER I CALL BACK N: AMBULANCE CO PAN : PT AMBULATORYO) PATIENT TAKEN TO AMBULANCE: Com' RESPONSE ZONE r YES ❑ N S 1 ❑ WAL"ED UERNEY ❑ OTHER - _ to + PATIENT CONDITION. DRIVER Qft�+11 % ' FAI � T-tA J i T E C H N I C I A 3 y0 PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT, DRY DRY RUN: ❑ YES ANO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGEUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. itS -- PRIVATE INS. CO-:.-.___-.._.___ - - BASE RATE: KAISER a MULTIPLE PTS. BASE RATE ) BLUE CROSS a'_ __-_.- --__ TOTAL MILES: X MEDICARE N: E.O.B. ATL ROUND TRIP: ❑ YES ❑ NO );Tt ❑ YES ❑ NO NIGHT: (19:00-07:00) r •.�) CCHP;PPHP a: __ EMERGENCY RUN: / MEDI-CAL a: ___- CODE 2/3 TS v, 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 rr DRUGS: (PER ADMIN.) X NAME LV, ' Jam. %RELATIONSHIP:L-WI E.O.A.: (IF NOT REPLACED) - ADDRESS:_.�._�.'__��/�`J��_.C` _ _ ORAL AIRWAY: (IF NOT REPLACED) CITY _..Sii itJ.`�/s._. ... _ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE .Z Z__.}.. .�6_cj WORK PHONE .- _- DRY RUN: ,(AUTHORIZED) EMPLOYER: _._____-__._._____ OCCUPATION:___.--- OTHEP: ADDRESS: -------- --- - _ ;-_ �J•of /7 CITY: STATE: ZIP:- COMMENTS: IP:COMMENTS: _ --- ----- -_ TOTAL: l L J`0 -_- - ,-_-- PATIENT RECEIVED BY:X �( /�•nvi drr rr l,;ia g1, (SIGNATURE) c i r. i ir -r;. P.•:,n• r�-.•� •n;,, mac' the: t i 1 ia� 015-1 I NT A COSTA COUNTY AMBULANCE �3 U a PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION M d 1 --CHECK OR FILL IN APPROPRIATE SPACES DATE: _ 1 'PATIENTS NAME - V D M O F COMPANY N 1 ADDRESS . 2 2 Q C 1� f^ �� I n—SEE AGES /f CITY - STATE_:,._._,. ZIP DOB ❑ Sn ❑ M O T D'`iV O Th O F OS DRIVER'S LICENSE N PHONE NATURE OF DISPATCH L �� - I TYPE:OF TRANSPORT: AMBULANCE 0 OTHER 0 _ — STATION 1(A)_2(8)_3(C) 4(D)_5(E)_ C Y7 INCIDENT LOCATION: I RESPONSE CODE! RE UESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED I �— o G ree►� WWI , . 3 �—,_ . IJ�.J.� Fr" .:: �� ❑ P.D. TIME 10-8 PATIENT DESTINATION! ---• FROM SCENE - ❑ FIRE TIME 10-97 .r 6 O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 c(56 TOR - 1 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL /K STANDBY TIME j❑ NEAREST,.:. O FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBUL�!CE PO�PAI'lY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SO RESPONSE ZQ�f�� ;..�„ O YES ❑ NO O WALKC3 O OTHER ` S PATIENT CONDITION: DRIVERC I1 �^ �� _ EMT-1A M ` TECHNICIAN CQ, "S -)L PARAMEDIC H.: IC'-22 IO t' ,.SUSS 1 1�!t S �� . . DISPATCHER: �04 CHIEF COMPLAINT: I DRY RUN: �7 YES ❑ NO REASON FOR DRY RUN Per cI=(J (o AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I n. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: . ... INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: y/ S.S.w I i PRIVATE INS.CO.: - , BASE RATE: 1 KAISMULTIPLE PTS. BASE RATE BLUE CROSS M: I TOTAL MILES: X MEDICARE N ' E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP C ' ' t EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER:_j 'u 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/ ESPONSIBLE 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) S.ZUc ! ` EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: '-COMMENTS:- 0 L TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY:X .�c �.. ... , ISIGNAI UAEI r ; . f f CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHICK OA/Ill IM APPROPRIATE SPACES DATE: PATIENT'S'NAME I L O M ❑ F COMPANY M 12 t 7 ! 1 1 ADDRESS;, AGE 0 C f CITY STATE ZIP DOB ❑ Sn ❑ M ❑ TW O Th ❑ F OS lK / - ► DRIVER'S LICENSE 0 PHONE _— NATURE OF DISPATCH di r+ 0^ OL" - TYPE Of TRANSPORT: AMBULANCE THER❑ 1 - STATION 1.(AI 0_3(C)_4(D)_5IE), INCIDEA0LOCATION:!-� t RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO VCENE- A S.O. CALL RECEIVEDCy - S O P.D. TIME 10-8PATIENT DESTINATION:DESTINATION: FROM SCENE- FIRE TIME 10-97 _/ -- 11PSAP TIME 10-49 Df� 'r } !x`22 MILEAGE: ❑ OTHER/PVT TIME 10-7 tl-- ► END TIME 10-98 r 7 SiDOCTOR'' "' ;' :- PMD/ER STAR T-?� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST•'_r, ❑ FAMILY ❑ TRANSFER WAIT TIME ! ❑ PATIENT O DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COOOMMP yY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 50 RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER- ,6 cr PATIENT CONDITION: 1 DRIVER BteG - 125 EMT-1A 'r -'1 1 - ( TECHNICIAN ?0 PARAMEDIC 1i Hx: I 1-'2 Z >>('I-!LL DISPATCHER: L CHIEF COMPLAINT: DRY RUN: KYES ❑ NO REASON FOR DRY RUN ^152 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) i:_).PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: .. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: " S.S. 0 PRIVATE INS. CO.- BASE RATE: j KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS 0: ; ' ' TOTAL MILES: X MEDICARE M;' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) If CCHP/PPRP M: ' ' EMERGENCY RUN: MEDI-CAL N: 1 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/R PONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ---NAME:..7-- 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: 1 ADDRESS: M CITY: STATE: ZIP: - COMMENTS: n• - -- TOTAL: Jfl PATIENT RECEIVED BY:X CONTRA COSTA COUNTY AMBULANCE f 1 .PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: - ��, PATIENT'S NAME��'_% t1:a_.�.�•� r 1 c ir.' M ❑ F COMPANY M ADDRESS 12 t I�r 1 ( ':( y AGE— CIT I Y GE CITY C C 11( STATE 11 • ZIP-,-y Z.o DOB 3 I'-1" y ❑ Sn ❑ M ❑ T )2rW O Th O F O S. ! DRIVER'S LICENSE a _tt. l..____(i(.__r-=�__ —_ PHONE NATURE OF DISPATCH 1-1 Q TYPE OF TRANSPORT: AMBULANCE D OTHER❑ STATION 1(A)_2(8)_31C1_4(D)_5(E)_,–.... ...' IN&,bENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) _ as,. ;r TO SCENE- S.O. CALL RECEIVED t (7 lz lj c t1r[lu� �� �� Z— ❑ P.D. TIME 10-8 ' �f,. :.���.., 1 PATIENT DE TINATION: FRO' M SCENE- Z D FIRE TIME 10-97 - O PSAP TIME 10.49 2- c c : -SSS !-/ _ MILEAGE: '110-OTHER/PVT TIME 10-7 r END f TIME 10-98 2-Ef DOCTOR 712 P / .��' PME�7EW_- START 7. L TIME 10-22 -- HOW CHOSEN: TOTAL ��' STANDBY TIME - ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT VDIRECT 11OTHER (%' CALL BACK M: AMBULANCE COMPANY: _ 7/ PT/AMBULATORY? PATIENT TAKEN TO AMBULANCE: j v ' RESPONSE ZONE �� l YES ❑ NO WAL"ED O GUERNEY ❑ OTHER t PATIENT CONDITION: DRIVER LA., H L I< <R 3,T0 0 T.ik Z� i TECHNICIAN tit 6 r[ t 13 PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: i r,� +C�tem T_4r?{DRY RUN: ❑ YES NO REASON FOR DRY RUN r% ,r ,r((_ I ') c }�� _c 1'17. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ! `5 PRIVATE INS. CO.: BASE RATE: //y aJ_- KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS q: TOTAL MILES: X ti MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO i ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: -• / MEDT-CAL M: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ 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' 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: ls` „rcc w OCCUPATION: mec hrltliC OTHER: ADDRESS: CITY: STATE: ZIP: 2-- COMMENTS: -'r- is,,lr rr!r'CI 1Ln rzr ;sk-Ir - i- I ? TOTAL: PATIENT RECEIVED BY:X S� Provider n•ta:r Vh., •r•9 !•j.; ,•Ipp :;rt.r+ )'P .•:P Topp f• ON when bf2'inp IG A R ) OIS-1 CONTRA COSTA COUNTY AMBULANCE G�r PRE-HOSPITAL CARE FORM I UNIT fes/ AUTHORIZATION /N pO A TMJ• CNECK OR FILL IN APPROPRIATE SPACES ( a DATE: }(PATIENT'S NAME ❑ M ❑ F COMPANY M_! , X, - . ADDRESS AGEr v A-/ CITY- K4,Z-TTE ZIP DOB 1O Sn ❑ M 13T 04 ❑ Th 0 F O S DRIVER'S LICENSE N _ PHONE _ NATURE OF DISPATCH t0 TYPE OF TRANSPORT: AMBULANCE EP05THER❑ INCIDENT LOCATION: RESPONSE CODE: REO ED BY: TIME— (24 HOUR CLOCK) V7e f TO SCENE vs.o. CALL RECEIVED .�C NQU-)e1I kJ 4152 f PQFk. � ❑ P.U. TIME 10-8 `PATIENT DESTINATION: FROM SCENE_- ❑ FIRE TIME 10-97fzu / ❑ PSAP TIME 10-49 _ \ J MILEAGE: ❑ OTHER/PVT TIME 10.7 `��_ fff END TIME 10-98 1 "` .?�_. 1('167 DOCTOR PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULES OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE S� ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER a 0`A' �J s FMS T-1AJ TECHNICIAN PARAMEDIC �) CHIEF COMPLAINT: kAl DRY RUN:HER � YES ❑I NO (REASON FOR DRY RUN�'?O� -D' I�1 Y 1 q AUTHORIZATION FOR DRY RUN (EMS USE ONLY ►' JJ PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N k PRIVATE,NS.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) 14 CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 J OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST R ELATIVE/REI 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) PHONE: ORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: CGUPATION: OTHER: • ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL_ PATIENT RECEIVED BY: X (SIGNATURE) rN• 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N�r3- ( � 4 CHECK OR FlLL IN APPROPRIATE SPACES 1 DATE: J � 'PATIENT'S NAME- I J ❑ M ❑ F COMPANY 0 ADDRESS' I AGE NN CITY STATE ZIP DOB -❑ Sn O M ❑ T *A W O Th O F O S DRIVER'S LICENSE$1 PHONE NATURE OF DISPATCH /tel E-9 L'" ad��to. r� TYPE TRANSPORT: AMBULANCE 0 OTHER 0 — — STATION 1(A)_2(B)_3(C)._4(D)_5(E)-.l v lam' INCIDENT,LOCATION:' �I ( RESPONSE CODE: EOUESTED BY: TIME—(24 HOUR Cy/OCK) �{ - TO SCENE- J S.O. CALL RECEIVED /f O���C� {'� !'� ❑ P.D. TIME 10-8 .. �s�! PATIENT DESTINATION: FROM SCENE- 13 ` FIRE TIME 10-97 '' :Oji 1 , /j• ,' ' ' "1 ❑ TIME 10-49 MILEAGE: 13OTH OTHER/PVT TIME 10.7 •� END T—�— TIME 10-98 OdCTOR' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ;!T-.E ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME 1 ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j; RESPONSE ZONE i U7 O YES..❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER' I i PATIENT CONDITION: DRIVER td!I I IG(mss / EMT-1A TECHNICIAN 1 PARAMEDIC `/ Hx: DISPATCHER: �sj 17 CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN e e� ALITHORIZAPON FOR Y RU EMS USE ONLY) "(5 Y. s?.'..• , PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.0 - + PRIVATE INS. CO.: BASE RATE: ': KAISER N: f MULTIPLE PTS.BASE RATE t.' BLUE CROSS 0: TOTAL MILES: X MEDICARE M:' E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL N: A CODE 2/3 OTHER: OXYGEN: (PER TANK) r P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (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) --,�,,,11 PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) .7�•�U EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: yam ;, "-COMMENTS: TOTAL: . ►' — PATIENT RECEIVED BY: X r.....,,,_ ... : .. .. .. (SIONAI URE) tM5-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I AUTHORIZATION N 1 1 CNfCK OR FILL IN APPROPRIATE 3PACE5 DATE: / }PATIENTS NAME ) ❑ M OT COMPANY k / 7 ADDRESS' "' ': /AGE ( Pe 1 _ CITY --STATE—ZIP DOB ' O Sn OM O T kW O Th ❑ F Os DRIVER'S LICENSE N ` PHONE NATURE OF DISPATCH TYPEOFTRANSPORT:,AMBULANCE OTHER 0 STATION 1(A)_2(6)_3(C)_4(D)_5(E)_ INCiOENT LOCATION: - RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) C.l - I TO SCENE- 2 t6:0. CALL RECEIVED AQ (.A I - �iLGO�wCj Y •-- — ❑ P.D. TIME 10-8 1 PATIENT ESTINATION:'. _-i FROM SCENE- ❑ FIRE TIME 10-97�l _ "` I ❑ PSAP TIME 10-49 :4 , I_ MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR _ w, PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST O FAMILY O TRANSFER WAIT TIME —_ ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBUL NE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �� 1 RESPONSE ZONEti ❑ YES ;❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ITTr. l �,3 PATIENT CONDITION: � ' ) DRIVER �✓ I L EMT-IAP,2 s:�1lr: G Z TECHNICIAN 1A PARAMEDIC y r/ Hx: DISPATCHER: /o1G' CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN -J�! AUTHORIZATION FOR DRY RUN(EMS USE.ONLY) QC /� PATIENT REFUSED SERVICES: (SIGNATURE)X J MEDICAL COVERAGE: .. INDUSTRIAL ❑ YES 13NO NO. OF PATIENTS: r el i S.S.M PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: - ` 1 TOTAL MILES: X MEDICARE C ' E.O.B. ATT. ROUND TRIP: O YES ONO J _ _ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: ► i EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: �' ' l 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: - 1. STATE: ZIP: -' COMMENTS:' -' TOTAL: �57V, 005 _>G - PATIENT RECEIVED BY:X (SIGNA1 URE) Pw+i 1ir rota Vhi�s ,n.l !'in,L .•,.�,L u•r..- ," ;.�, nr ,,.... I ,. [Mt-1 ' f CONTRA COSTA COUNTY AMBUL Cf, PRE-HOSPITAL CARE FORM I I ET. UNIT AUTHORIZATION# IIIIJJJJ 1 CHECK OR FILL IN APPAOP IA If SPACES DATE: I PATIENTS NAME _ ❑ t�F COMPANY# { ADDRESS AGE— cm GE CITY STATE w f P DOB _ ❑ Sn ❑ M ❑ T ❑ ❑ F OS i DRIVER'S L CENSE# PHONE__ __.. -- NATURE OF DISPATCH T(PpOFTRANSPORT: AMBULANCE❑ OTHER❑ _.____. .__..._..__... INCIDENT LOCATIO RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK). L�+ Y — ` � TO SCENE- 0. — CALL RECEIVED J� 'J-�- 1 c � ') 1 ❑ P.D.— TIME 10-8 3r PA TENT DESTINATI0 FROM SCENE- ❑ FIRE TIME 10-97F n ❑ PSAP TIME 10-49 MILEA ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR 1 . I PMD/ER START_ TIME 10-22 T7T— HOW CHOSEN: TOTAL A STANDBY TIME ❑ NEAREST. ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COtAN�( PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S0 RESPONSE ZONE' f / r. ❑ YES ❑ NO WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER :570 EMT-1A ' TECHNICIA 1 � PARAMEDIC ^ j Hx: DISPATCHER: Y CHIEF COMPLAINT: DRY RUN:AYES ❑ NO REASON FOR DRY RUN UTH RIZATION FOZ.l R EM USE ONLY) Q 5,2 PATIENT REFUSED SERVIC (SIGNATURE) X— �� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: /N 7, / /✓CSS/ S.S. # PRIVATE INS. CO:: BASE RATE: ` KAISER#: MULTIPLE PTS. BASE RATE t 1 BLUE CROSS# TOTAL MILES: X 1 MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP EMERGENCY RUN: i MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O Y ❑ NO NEONATAL: (INCUBATO DATES BILLED: STANDBY: (OVER 15 M ) E.K.G.: (PER FPD NEAREST RELATIVE/RESPONSI LE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER AD N.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT RE LACED) ADDRESS: ORAL AIRWAY: (I NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NO REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHOR ED) S EMPLOYER: OCCUPATION: OTHER: ADDRESS: I CITY: STATE: ZIP: COMMENTS: TOTAL: __.�. PATIENT RECEIVED BY: X Provider retain, White rxd Pi- cope heeuni y, , I f.% rah r: 7:l'i.;., (SIGNATURE) Ens-1 .,* CONTRA COSTA COUNTY AMBULANCE ��� PRE-HOSPITAL CARE FORM i UNIT Z AUTHORIZATION# CHECK OR FILL INAPPROPRIATE SPACESa z- DATE: III �J ` t PATIENT'S NAME i✓ O M O F COMPANY III I 4 ADDRESS AGE G CITY STATE - ZIP DOB_ _ O Sn OM OT XW ❑ Th OF OS DRIVER'S LICENSE# _ PHONE_ ___ NATURE OF DISPATCH ��N�1�M to -,# TYPE OF TRANSPORT: AMBULANC OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK �^ TK TO SCENE - O. CALL RECEIVED —� . }1' 06 p.U. TIME 10-9 ` iT- PATIENT DESTINATION_ : FROM SCENE 0 O FIRE _ TIME 10-97 ; f O PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END / TIME 10.99 DOCTOR PMD/ER START_[__ t ` TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME s I- ❑ PATIENT 13 DIRECT O OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES O NO O WALKED AUERNEY O OTHER PATIENT CONDITION. DRIVER a©Q FMT-tq _ TECHNICIAN _ ( Soo 3q5- PARAMEDIC /Qf Hx: DISPATCHER: Liq / CHIEF COMPLAINT: DRY RUN: ES ❑ NO REASON FOR DRY RUN YY`T AU,THORI Ti N FQR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X� _ _ t CAL COVERAGE: INDUSTRIAL ❑ YES ;5,NO NO. OF PATIENTS: S_S # PRIVATE INS.CO.: BASE RATE: i KAISER#: MULTIPLE PTS. BASE RATE ' BLUE CROSS#: TOTAL MILES: X I MEDICARE#; _ —E.O.B. ATT. ROUND TRIP: ❑ YES ONO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: ' EMERGENCY RUN: MEDI-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ Y S ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) } NEAREST RELATIVE/R SPONSIBLE 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: �� CONTRA COSTA COUNTY AMBULANCE 3 ` If PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N • CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME �/ - S M ❑ F COMPANY ... I r 1 ADDRESS AGE ISR �� (.) • J CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T O W D Th tF ❑ S DRIVER'S LICENSE 0 _ __ PHONE____—__—_ NATURE OF DISPATCH fAI& TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION:1 I RESPONSE CODE: EOUESTED BY: TIME-- (24 HOUR CLOCK) , �� 33 o e (� P TO SCENE 3S O _ CALL RECEIVED ' v I rr � ❑ P.U._ TIME 10-8 .L PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MIL E: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 L/ � 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 p"Y: C .A i PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 150 RESPONSE ZONE) O YES ❑ NO ❑WALKED ❑ GUERNEY ❑ OTHER ' PATIENT CONDITION: DRIVER C ANe-7 /IM 5 O EMT-1A TECHNICIAN W 1 L L - IC Hx: _ f A L DISPATCHER:, CIS. P /41 U i CHIEF COMPLAINT:GAC T_9_9A6A_V_ DRY RU ❑ YE ❑ NO REASON FOR DRY RUN t _- 60141 6 0'y AUTHORIZATION OR DRY RUN(EMS USE ONLY) /qq PATIENT REFUSED SERVICES: (SIGNATURE) X�/ ('I tt511� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: r S.S. N PRIVATE INS. CO.: BASE RATE: I KAISER N: MULTIPLE PTS. BASE RATE 1 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 k: 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) m— PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) _ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: e wEs 1 cny A i y tIIRt-" Or-if. mu-nirrz m c-Q .SI1F w—no_L_0 =14ATOTAL:—_ Uusn_4r_.. ._...._. 0 0 5 W PATIENT RECEIVED BY: X_ n (SIGNATURE) Fti+niArr rrf rr, 4 ri f.. ,r r r/.•' ,..r,r. r.,-lo.... 1. . . I'll .r r ', fM CONTRA (:OSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT ;` AUTHORIZATION 0' CHECK OR FILL INAPPROPRIATE SPACES (� DATE: _� - y PATIENT'S NAMEI �lv K Lt n l �� • M ❑ F COMPANY 0 1, CG AdDRESS 3 3 4[L ! �1�,-)_L—T':)I�F 2T AGE -7/ .2— - CITY L� STATE _ ZIP__ DOB�'Z-O,Z-�/❑ Sn O M 13TW O Th O F O S DRIVER'S LICENSE q ____ —._ _._ PHONE4S ��7 NATURE OF DISPATCH 62 TYPE OF TRANSPORT: AMBULANCEV OTHER O STATION 1(A)_2(B)_3(C)._4(D)_5(Ek__._. INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE - O S.O.—. CALL RECEIVED — I A _ ❑ P.D. TIME 10-8 �} I PATIENT DESTINATION: FROM SCENE ❑ FIRE —_ TIME 10-97 ( ❑ PSAP TIME 10-49 - 1 ' C At, s L' — MILEAGE- >� 1�OTHER/PVT TIME 10-7IT n ���• END — G C L ��TIME 10-98 DOCTOR _ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME I ❑ NEAREST O FAMILY ) TRANSFER WAIT TIME ' O PATIENT O DIRECT O OTHER CALL BACK N: AMB LANCE COMPANY: 4.s PT. AMBU TORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES PNO VWAL'<ED ❑ GUERNEY ❑ OTHER t;l I PATIENT CONDITION: DRIVER TECHNICIAN PARAMEDIC Hx: S I�zv �_ DISPATCHER: CHIEF COMPLAINT: � IA I DRY RUN: ❑ YES K_NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r t PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YESVNO NO, OF PATIENTS: S.S. K I PRIVATE INS. CO.: BASE RATE: l/u LkiEER — MULTIPLE PTS. BASE RATE 1 6Rp5 p: G�� I" G -�Sw S TOTAL-MILES: X G �� MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO , d� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: ��' -s).y MEDI-CAL K: CODE 2/3 —•- I OTHER: OXYGEN: (PER TANK) ; P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) I i L DATES BILLED- STANDBY: (OVER 15 MIN.) IIVr� E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER(PER ADMIN.) X NAME: Ot E �_ N 0 RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: 6UN' ( ORAL AIRWAY: (IF NOT REPLACED) CITY: h1 1+��-`r - STATE-:C-11 ZIP: C COLLAR: (IF NOT REPLACED) - PHONE. �y �L(� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: -"-� ADDRESS: CITY: STATE: ZIP: COMMENTS: t TOTAL: - - PATIENT RECEIVED BY:X G Pmvidrr rrra:! Ai,r (-rd ^ir, •opt .4eturr Yo'l,c n,y Ewl� when Eil'inp ISI TORE) Oli-1 CON IIlA COSTA COUNTY AMBULANCE II PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M �� ' CHECK OR FILL IN APPROPRIATE SPACES DATE:.. o If 1 PATIENT'S NAME.i}�'__1_ �;j��_7 ' �'�� _ _ Q_M F COMPANY M_AX AQREZ � 3AGE STATEC—ICI ZIP41 Ll S �r' > D08 � O Sn ❑ M ❑ T ❑ W ITh 0 F O $— f' DRIVER'S LICENSE a __ PHONE_ 3=5�6 _ NATURE OF DISPATCH��C L - I 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 CLOCK) TO SCENE- S.O. CALL RECEIVED ) �' ❑ P.D. TIME 10-8 r. PATIENT D4ESTI FROM SCENE ❑ FIRE TIME 10.97 11 I � 11PSAP TIME 10-49 - 1 MILEAG ,, ❑ OTHER/PVT TIME 10-7 (.115P� END—(' TIME 10-98 DOCTOR rr 'v PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 'PATIENT DIRECT ❑ OTHER 7� ' CALL BACK-,a: AMBULANCE COMPAN.Y:5 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: Sv [RESPONSE ZONE ❑ YES NO ❑ WAL'',ED GUERNEY ❑ OTHER 5 f PATIENT CONDITION: DRIVER 1����}'( r 67EMT-1A TECHNICIAN Z4_ L 7C)O PARAMEDIC -� I Hx:/l1 I�I F l jjj 3I a>J DISPATCHER: ��%( (.- i I_ (i4 CHIEF COMPLAINT: Nt i C E(_ f OC-L- .9/AJ(9H 1P DRY RUN: ❑ YES O REASON FOR DRY RUN I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X__ �V MEDICAL COVERAGE: _ INDUSTRIAL ❑ YES/1�11NO NO. OF PATIENTS: / ��(-• S.S. PRIVATE INS. CO.: BASE RATE: ftklSl R p:' ei �7G,�� MULTIPLE PTS. BASE RATE i T- ---7 "j BLUE CROSS M: y TOTAL MILES: X J. D-1 (.� ,� Ij .\ iVfE DICE.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O S y I ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP a: EMERGENCY RUN: a U �l MEDI-CAL a: CODE 2/3 OTHER` OXYGEN: (PER TANK) I I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) G DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X . T t DRUGS: (PER ADMIN.) X V NAME: �t]�� L Lny/�� RELATIONSHIP" F�`'L E.O.A.: (IF NOT REPLACED) ADDRESS: L-I II Imo ') n) f'lrc I ORAL AIRWAY: (IF NOT REPLACED) _ CITY: 1sL�(��[�._�� r.L�_—_ STATE C4-- ZIP:•(� C-COLLAR: (IF NOT REPLACED) ' ` •- PHONE- 'ice-i-r 1 ( WORK PHONE: DRY RUN: (AUTHORIZED) L 1�c7L-z� EMPLOYER: -�L<f j f=�4 •7 OCCUPATION: OTHER: 1t' ADDRESS: CITY: STATE: ZIP: �- COMMENTS: rnTel • PATIENT RECEIVED BY:X (SIGNATURE) C P?-.wider retair whir :rd F:r.: --Pt, RrILrI Ye':oc ropy LN: when t•ii'ina o 01ST r 0600 CONTRA COSTA COUNTY I AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTO RIZATIONO CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME O M ❑ F COMPANY N �`� ' ADDRESS AGE CITY I • STATE -ZIP DOB_,_ ❑ Sn OM O T /O W Th ❑ F O S DRIVER'S LICENSE N ' PHONE NATURE OF DISPATCHyNCoA)SUOUS TYPE;bF TRANSPORT: AMBULANCEV OTHER O _ STATION 1(A)_2(B)-3(C)_4(D)_5(E)_ INCIDENT LOCATION! RESPONSE CODE: REMESTED BY: TIME- (24 HOUR CLOCK) n -I I J f� (' TO SCENE- Rf S.O. CALL RECEIVED _L I C 1 7 IC:SCC ELAy! O P.U. TIME 10-8 1 / PATIENT DESTINATION: FROM SCENE- _� ❑ FIRE TIME 10-97 ' �/ 2 V ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 .:DOCTOR'T I PMD/ER START TIME 1042 HOW CHOSEN: TOTAL STANDBY TIME r•�`."....❑ NEAREST r; ❑ FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULAN E,CQMPANY: t 1-fJ 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES .❑ NO ❑ WALKED ❑ GUERNEY O OTHER • 'i7 PATIENT CONDITION: ' DRIVER U ALE 00EMT-tA L i AN o1 —a TECHNICIAN RAMEDI Q Hx: DISPATCHER: l •'^ . D bl CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l�r02 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 L 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: 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.) 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: I ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL S 00601 % PATIENT RECEIVED BY: X __.- __ 1. CONTRA COSTA COUNTY AMBULANCE 1 PRE—HOSPITAL CARE FORM I I1NIT AUTFk�RIZATION M CHECK OR FILL IN A PPROPRIATE SPACES DATE: PATIENT'S NAME/ ,�a-.___._ ___1_.��_ ❑ M COMPANY 0 ADDRE6 AGE O 7.�O CITY Z QAC''`c�___ STATE.-_.`-�. ZIP_. _ OB /���� Sn ❑ M T ❑W O Th OF OS 25� \ _ DRIVER' LICENSE p ___ _.___ . , . ._. .___.. . _. PHONE .21 ATURE OF DISPATCH =€ TYPE OF RANSPORT: AMBULANCE OTHER❑ INC1flENT OCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C CK) -" y•1 L G n P_ TO SCENE - 2 4 S.O. CALL RECEIVED / I --Sj _5 ___ _ O P.U. TIME 1Q-8 L� PATIENT DE TINATION: FROM SCENE j IRE _____ TIME 10-97 L� PSAP TIME 10-49 MILEAG ! n� ❑ OTHER/PVT TIME 10 7 - END_ _ �( — 0- DOCTOR .__ PMD/ER START f __ _ /`` _ TIME 10-2 (_-_i HOW CHOSEN: TOTAL ____—__. _ STANDBY TIME NEAREST El FAMILY ❑ TRANSFER - WAIT TIME .❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK It- AMBULANCE COMPA Y: PT AMBULATORY PATIENT TAKEN TO AMBULANCE: S O RESPONSE ZONE_ ❑ YES ❑ NO ` 0 WZL':ED ❑ GUERNEY ❑ OTHER /I PATIENT CONDITIO�1 DRIVER_( _ . LyZ73 rLO/nEMT-1A_ TECHNICIAN OaARAMEDIC �j ► Hx: ..-- -- -- -- ------- DISPATCHER. 71 J CHIEF COMPLAINT _�_____-_....___--____ DRY RUN: YES ❑ NO REASON FOR DRY RUN T� d 'I TH RIZATION gbFI DRY ( S USE ONLY PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE- 1 INDUSTRIAL O YES O NO NO. PATIENTS: S.5 ++ ----- --- 1----- - -- -- PRIVATE INS. CO.:._.._..' _-_.____ _ BASE RATE: KAISER t+: _ MULTIPLE PTS. BASE RATE BLUE CROSS#:— __ -__--- TOTAL MILES: X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES O NO _► t ❑ YES Cl NO NIGHT: (19:00-07:00) CCHP;PPHP is: —_ . EMERGENCY RUN: MEDI-CAL CODE 2/3 OTHER:— _ OXYGEN: (PER TANK) r\ P.O.E. STICKER ❑ YES Cl,NO NEONATAL: (INCUBATOR) 11 DATES BILLED: STANDBY: (OVER 15 MIN.) jS E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPON51(3LE PARTY: I V.:. (PER ADMIN) X L/0 i/4� 1 I ` DRUGS: (PER ADMIN.)- X NAME:./7'L' "'C !_.__- RELATIONSHI�d, 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 EMPLOYER —__ _.._...._ OCCUPATION -- OTHER: ADDRESS ---_--------_------ CITY_ _--____-_ STATE: ZIP: COMI,AENTS: ._.--. - TOTAL: -io PATIENT RECEIVED BY:X (SIGNATURE) F7"Vi._'�r rrt.:• h,r.. �.? n:,,: r� =,t.r 1'r':,�• -.�i. nl!' V5r•v Li1'inJ �. RE: '_r'7us I r � CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I _ / UNIT L, AUTHORIZATION M � S�l CYECK OR FILL INAPPROPRIATE SPACES V DATE: ._Y_.l ' 1r _y L'1f 1 •1� � 1^ PATIENTS NAMEp �NS�y-� �_!�_ ❑ M AF COMPANY a__ 1 13 ) ADDRESS I! l� (/i/Z Lla AGE -3 !�__'/ CITYTZ STATE - - DOB3' .Z��Y ❑ Sn ❑ M ❑ T ❑ W Th ❑ F ❑•S - Z� y�, I DRIVER'S LICENSE K ------ ----._ PHONELa - �c' - NATURE OF DISPATCH ,►�/VS TYPE OF TRANSPORT: AMBULANCE OTHER❑ L_J.. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME - (24 HOUR CLOCK) Nq^Q 'l TO SCENE-n ❑ S.O. -- ___ CALL RECEIVED P_ : L1 -1 cc C _ — ❑ PD. _____ TIME 10-8 `) : PATIENT DESTINATION: FROM SCENE ❑ FIRE .__-__ TIME 10-97 2a: ❑ PSAP TIME 10-49 -.L_ : (a /* ��1x__n/!2 /Z��1 _L—CY MILEAGE: V 0 FIER/,PVT TIME 10-7 r END yl !'L! L. TIME 10-98 - L DOCTOR PMD/ER START_ �' _ ��� TIME 10-22 HOW CHOSEN: TOTALi_. STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER t) CALL BACK u: AMBULANCE COMPANY: AS PT. AMBULATORY? PATIENT TA N TO AMBULANCE: 1 + `( RESPONSE ZONE ❑ YES !k NO ❑ WAL`:ED GUERNEY ❑ OTHER I • - _ PATIENT CONDITION. DRIVER_,,�4.� EMT-1A cRo _ TECHNICIAN, t�� �� + ^� PARAMEDIC /�) Hx: "'' DISPATCHER: -� •I��,__- + + _ _ I C CHIEF COMPLAINT. - _- - DRY RUN. ❑ YES NO REASON FOR DRY RUN—_ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - f PATIENT REFUSED SERVICES: (SIGNATURE) X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS S.S. a t / PRIVATE INS. CO.: _ BASE RATE: KAISER#: — MULTIPLE PTS. BASE RATE BLUE CROSS#: _ TOTAL MILES: ___ X o MEDICARE a: E.O.B. ATT. ROUND TRIP: Cl YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07.00) � ln} ` CCHP/PPHP#.0,7- `� GI Sy�O L�•!Z EMERGENCY RUN: 0, D CA q �*_S_Y...r1� 'i '- �v CODE 2/3 I�I OT® 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) EMPLOYER. OCCUPATION:- OTHER: ADDRESS: - -- - -- ----- -- - CITY: - STATE:-----ZIP:-- - ------.__ ._-- ._. --- _—._-- COMMENTS %JVUUrte. TO TAI 166.00 �_ r . . .► .If mllmm 1,1")803 3 5f� ��� it�J SEP I 35G Pl'i 133 n SSP I 3 5s I'M '� i / J SO NUMBER - 14 Cj tq L ; CALL RECEIVED _- AMBULANCE D! PATCH!! _ AMBULANCE ENROUTE 10.8 J n CALLED BY- t: �j'TZt PATIENT INFORMATION .ts DNAME: -__ '-�"•�-'Ll. .�. ._ (✓� AGENCY: _ C-� G - - -- �`�-'� CUSTOMER T. 1}: DOB: pEPTJFtOORJRQOM p: -�� �? j �- �i�iQ L� NAME: n () Z 3 7 Z _4 2-��_.._ ! j m .. a CALLBACK a INS. TYPE: PVT MCAR At K�P PHP IND CHAMPUS > ' •� Vi V INCIDENT LOC: . c Q 213 . CQ�� i POUCYJMCAL N: �� -�_._. MCAR p: L�1 .�`S� D SQ -9p'D 7— Z m D CROSS STREE VERBAL PRIOR: o a JURIS: Gt - --- DESTINATION: _.__t-! _•_- �L PT. $12 NAME: DOB: NATURE: -n--)—_- ST. N ! a --- --- J ." -T7 -- - r �� PT. a3 NAME: DOB: '0 o TYPE OF CALL: EMG � TIME UNITb O COST. # z ..� m CREW: _._ WAIT TIME: YES NO REASON: 2 O UNIT TYPE: At5 yi W RESPONSE CODES 4 REASON FOR 1022: O a INCREASE/DECREASE CODE:2 3 10.49'CODE: 0 1 4 3 CANCELLED BY: m to u BY: END MILEAGE: 7 `L COMMENTS: s --a a TIME BEG MILEAGE: D' 00604 � D DI5PATC LJ6 a TOTAL MILES: ' 6Ai `XL Ot NO 1 33NVTnewv 61-Ol `O"NINNni tl 3DNo ln6Wv 8601 3T9vTtt+Av 33Nv1f18wv L^01 1v1idSOH ld 3�NVT119wY p 1 f �'�L ►,� �� � � ��� Ind ez � I X35. £8, F'' s� � �.. wm-Aa FEW .f N`•�'. :r( �'�.... 4.-�',wYs+•. .y'R: :'?�s fk•�'LI+Ii'T..1".�'.' .�.�.. ':x o.,•.J[*'�.�Y: � y�. ' 7 777(- Hit• •:'!:. .�. 7 ��5 ik� + _yi(ytd F ..y i+ ''('• •tn. •t� L�'M �'ti 9y.r �•ar'k�fz t '�t: ' .1: - ._ � ,� "-j i i 1'�!•^�!4'�� r,x�' .gip.'.. M�r �,, ..�: �.. A . .� "7.': . � '114•' ,�' Yy �.'�L�' � � I�1 �, i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FM I UNIT AUTWORIZATION N 15 _ - 150 .///�//�!F ,_ . . . .:.,. .,..(. ,•�S is iit+r;�: c CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME__Iq t`-U L S 1� YY�I� u (�-1 c 0 D F COMPANYN ADDRESS _� G CLO IZ h. 3 1' •� f _ ^ AGE��� CITY3L STATE (;� ZIP 1 ��0 y X08 ❑ Sn D M D Tl !3 D F DRIVER'S LICENSE# LS_S? g PHONE — NATUR TCH0T L)AD I TYPE OFTRANSPO t: AMBULANCE HERO _ STATION 1( (8)_31CI��4(br='61E)" I INCIDENT LOCATION: RESPONSE CODE: ; QUESTED BY: TIME— (24 HOUR.C 1 TO SCENE- I S.O.- CALL RECEIVED L. C y 7 �� NG�L� �. �/v� �1 C C►2., vL, ! O P.D. TIME 10-6 f 1: !� PATIENT DESTINATION: FROM SCENE- D FIRE TIME 10-97 O�- ��/1� � �J ❑ PSAP TIME 10-49.A�T y _ 1 ,\ YJ♦ MILEAGE: t 13OTHER/PVT TIME 10.7" `9 ENp ' TIME 10-98. '�f J o•:- i DOCTOR V�L PMD/ START TIME 10-22 '�V 3'•. �EH CHOSEN:> TOTAL STANDBY TIME Sfi WAIT'TIME• 3 �2 ❑ FAMILY D TRANSFER D PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY, PT.A ULATORY? P TiE EEN TO AMBULANCE: ..-.. .�i2 RESPONSE ZED i YE ❑ NO WAL!CEO,u GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 4 �EMT-lA*x TECHNICIAN m Tt �i Z a 7 ERIC Hx: 0 0 DISPATCHER: 6 O CHIEF COMPLAINT: CI-o _'L 5251 PA2A 4 DRY RUN: D YES REASON FOR DRY RUN ; A L rO5 Q QV/_, C`( O H AUTHORIZATIOrJ FOR DRY RUN(EMS USE ONLrJ C. PATIENT REFUSED SERVICES: (SIGNATURE) X ` (� .� rG•�a.'J 7 ,)� MEDICAL COVERAGE: INDUSTRIAL D YE ® N NO.OF PATIENTS: £ r , S.S.# 1 i PRIVATE INS.CO.: BASE RATE: r KAISER M: MULTIPLE PTS.BASE RATE �) .BLUE CROSS M: TOTAL MILES: X r N: E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO f ❑ YES ❑ NO NIGHT:(19:00-07:00) N: EMERGENCY RUN: po S �'7 - - a u 6 3o 7: C� ! COD 2 3 i i�i.I«Mr,)i /tH i X3- '(-000 OXYGEN: FFR TANK) S) 'V ER DYES D NO NEONATAL: (INCUBATOR)TH7Z3�'I 3V l % :.. ED: STANDBY: (OVER 15 MIN.) ' ^ E.K.G.: (PER EPISODE) y ELATIVE/RJFSPONSIBLE PARTY: PT StATLS I.V.: (PER ADMIN.) VfS BI 1II►"+541'F • DRUGS: (PER ADMIN.) Xp NAME: RELATIONSHIP: -E.O.k!(IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED)=--• ye.oQsv+t►. PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) •-- a EMPLOYER: OCCUPATION: -OTHER:--- ADDRESS: OTHER:--ADDRESS: - • CITY: STATE: ZIP: r COMMENTS: 20 PATIENT RECEIVED BY:X Provider rota:.. White and Pi.,: roup Return Ye:l(w np. !N.';when bit•ina (SIGNATURE) =-I. . I CONTRA COSTA COUNTY AMBULANCE ( � PRE-HOSPITAL CARE FORM I UNIT AUTHOR FIZATION K A. CJ ! 9 CHECK OR FILL IN APPROPRIATE SPACES DATE: / - PATIENTS NAME ul,M O M ❑ F COMPANY N (• ADDRESS AGE J �j CITY STATE ZIP DOB ❑ Sn ❑ M O T ❑W Th ❑ F D S DRIVER'S LICENSE M PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER O _ INCIDENT tOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLOCK) V 7 TO SCENE 0. CALL RECEIVED �5 Cµ P.U. TIME 10-8 o ,-7�— PATIENT DESTINATION: t FROM SCENE- ❑ FIRE TIME 10-97 _ ! ❑ PSAP TIME 10-49 MILEA O OTHER/PVT TIME'10-7 ' END TIME 10-98 DOCTOR I } I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- O PATIENT ❑ DIRECT ❑ OTHER CALL BACK q: AMBULANCE COMPANY 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S U RESPONSE ZONE t + ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER a .PATIENT CONDITION: DRIVER �y`� EMT-1A TECHNICIAN PARAMEDIC Hz: DISPATCHER: /�� CHIEF COMPLAINT: DRY RUN: YES 11 NO REASON FOR DRY RUN Nod (� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a I 11 i PRIVATE INS. CO.; BASE RATE: I KAISER C MULTIPLE PTS..BASE RATE BLUE CROSS K: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C 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) _n PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: i COMMENTS: - TOTALS _._ PATIENT RECEIVED BY: X i1•^i,frr ••.•t +; ,.i ry.: (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUT90RIZATION N 1-3-1 S(, / CHECK OR FILL INAPPROPRIATE SPACES DATE: 9 — A - /' . ' PATIENT'S NAME-I'.1.1�_L� �_LI_�.1LS.CL!L�(_` 13M F COMPAN74, / �y oL{ �� _ I�� �?41 ADDRESS AG �] - CITY._-- . STATE- .— ZIP---- DOB_--- O Sn ❑ M ❑ T OW(" OF 0 S DRIVER'S LICENSE #-.__.. .. _..._.__._-- PHONE_.___. -__- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ ___._____.____-. .. INCIDENT rLOCATIIO]N: f i h RESPONSE CODE: REOUESTED BY: TIME - (24 HOURC,LgCK'� ,� TO SCENE A0 P.D. __ TIME 0-8EIVED t,/-��� <� PATIENT DESTINATION: � FROM SCENE- ❑ FIRE ___ TIME 10-97 pZ,L }' r �tL�.U_[1- LSLL_11' L�L1 _ ---- 1� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 Ll- (^� ��j( S END TIME 10-98 DOCTOR .�LL z. �f PMD/ER START- 15-6-51 - TIME 10-22 HOW CHOSEN: TOTAL _ '{ v STANDBY TIME ❑ NEAREST Cl FAMILY Cl TRANSFER / WAIT TIME ❑ PATIENT ❑ DIRECT OTHER ���1 \•- ) / CALL BACK It: AMBULANCE COMPANY: i _ CA S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S 0 RESPONSE ZONE YES ❑ NO WAL':ED ❑ GUERNEY Cl OTHER O PATIENT CONDITION: DRIVER__..Vh���L11- 7 1 �EMT:1A TECHNICIAN b(so ,til PARAMEDIC Hcf_L .Lin'.L___ _ _. DISPATCHER:� �l I 6 i i 3HIEF7C��O�MPy AINT: _���;�])._/_�(AIS.L�1. DRY RUN: ❑ YES i -. REASON FOR DRY RUN LLL"mi tl�fll-,y� CC.�lLtJ�/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X_�_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES LNO, NO. OF PATIENTS: OVA cc _ S.S a --- ---- PRIVATE INS. CO. __ ____-_— BASE RATE: KAISER x: 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#: C�-���-� 'G2 EMERGENCYRUN: • MEDT-CAL#: CODE 2/3 OTHER: 71 ---� A, r OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: __ - STANDBY: (OVER 15ITv11N.) E.K.G.: (PER EPISODE) NEAREST RELATIVE'RESPONSI173LE 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 '1 F�•>rii. r�Lci r' r•. J:=rl:,n ^'.' ::h^v F!J- (SIGNATURE) [MS-1 I I CONTRA COSTA COUNTY AMBULANCE Q t� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION A3_ CHECK OR FILL IN APPROPRIATE ))SPACES DATE: - PATIENT'S NAME C_.'t I �..I}:I _I'.Lx� ._._ _ ❑ M F COMPANY# ADDRESS � �-�---- -_ll.C.L��------ AGE -13 72 / CITY_ Oil_• STATE I ZIP"I I t1() h DOB_L LLLL%J ❑ Sn ❑ M ❑ T ❑W ❑ Th XF O S DRIVER'S LICENSE# ___._____ _ PHONE �—I�NATURE OF DISPATCH�W _A � TYPE OF TRANSPORT: AMBULANCE�l OTHER❑ __. `—___ • . i INCIDENT LOCATION: RESPONSE CODE: EQUESTED BY: TIME— (24 HOUR C^LgCK)7�_. tt ^ ,� k�t , r TO SCENE S.O. CALL RECEIVED U ✓������ __ `` ❑ P.U. TIME 10-8 dJ tZ�_ PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 �7s1 ❑ PSAP TIME 10-49 1 , lez, MILEAGE: ❑ OTHER/PVT TIME 10-7 END��1 TIME 10-98 (J� _ DOCTOR - _. _ PMD/ER- STARTTIME 10-22 HOW CHOSEN: TOTAL ��Y STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT �DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5RESPONSE ZONE - YES O NO ❑ WAL':ED 0 GUERNEY ❑ OTHER PATIENT CONDITION: DRIVEFI a 3 _ EMT-1A TECHNICIAN b V PARAMEDIC Hx: DISPATCHER: (}( CIEF Clp) PLAINit �1 Y-' t UTHORIZARY RUN: ❑TION FOR DRY RUNAYES A&O SEMS DOSE ONLON FR DRYY) N ] {{ �i PATIENT REFUSED SERVICES: (SIGNATURE) X__ (7 l/ MEDICAL COVERAGE: INDUSTRIAL ❑ YES P�NO NO. OF PATIENTS: S.S. a_ _2 PRIVATE INS. CO. � ��1_LS��?11b �( �F �n BASE RATE: -v KAISER #: _ _— — —_ MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: �y 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 Q NO NEONATAL: (INCUBATOR) cif DATES BILLED: STANDBY. (OVER 15 MIN.) (J f V E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X l� DRUGS: (PER ADMIN.) X NAMEJ-�11L�Iq.. lllRt RELAT10NSHIP L1. E.O.A.: (IF NOT REPLACED) ADDRESS: _` _ ORAL AIRWAY: (IF NOT REPLACED) CITY:,_ �_( f r�]�r _c.� STATE._._ZIP: C-COLLAR: (IF NOT REPLACED) PHO NE: _�/ �___ WORK PHONE' DRY RUN:. (AUTHORIZED) EMPLOYER ____---_____ OCCUPATION: __ OTHER: ADDRESS: ------- -- '.�` -7, /✓��/ CITY: _ STATE: ZIP:-- COMMENTS:— IP:__COMMENTS: _._____. .— _ ( cl.—_ TOTAL: r - - PATIENT RECEIVED BY:X F7^P:.iri' Trt is 4r,iln. +,i �i•::. .•:pp Prtrr+ Ya'7_w Tapp t• nr when til'ing (SIGNATURE D1i-1 CONTNA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR TILL IN APP OPRIATE SPACES ,,,,� DATE: PATIENT'S NAME <�7/�1 �� O M k�F COMPANY N ' �e '6 'z' ADDRESS AGE 13 7 CITY 1 z STATE ZIPV'qs!; 3�� DO��� , ❑ Sn ❑ M OT ❑ W ❑ Th /tl/F ❑S DRIVER'S LICENSE a ____ — _. PHONE NATURE OF DISPATCH �' � � _-S - TYPE OF TRANSPORT: AMBULANC OTHER❑ — STATION 1(A)_2(B)_3(C)_4(D)_5(E .- INCIDENT LOCATION: REOCODE: REO STED BY: CALL RECEIVED R CL/CK)q� SCENE O❑ PP.D. TIME 10-8 �� I PATIENT DESTINATION•. FROM SCEN� ❑ FIRETIME 10-97 ❑ PSAP TIME 10-49 MILEAGE ❑ OTHER/PVT TIME 10-7 - END TIME 10-98- DOCTOR Q- PM ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O PAREST ❑ FAMILY O TRANSFER WAIT TIME PATIENT O DIRECT ❑ OTHER (� CALL BACK N: AMBULANCE COMPANY: E . AMBU ORY? PATIENT TAKEN AMBULANCE: S(] RESPONSE ZONE YES /NO ❑ WAL'<ED GUERNEY ❑ OTHER / PATIENT CONDITION: DRIVER 6 D ��ET-1A > TECHNICIAN n PARAMEDIC I Hx: .�( =-f � iSPATCHER: t4ln CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ --�� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a C) •- Z PRIVATE INS. CO.: BASE RATE: 300.0 i KAISER it: MULTIPLE PTS. BASE RATE .�- a'J BLU ROSS a: TOTAL MILES: (� X - J �'� ' ClJ: l E O.B. ATL ROUND TRIP: O YES ❑ NO 0-.,5 7V J"J j O YES ❑ NO NIGHT: (19:00-07:00) � CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL a:. CODE 2/3 I OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) "y'� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X --�- ""'1 NAME o ELATIONSHIP:552,ef�_ E.O.A.: (IF NOT REPLACED) ADDRESS: st ,,-2 ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: y CITY: STATE: ZIP: COMMEN S: O 444 w/ QO TOTAL: %• .,J , + PATIENT RECEIVED BY: X (SIGNATURE) Provider retaic White •nd !§'..K roPL FQh.r Yo';,v No Whom hf l ino WS-1 i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION a CHECK OR FILL IN APPROPRIATE SPACES DATE: T PATIENT'S NAME.- ~.1_______.!'V` ---._ -_-._ ❑ M ❑ F COMPANY#-/ y `�✓, 1 ADDRESS ---- --- -----------. AGE_____ I ! CITY— —_—_ STATE__._____.__ ZIP--.._____ _ ._ _ DOB ------ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE $' _ _.__.__._. _-.... _ PHONE . _ .. NATURE OF DISPATCH _. Lw u f TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: Q RESPONSE CODE: REOUF.SiED BY TIME - (24 HOUR C,_OCK) i iy :. v 7 -a.I-- V-„�+� �_Cl�:l TO SCENE- P.D. ___-_.._ TIME 0-8. CALL EIVEO PATIENT DESTINATION: FROM SCENE - ❑ FIRE -- TIME 10-97 ❑ PSAP TIME 10-49 ' MILEA ❑ OTHERiPVT 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 COMPA Y: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: I RESPONSE ZONE 1 ❑ YES ❑ NO ❑ WAL:ED ❑ GUERNEY ❑ OTHER —_ - PATIENT CONDITION. DRIVER-__ A �C —1�- EMT-1A— TECHNICIAN -.``J� =' PARAMEDIC Hx: _.__ DISPATCHER: CHIEF COMPLAINT: -_-___ DRY RUN: 1 YES 6/NO REASON FOR DRY RUN _fel4Sc AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I I I PATIENT REFUSED SERVICES: (SIGNATURE) X-__--- _ I 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 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: ? MEDI-CAL #: CODE 2/3 OTHER'- __ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: _ STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) (` NEAREST RELATIVE/RESPONSIBLE PARTY: I.V:: (PER ADMIN)___ X DRUGS: (PER ADMIN.)__ X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _ ORAL AIRWAY: (IF NOT REPLACED) CITY: _ __,.._ STATE___ZIP:._-__-_ C COLLAR: (IF NOT REPLACED) CPO PHONE: __- WORK PHONE:--_--_._-___ DRY RUN: (AUTHORIZED) EMPLOYER: _--.._. OCCUPATION:_-_-_____-.._. OTHER: i ADDRESS: CITY: STATE:—.-ZIP:_-_.. COMMENTS: ---- --..-.- ------.— �_ TOTAL. _-. - .---__... ...... ........ .... . . _.. F'A11F_N1111(;fIVFf)!7Y X 00610 Iy.ni�/.•r• r�(.li�: k'I;i(. .c: Pi..: I.. r. , • (SIGNAI URE) r f`. .. LM:. I f CONTIIA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM,i UNIT AUTHORIZATION M CHECK OR rI!1 IN Arrn OPRIA 1r GpA f,rS , OAT E: t . 7 1 ATIENT'S NAti1E� �,G' C� M ❑ F COMPANY M J G ADDRESS i__(f 1'I AGE-3-9,,- CITY GE CITY LLLC :.. __ . . STATE C�,--'---. ZIP------.------- - DOB .-P2z _r/ ❑ Sn ❑ M ❑ T ❑ W ❑ Th OS DRIVER'S LICENSE It . ... . _.. PHONE _ 3.Y-$�UATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: l RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- 9(S O. CALL RECEIVED _/1- :01- L --• _L��`- -- ---_—� 11P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE)- ❑ FIRE TIME 10-97 1 �. ❑ PSAP TIME ID-49 ' `11- MILEAGE: ❑ OTHER/PVT TIME 10-7 END_ D' TIME 10-98 DOCTOR �11� �1! _... PMD 'START:E�.J__ _ TIME 10-22 HOW CHOSEN: TOTAL . -_ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER _ 50 WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER 1 CALL BACK#: AMBULANCE COMPANY: a PT AMBULATORY?, PATIENT TAKEN TO AMBULANCE: ^- RESPONSE ZONE ❑ YES ❑ NO ❑ WAL°:ED ❑ GUERNEY ❑ OTHER -J '- PATIENT CONDITION: DRIVER ..., � 17'rv(, EMT-1A TECHNICIAN _.._.__mss+.- �L PARAMEDIC Hx: . __LJ.f(L'_.-----__.f � 7DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES a1 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: WSJ KAISER #: MULTIPLE PTS. BASE RATE _ I , BLUE CROSS# - --_ TOTAL MILES: .-- �- X �•_ 1( � MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �� 4 CCHP PPHP"#": -_ _ EMERGENCY RUN: �J•T n_cy CODE 2/3 OTHER: __._- OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL' (INCUBATOR) l WES�BILLEO: 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) RK PHONE. (P EMPLOYER: _.–__.-- WOOCCUPATION: OTHER :N: (AUTHORIZED) k ADDRESS:--- ------ -- J CITY: - _-_._.__- STATE' ZIP:— COM MENTS:_ 6t IP:COMMENTS-- rn _ TOTAL:_ __—.--_-- - _-_- __--_--_ PATIENT RECEIVED BY: X 0 0611 �C Py-V dr- rrf... 4 _ I• . rp ir••rr+ 7r Fi,_ (SIGNATURE) •��•: �•►,r. t." •:J DIS"1 CONTRA COSTA COUNTY AMBULANCE �^ /, p v PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M / / CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME uC. '/vI( I .Gu / ...____._..V.'__.____ � M ❑ F COMPANY ADDRESS �.--� - it IL y('ICJ d IhuS!'J , .') 7 CITY.\ICNA1vti0- - _ S{{TATE_CL'` _ ZIPJyQ=(_2 — DOBL__t—I ❑ Sn 11 13 0W GTh 1$\F 13S DRIVER'S LICENSE-J, ._._....__ .1.� .._____.._._____-- PHONE2_,;9._-SO_51- NATURE OF DISPATCH -MEn/G/a TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CJ.. CK)y - /� TO SCENE - S.O. CALL RECEIVED Ll Y ? �_J__A4 V_�/ t I�S_--/�D�-- -- - P.U. TIME 10 8 PATIENT DESTINATION: FROM SCENE- Cl FIRE E 1 ` o^ ❑ PSAP TIME 10-49 MILEAGE:Z ❑ OTHER/PVT TIME 10-7 (� END_L)- TIME 10-98 DOCTOR - __603 KQ f Z. PMDO START_ 31�! TIME 10-22 ` HOW CHOSEN: TOTAL � J_ STANDBY TIME ❑ NEAREST Cl FAMILY ❑ TRANSFER _ WAIT TIME PATIENT ❑ DIRECT ❑ OTHER 1 CALL BACK#: AMBULANCE COMPANY: ;- C PT AMBULATORY? ETIENT TAKEN TO AMBULANCE. 5Q RESPONSE ZONEAlYES ClNO L':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER._.w)L (,//,1,1_1 E IOS EMT-1A l� 1 TECHNICIAN L ANG dA V r Hx: --f-A-1 c - ------ DISPATCHER: . �LSJ C_r Z C`lf � O D 1 CHIEF COMPLAINT: Roti N_!�FRO DRY RUN: 11 YES' REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE- INDUSTRIAL ❑ YES NO NO. OF PATIENTS: _ �S S.S. N PRIVATE INS. CO.:V—.6 BASE RATE: KAISER I$: _ MULTIPLE PTS. BASE RATE I BLUE CROSS#: — TOTAL MILES: C� X 11 MEDICARE#: -_. E.O.B. ATT. ROUND TRIP: ❑ YES 13 NO - ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: _,__ EMERGENCY RUN: Q I MEOI-CAL#: ___ CODE 2/3 OTHER:_ -_-_.- OXYGEN: (PER TANK) _T= O.E. STICKE ❑ YES ❑ NO NEONATAL: (INCUBATOR) (ETES BILLE :______.-__._._-_. -- STANDBY: (OVER 15 MIN.) E K.G.: (PER EPISODE) NEAREST-RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAMEC/6L_.O�NN '(-el RELATIONSHIP:60"t-r-rt 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:sl_�C-T HvS QC/U r ,,V c0LlL0 AA LO,c FTr_ Q/�PEYZwQt21: TOTAL ®06. 2 .5c PATIENT RECEIVED BY:X n.r: (SIGNATURE) R•nnidrr retci� LM1itr ;r.: ,•ark ,..;,�.. Ya': -n„ !•�.: ctir� t�.'iac DIS-1 i CONTRA COSTA COUNTY AMBULANCE �7 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#F CHECK OR FILL INA PPROPRIArr SPACES �►-� DATE:.-1 3 - PAT IENT' PATIENT'S NAME _ _ �,1' - �Q M O F COMPANY N AZ ADDRESS - � _ _ _ AGE CITY_-----_. STATE.-__-. ZIP. ___.__-_ _.._ DOB _ ❑ Sn ❑ M O T ❑ W O Th C�F ❑ $ i DRIVER'S LICENSE# ___-_ ,._ . .... . .. ....._. PHONE -. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) Y _14_, �O 3 � S r R i ,} TO SCENE- 2-) -- 'yS O. ___-._.__ CALL RECEIVED ❑ P.U. _-- TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE --- TIME 10-97 -/ ❑ PSAP TIME 10-49 O 7 MILEA ❑ OTHER/PVT TIME 10-7 -� END —_. _ TIME 10-98 DOCTOR — PMD/ER START_ TIME 10-22 �y- HOW CHOSEN: TOTAL __ _-__.. STANDBY TIME 11NEAREST O FAMILY ❑ TRANSFER --_ WAIT TIME -- j ❑ PATIENT ❑ DIRECT O OTHER CALL BACK q: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE j ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER.___ V_ ���` •1 "�'� .-=� EMT-tA TECHNICIAN ,.���!-_� r- - I > ARA D Hx: _ __ i DISPATCHE ' CHIEF COMPLAINT: _ __-. _._ ___ -_.___ - DRY RU ❑ Y S ❑ NO REASON FOR DRY RUN Pr p Ulu __Y- -".L AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REF SERVICES: (SIGNATURE) X�-____.-_______ ) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: - S.S. # PRIVATE INS. CO.. - — BASE RATE: I KAISER#: _-- MULTIPLE PTS. BASE RATE BLUE CROSS#: — TOTAL MILES: —_—.. X _ MEDICARE w E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: ___ — CODE 2/3 OTHER: _ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY. I.V.'. 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: �— ---- - ----"- -- -- - SO - TOTAL _. -- - -- - VAI it NT HLCF IVI 1) BY X r I`arIN.111nF) CONTRA COSTA COUNTY AMBULANCE 4 PREHOSPITAL CARE FORM 1 UNIT AUTHORIZATION M •� rr•1' V - 1 �I! CHECK OR FILL IN APPROPRUTE SPACES DATE: '� r r�( li9 PATIENTS NAME c � S r_ __r_�1 I�� f% 14'M O F COMPANY N ADDRES I L AGE r� J r CITY .ST �- - ZIP_ DOB_.L b Sn AT ❑ M ❑ T ❑ W ❑ Th ..1�'F ❑ S DRIVER'S LICENSE NPHONE 2 - NATURE OF DISPATCH 0011 i'b►fa, &64,LLS TYPE OF TRANSPORT: AMBULANC OTHER❑ STATION 1(A)-2(B)_.-,3(C)_4(D)_5(E)_ P L c INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 7TO SCENE ❑ S.O. CALL RECEIVED _T^ �'t 18 KIC N+ilon(D /i['9LTN (�\)T& ❑ PU. TIME 10-8 ;1 ` PATIENT DESTINATION: FROM SCENE -7 ❑ FIRE __ TIME 10-97 Y— ❑ PSAP TIME 10-49 c j� 1 ' MILEAG � OTHER/PVT TIME 10-7 TIME 10-98 DOCTOR p D/ER STARVE �_— TIME 10-22 HOW CHOSEN: . _ ` TOTAL / STANDBY TIME ❑ NEAREST ❑ FAMILY _,57-TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER ( i CALL BACK M: AMBULANCE COMPANY: PT/AMBULATORY? PATIENT TAKEN TO AMBULANCE: j RESPONSE ZONE'—' ,�,�^ f I YES ❑ NO ❑ WAL'<ED ODUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �I EMT-tA TECHNICIAN PARAMEDIC Hx: ���`'�� DISPATCHER: I I CHIEF MPLAINT: DRY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION'FOR DRY RUN (EMS USE ONLY) t PATIEN RE SED SERVICES: (SIGNATURE) X— ~ MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: - `c'' 1 S.S. M 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/PPRPC EMERGENCY RUN: MEDI-CAL k: b r7 L!if 1 t'�/ CODE 2/3 OTHER• OXYGEN: (PER TANK) P.O.E. STICKER 13 YES C3 NO NEONATAL: (INCUBATOR) ATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAR RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME S %�� T ��. I' -'�� RELATIONSHIP:'S'� E.O.A.: (IF NOT REPLACED) ADDRESS: ( '- ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) �V PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: • l J ADDRESS: i CITY: / STATE: ZIP: COMENTS: Yj1` _ .LLi + ..�-.>Lt ;'`;i TOTAL' _. �' ----- L. l_t �c�41-- ------•-- -. ..---_ I'AIIfNI NECEIVII) IlY X,_ .'1..-- 1 r. .i L•. rvr r w. (!a(.NAI. 1-IF) 1 1 • �(/]/ ' . IFI CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 CHECK OR FILL IM APPROPMATE SPACE DATE: PATIENTS NAME.� OM ❑ F COMPANY 11 ADDRESS'' y AGE_, — 1 v CITY STATE..,.. ZIP DOB D Sn O M O T ❑W ❑ LSF 0S ! " DRIVER'S LICENSE It 1 PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE'S OTHERD STATION I(A)_2(8)-3(C)_4(D)_5(E)•_ INCIDENT LOCATION:( RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) i jr) TO SCENE- S,O. CALL RECEIVED 1- - / �� / �rUA�j_,. FAJ�G/I ` ... O P.D. TIME 10-8 _ :7 PATIENT DESTINATIO :- - FROM SCENE-� ❑ FIRE TIME 10-97 �J ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 yr, END TIME 10-98 .TDOCTOR 1T_' PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME •O-NEAREST •' O FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMB C�COMPANY: •� I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i 5U RESPONSE ZONE ° ❑ YES, ❑ NO . ❑ WALKED O GUERNEY ❑ OTHER' PATIENT CONDITION: DRIVE 10 `r r-� EMT-1A 1 f Z 8 1 TECHNICIAN l I/ PARAMEDIC O Hx: DISPATCHER: U CHIEF COMPLAINT: 1 DRY RUN: tTYES ❑ NO REASON FOR DRY RUN /fV AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4 qq i' I U. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE:. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 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: O YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPHP N; i EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: I OXYGEN: (PER TANK) , P.O.E. STICKER O YES ❑•NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) --NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 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: cz/ ^ ^ ^ PATIENT RECEIVED BY:X ProfJi� rvtofn Yhft• /-+d fink oopb hitum Yi'Lno '-fly r VC when (SIGNATURE) LM5-1 VCONTRA COSTA COUNTY AMBULANCE Q / PRE-HOSPITAL CARE FORM I UNIT AUtHORIZATION N O o CHECK OR Fitt IN APPROPRIATE SPACES DATE: k/0 3 PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE-k ^ , A CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N _ PHONE-- NATURE OF DISPATCH �I 9 TYPE OF TRANSPORT: AMBULANCE❑ OTHER INCIDENT LOCATION:_ RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) � J 7 n (� TO SCENE- Q S.O. CALL RECEIVED oiy. ly 2 A � /l� 3 ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE - TIME 10-97 _Q...r ❑ 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 V ._ ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPAN PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: So RESPONSE ZONE ❑ YES ❑ NO .,. ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: DRIVER "�lf e � O GQ st,r i^ 610 EMT-IA I TECHNICIAN !!77� / -*9/V .Z 3.APARAMEDIC Hx: DISPATCHER: �L-`L L E L E C2,64 yap CHIEF COMPLAINT: DRY RUN: 0 YES 13 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 7 y� 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/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). EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X Pmvidir 1Ntain Whit• and Pillk na Nilurn 1•'l w ISIGNATURE) f'Y ••�'t'Y t•• ITI•: uhen f•it(in�I LMS-1 i CONTRA COSTA COUNTY AMBULANCE I�,�� PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION N CNECK OR FILL INAPPROPRIATE SPACES DATE: - 7 jPATIENTS NAME O M ❑ F COMPANY ADDRESS AGE ' k" /� CITY I STATE__ZIP DOB - O Sn OM ❑ T OW. O Th eF DS DRIVER'S LICENSE N - I PHONE NATURE OF DISPATCH S -� K��YCk TYPE OF TRANSPORT:' AMBULANCE OTHER — STATION 1(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOGAT)ON:!_ Iia RESPONSE CODE: RE96ESTED BY: TIME-(24 HOUR CLOCK) �• ^^��`- - TO SCENE- S.O. CALL RECEIVED -3� 1..1 y r' W �N, .� ��+�•l' O P.D. TIME 1G-8 PA )ENT DESTINATION: --- FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 . MILEAGE: ❑ OTHER/PVT TIME 10-7 11 END,___ _ TIME 0-98 R-DO&CAT f IT`112 ! - } PMD/ER START HOW CHOSEN: TOTAL STARDBY TIME PT�L ..-.13.NEARESTr? O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHERCALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE CL O YES.,.0 NO 13WALKED ❑ GUERNEY O OTHER: PATIENT CONDITION: ` ` DRIVER C4n.y,-Lb 1 z X V U EMT-tA TECHNICIAN123 A PARAMEDIC ' HX: - DISPATCHER: J? Yom. 00 - f)0 CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN EALS E.AIAQM l (Q AUTHORIZATION FOR DRY RUN(EMS USE ONLY) :1/`i:i yyy PATIENT REFUSED SERVICES: (SIGNATURE)X--� ( 52 MEDICAL COVERAGE: .. ( INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: ` S.S. N PRIVATE INS. CO.: BASE RATE: KAISER N: r 1 MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N: i E.O.B. ATT. ROUND TRIP: '13 YES ❑ NO _ ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N:" ' EMERGENCY RUN: MEDT-CAL N: 1 CODE 2/3 OTHER. I" 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) l ,3 CITY: - STATE_=ZIP: C-COLLAR:, (IF NOT REPLACED) PHONE: WORK PHONE' DRY RUN: (AUTHORIZED) �.:. EMPLOYER: ' - OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: " COMMENTS: jO-2� VPoN A wi VA L rr u. F,n" PALS- LAK TOTAL ',y� 1 l7 _ PATIENT RECEIVED BY: X r•,....,i l._ :. (RIONATUAF) ' AMBULANCE -+ RM 1 `- UNIT ® AUTHORIZATION# . 83 !_ .. . • n,A*[soAces GATE: 0q , a T ,..c NA14E —�_- O M 'O F COMPANY N ADdRESS 3aS 2-P��� 6 As'i�k AGE �a r_.._`l --- CITY�IC. MAn- STATE G� ZIP_ DOBO Sn O M O T O W O Th O F j O S -( 11 �, i DRIVER'S LICENSE++ -------...- ._--..__--_--.---.-._-- PHONE— -_-_--- NATURE OF DISPATCH•��� �GjjnjR iC TYPE OF TRANSPORT: AMBULANCE OTHER D __ __ __ 2 .. : :.': INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOURCK TO SCENE- ❑ S.O. CALL RECEIVED /-E4--1 I ❑ P.D. TIME 10-8 - ­17 • :7b I l I PATIENT DESTINATION: FROM SCENE O FIRE TIME 10-97 :�' ❑ PSAP TIME 10-49( ° MILEAGE: KOTHER/PVT TIME 10.7 END -5 I TIME 10-98 DOCTOR W5 /ER START_ ' TIME 10-22 r.: HOW CHOSEN: TOTALSTANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER ! WAIT TIME ❑ PATIENT ❑DIRECT ❑ OTHER CALL BACK N: AMBULANCE CO PA PT, AMBULATORY? PATIENT TAKE TO AMBULANCE: , �� RESPONSE ZONE 13�1,yES ❑ NO ❑ WAL':ED KE ❑ OTHER J PATIENT CONDITION: DRIVER _ MT-tA q� TECHNICIAN 7 ARAMEDIC Hx: _ DISPATCHER: CHIEF COMPLAINT: DRY RUN: D VES NO REASON FOR DRY RUN > U AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (? .7 PATIENT REFUSED SERVICES: (SIGNATURE) X_ 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YES-*ONO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE ` BLUE CROSS#: y TOTAL MILES: ! MEDICARE#: -3� -Su U` E.O.B.ATT. ROUND TRIP: O YES NO i ❑ YES ❑ NO NIGHT: (19:00-07:00} 2 HP/PPRP#: EMERGENCY RUN: ' MMDI-CAL#: CODE 2/3 R: C ^ () n Y OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) ( ' `T J TE BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) - /J NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: WER ADMIN.) X•- DRUGS: (PER ADMIN.) X 1 NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) —•-—�-• - - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) I CITY: _ STATE— ZIP: C-COLLAR: (IF NOT REPLACED) -- PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: _ _ _ ------ -•-- —• ADDRESS: -1:.!X•.6sS- / 7' CITY: STATE• ZIP:- 0 M NT IP:OMMENT 121 M � 1 TOTAL: PATIENT RECEIVED BY:IN ' (SIGNATURE) as-i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: / 2'z O 3 } PATIENT'S NAME__le�lm L L--TU_�j-- `��_ 1,VM ❑ rF COMPANY M ADDRESS 2U LI r V k�J ( /� AGE h_ i 7 7-5-- CITY-- U _-_ STATE.AC.1CJ.E_ ZIP_ _—. DOB NIJ01 46 ❑ Sn ❑ M ❑ T!7❑ W ❑ Th ICF E3S_�� DRIVER'S LICENSE a _.._ ...._.. _.___...-. ___.. PHONE 1 1.-T. 4�_._ NATURE OF DISPATCH I-SLAT!ILC-I '"S TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR K) 1 C _L5 y ^l n� OF_0 TO SCENE- S.O. CALL RECEIVED M �lJ �/ ❑ P.U. TIME 10-8 t PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 .2 _ 00 CCC - ❑ PSAP TIME 10.49 MILEAGE:,� -� ❑ OTHERiPVT TIME 10-7 O END—�-L-�_- TIME 10.98 DOCTOR _�i_L _._:___ PMD/D START-1-S r TIME 10-22 _. HOW CHOSEN: TOTAL STANDBY TIME C) NEAREST Cl FAMILY ❑ TRANSFER 7 - WAIT TIME PATIENT ❑ DIRECT ❑ OTHER / -3 CALL BACK a: AMBULANCE COMPANY: EAULATORY17 PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ NO ❑ WAL"ED GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER____Z!3L L_ 5700 EMT-1A � tt TECHNICIAN _ du� PARAMEDICy Hx. - - J_N...�- - - ---- ----- DISPATCHER: _ ,••,'_J CHIEF COMPLAINT: LL '� DRY RUN. ❑ YES /'NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) l�? I PATIENT REFUSED SERVICES: (SIGNATURE) X-_._- - i ' MEDICAL COVERAGE: INDUSTRIAL ❑ YESNO NO. OF PATIENTS: PRIVATE INS. CO.:.-/�r�_t1_�— BASE RATE: `�' KAISER a: --_ MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: x MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (190 00-07:00) f w y CCHP/PPRP a: _-_-___— EMERGENCY RUN: u- I MEDI-CAL a:_ --_ CODE 2/3 OTHER —_ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) n Ac DATES BILLED: _ -_- STANDBY (OVER 15 MIN.) 1 E K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME�DR�£-_ � _ RELAT10NSHIP: E O.A.: (IF NOT REPLACED) ADDRESS:_ _.__-.___-__- __....__. ORAL AIRWAY: (IF NOT REPLACED) CITY __-7, STATE__. ZIP:-.___-. C COLLAR (IF NOT REPLACED) PHONE `_ WORK PHONE .- DRY RUN.. (AUTHORIZED) N EMPLOYER: 1A �P'-W JiA. OCCUPATION: OTHER: ADDRESS: CITY: ___(`_- STATE: ZIP: . i CO MEN S:_ 4• �C( '1S� �� SIGN c� ---- -- T0TAI: PATIENT RECEIVED BY X s c- (/- ISIGNATURE) •., �.�. . ( r as-1 33 CONTRA COSTA COUNTY AMBULANCE r Pf E-HOSPITAL CARE FORM I UNIT AUTHORIZATION N A] " - -Z­�'z� 'rl ," - � , /,P, CHECK OR FILL IN APPROPRIATE SPACES DATE: IkT1ENrS NAME ❑ :�FL COMPANY NADDRESS •\ vL- AG / 7 7F' CITY-W STATE ZIPq,�JA� DOB ❑ Sn ❑ M D T O W Cl Th F ❑ S DRIVER'S LICENSE N I— _ PHONE . _) �-- NATURE OF DISPATCH , TYPE OF TRANSPORT AMBULANCE V OTHER❑ .._.__—__..___ __.__ -__ STATION I(A)_2(8)-3(C) 4(D)-5(E)— INCIDENT LOCATION: RESPONSE CODE: REO TED BY: TIME= (24 HOUR CLOCK) TO SCENE-� O. CALL RECEIVED �e 5 zz�- , V D P.D. TIME 14-8 „�- : ' PATIENT DESTINATION: FROM SCENE D FIRE TIME 10-97 y D PSAP TIME 10-49 / N51 �ti� �rn� MILEAG : D OTHER/PVT TIME 10-7 • :1� END--+ TIME 10-98 DOCTOR P T— M E START_ TIME 10-22 HOW C SEN: TOTAL STANDBY TIME EST E3 FAMILY 13 TRANSFER WAIT TIME W PATIENT 13DIRECT 13OTHER CALL BACK N: AMB ANqE COMPANY: PT. BULATORY? PATIENT TAKEN AMBULANCE: RESPONSE ZONE 19 YES 13 NO ❑ WALKED UERNEY D OTHER PATIENT CONDITION: , DRIVE;4& I 1_1 TECHNICIAN - Z PARAMEDIC 75� Hx: V� S - DISPATCHER: / C�j IEF C MPLAINT: ( DRY RUN: D YES NO REASON FOR DRY RUN I{�1Y CCC a I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X -- J / MEDICAL COVE AGE: ItQUSTRIAL ❑ YES Q40, NO. OF PATIENTS: S. '? 2 RIVATE I S BASE RATE: N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: D YES D NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) f, CCHP/PPRP N: ! EMERGENCY RUN: •� a L MEDI-CAL N: CODE 2/3 jjjOTHER: OXYGEN: (PER TANK) V P.O.E. STICKER D YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) aQr� [J,� 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:_- S v_cA S � --- TOTAL: - - ---- --- '�� 20 PATIENT RECEIVED BY. X�� /1 ��.j Pnwidsr /vtair. White .v-1 �:.:: .•..q f 5atum Y.•':..0 r FAA .4.•i 1 i 1 7n (SIGNATOR LMS-I •ra ,, �.4 PATIENT'S NAME: Belinda Nicholson ADDRESS: 445 2nd st. #6 Richmpnd, Ca. DATE OF SERVICE: 09-02—$3 !. AUTHORIZATION NUMBER:$3-15143 AMOUNT DUE: $229.50 INCIDENT LOCATION: 451 2nd st. Richmond PATIENT DESTINATION: Brookside Hospital s! •t l: •r��.. 1Y :'x a. NOW 1281.22 SEP 2 -11 09 P `1 X03 SEP 2 11 09 PM X83 SEP 50 NUMBER '-) CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10,8 N CALLED BY— PATIENT INFORMATION N I o NAME: .____._... _ 3 AGENCY: ._...._... _ �,`_ /_✓- ..-..._;_ CUSTOMER a(PT. DOB _�_Sa w DEPT/FLOOR/ROOM a: ._ NAME: n i a CALLBACK a — INS. TYPE: PVT MCAR MCAL KH� VA IND CHAMPUS y C= v V INCIDENT LOC: 4_ POLICY/MCAL p: z m -� N4 m -- — MCAR#: � i ;.. CROSS STREET: _ VERBAL PRIOR: Q ;, ...qtr ,�. .---- --- V � JURIS: ..__. Gry: ��aA e CC__. ____ _ .. DOCTOR: C DESTINATION: _ �j ._._ _ PT. a2 NAME: DOB: NATURE: pC�5..�._ __.__V"'✓ � —_ CUST. $1 —. -----_---� — PT. a3 NAME: DOB: o TYPE OF CAL , EMG RAMS TIME UNIT a CUST. a n 0 4`t� n M m uj CREW: Z _— / '-�x/� WAIT TIME: YES NO REASON: m CA�� O UNIT TYPE: ALS BLS WC RESPONSE CODE: 0 1 2.0 4 REASON FOR 10-22: 0 = c a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1d 3 4 CANCELLED BY: ^2 . v BY : END MILEAGE: — COMMENTS: 0 i N TIME: .— BEG MILEAGE: --2!-i1_ co DISPATCHER: (�(� ? F r 4 ---- 7 TOTAL MILES: — ------- '. a tJV2 XL-Ol NOIIVIS IV 3DNVlf18wV 61-01 ONINdnI38 3DNV1nBWV 86.01 31OVIlVAY 3DNVInBWV L-01 1V11dSOH 1V 3DNMn8WV x. �:'_I IIS dig Ego }'I 44 11 2 djo EPNd 8z It 7 -.13n CONTRA COSTA COUNTY AMBULANCE g—? _ .00 1,. PRE-HOSPITAL CARE FORM 1 OMIT � AUTHORIZATION a I CHECK OR EILL'IN APPROPRIATE SPACES DATE PATIENT'S NAME_ «U—�___ ._._�_ .__ —...__ ❑ M 9�-f COMPANY S-3 y V-1-VI hl O v- c--�--1i , I I ADDRESS — -- ----------... AGE - CITY_�3_LrJ_Ol_t. _-- STATE.. �t . _— ZIP._.__. —___ DOB S- .�� ❑ Sr ❑ M OT 11 W 7❑ Th ❑ F -9 S DRIVER'S LICENSE # _ PHONE ! Z7 0.737 NATURE OF DISPATCH..! TYPE OF TRANSPORT AMBULANC THER❑ __. ..._ INCIDFNT LOCATION: ' RESPONSE CODE REQUESTED BY: TIME — (24 HOUR CLOCK) TO SCENE ❑ S.O. .____.._ CALL RECEIVED :y C Y ,� ❑ P.U. TIME 10-8 S 1 PATIENT DESTINATION: FROM SCENE - 40 FIRE TIME 10-97 :•�— �j ❑ PSAP TIME 10-49 ( ,� 3 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98DOCTOR .--- — PMD/ER START_— — TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER _— WAIT TIME ,.— O PATIENT ❑ DIRECT 9 OTHER / CALL BACK#: AMBULANCE COM?ANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �- ! RESPONSE ZONE-4- YES ❑ NO In WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_ TECHNICIAN �eLL '' _.. .t-� PARAMEDIC ! Hx: DISPATCHER: ,� •) _._-_ t __ _ CHIEF CORIPLAINT:0_5&4 Q-,c- c&ZL DRY RUN' ❑ YES lil�-NO REASON FOR DRY RUN _ 1 C+c� -i� __— —_. __- AUTHOR IZATION.FOR DRY RUN (E,'.1S USE UNLY) . f. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE INDUSTRIAL ❑ YES 09 NO NO. OF PATIENTS: PRIVATE INS CO.: — BASE RATE: KAISER a: —. _ _ MULTIPLE PTS, BASE RATE '_�� BLUE CROSS #: --- TOTAL MILES: _____—_.____ _ X _ n MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT. (19.00- 07.00) / L f'CCHP/PPHP R: EMERGENCY RUN' „1►/" MED�,CAL 1+: --- CODE 2 1 3 _ C G' 1`^ OXYGEN: (PER TANK) - + P.O.E. TICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATE BILLED: — -- STANDBY: (OVER 15 MIN.) — E.K.G.. (PER EPISODE) NeARtST RELATIVE/RESPONSIBLE PARTY: I.V: (PER ADMIN.) DRUGS: (PER ADMIN.)_—__ X _ NAME: '►'^�' RELATIONSHIP:__._....__- E OA.. (IF NOT REPLACED) ADDRESS: _.—_—_____--_.____.___—_.___...__._. ORAL AIRWAY. (IF NOT REPLACED) .— CITY: STATE_—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WOOyRKK CUPHONE- DRY RUN: (AUTHORIZED) Eel- — EMPLOYER: E - ''��7 OCPATION: — OTHER: .� ADDRESS: CITY: _.__ STATE: ZIP­— COMMENTS IP__COMMENTS TOTAL . X100 PATILNT RLCIAVI D 13Y X I J.r rrr-:. +'Li•. ISIGNA.I IIRE) EP.• 1 �� l ►''i re ►,o A!1 ' '� ScP 3 3 So SEP 3 3 53 AM '83 SO NUMBER -��� j '� CAII RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10-8 ,.... I CALLED BY- �l /).; f ;. PATIENT INFORMATION D ' of NAME: -- ---------- ----------- --- 3 M . AGENCY: CUSTOMER»(PT. / �► /�� 1 DEPT,'FLOOR;ROOM N: __- NAME: a^.�r, n ' v m W U CALLBACK q L ' ___--.________- INS. TYPE: PVT MCAR MCAI KHP PHP VA IND CHAMPUS y ' W INCIDENT LOCIS& _L:Z_ �_._r__V7_Z1 I'L^ POLICY/MCAL A: U.S- V /� m .. /\� /,?AMI2 MCAR a: m C3 D CROSS STREET: _ VERBAL PRIOR: c �. a JURIS: C tty / /Y ----- -- DOCTOR: r4 Vo 7 [/ V = ---- DESTINATION: __ .J6 S Al C DOB: y^Jb C= /T ._�__.�Tr._- Pi. H2 NAME:�J /r /' �1 NATURE: / --__-- ----- CUST. a /�� /c O.3 f_70 fru �Q j2 � 3>C/vecj� o ..... - ....,- ...----- PT. #3 NAME: 94I +�dj DOB: y 'D j o TYPE OF CALL E IRAN TIME UNIT a CUST. a __S`� Lt S n m . �Cr/t� f CREW: _c�. ��' '�11 WAIT TIME: YES NO REASON: Z ro •. O UNIT TYPE: ALS l5 WC RESPONS�tODE: 0 1 2 /3/ 4 REASON FOR 10-22: 7O VV O c a INCREASE/DECREASE CODE:2 3 10-44 CODE: 0 1 33 4 CANCELLED BY: m W BY: END MILEAGE: 0 • COMMENTS: _ u p O A a TIME: _ _ BEG MILEAGE: S'o �/r S N f DISPATCHER: TOTAL MILES: �— 00624 w a 1 _ XL-01 NODS 1V 3DNvinewv, 61-01 ONINMnl NVln,wv 116-01 3111V11VAV 3DNv1n11WV L-01 1VlIllOH!V 33141vinawV 00 . W Cog �it� 9E 5 £ AS CBS Nn BE d3S N' t 7. y .f ..I�'rCti-_..,�,�►�� f c�,�Lel= 't M AL y iv AT, i4► ft•.�. - i! - r � .yam-,. '��Yt,j��, ��•-r . f {rte �7 - � .a 1 v"' � - �' �">-i+ e CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION* 83-�SttG " CHECK OR FILL INA PPROPRIATE SPACES DATE: L - 3- Tf3 1-21f , r PATIENT'S NAME A 0'1'-?- E'c'�,. S_/R�_Jr', OM ❑ F COMPANY p L� �1 i ADDRESS --�1.�2__t/_�'=-!.�:.c' __� AGE -7 u M `(L,' - I CITY-__S.� STATE__ is ZIP _ DOB_.Lz'.2 7"S3 ❑ Sn O M ❑ T 12 W O Th O F S DRIVER'S LICENSE N _._.. ___ __ _.._.__....._______ PHONE_ Z _-�_(5..1 NATURE OF DISPATCH Gtl r TYPE OF TRANSPORT: AMBULANCE OTHER Cl- INCIDENT INCIDENT LOCATION RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL CK) f (� (�' TO SCENE- S.O. CALL RECEIVED _I l Ih�_ _�-.-� v-- - --- 3 ❑ P.D. TIME 108 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 i Lls I I - - MILEAGE: ❑ OTHER/PVT TIME 10-7 END _15 1 TIME 10-98 DOCTOR __C­ PMD/Efb START__j6 1 7 TIME 10-22 HOW CHOSEN: TOTAL - STANDBY TIME ' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT -B DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S RESPONSE ZONE j r 1�YES ❑ NO ❑ WAL';ED 0 GUERNEY ❑ OTHER _ I PATIENT CONDITION. DRIVER -..kc-L .f-k �7 S EMT-IA TECHNICIAN^F 11 �C PARAMEDIC Y Hx: __ uH L�.z(�x��^—______ DISPATCHER: ' CHIEF COMPLAINT: ,1,�._y.0--.� DRY RUN: ❑ YES-EFd REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_._._ ( r MEDICAL COVERAGE: INDUSTRIAL 11YESO NO NO. OF PATIENTS: -)Z 71C i S.S. it _ PRIVATE INS.CO.: — BASE RATE: KAISER it: _ ___.__ MULTIPLE PTS. BASE RATE BLUE CROSS TOTAL MILES: 1� X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPRP N: _ EMERGENCY RUN: ?:)•cy 0(,. MEDT-CAL a; —_— CODE 2 3 i 1 OTHER: �.r,+^ o ~ G�Q7 v __ OXYGEN: (PE TANK) I P.O.E.STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) t,(m x A1�ES BILLED: — STANDBY: (OVER 15 MIN.) �� 3� U vl AJ E.K.G.: (PER EPISODE) l/ NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) ) X t� _ 3 DRUGS: (PER ADMIN.) )( �> > cv NAME: ��=�.E _ f'._S.�^ri i ►_ . RELATIONSHIP: •ll C.1'l E.O.A.: (IF NOT REPLACED) ADDRESS: ��.5-_�`1,4ORAL AIRWAY: (IF NOT REPLACED) _ CITY:- ��� .. STATE-5-:-A ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: Z �—�G ALL_ WORK PHONE: DRY RUN: (AUTHORIZED) _ EMPLOYER: K,t•tt __.__ OCCUPATION: OTHER: ^ r ADDRESS: _.._. l�lz h2o y- le CITY: __ STATE: ZIP: ?-2 7il COMMENTS: --- -- TOTALz/, PATIENT RECEIVED BY: X 00625 ISrnidrr rrlc :Ziitr J:rf 1'in>. r'ru Srrypq y,.'t...•. ••nT+u t• "[" who" hiT•ino (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT r (y1 AUTH IZATI M L_�J(j C ECK OR FILL IN APPROPRIATE' SP.ACES / DATE- PATIENT ATE: PATIENTNAME _01-AK �M ❑ F COMFAY N O A OSAGE ADDRESS CITYSTATE_C ZIP DOOB/=_110I ❑ Sn O M D T c3 W ThFAZT- DRIVER'S-LI ENSE a �_ PHONFQ�(Q NATURE OF DISPATCH TYPE OF TRA SPORT: AMBULANCE OTHER❑ INCIDENT 1.0 ATION: J ✓ RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C K) L C Y S1� j• f Cyd ' TO SCENE S.O. CALL RECEIVED - F, IN, /-1 /---- J� _ - a P.U. TIME 10-8 _ PATIENT DESTIVATION: ( FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME10-49 MILEAGEy ❑ OTHER/PVT TIME 10-7 END r�' TIME 10-98 DOCTOR _ LVO-_ _ _ -- PM /ER ST TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME Cl NEAREST ❑ FAMILY TRANSFER WAIT TIME Cl PATIENT Cl DIRECT ❑ OTHER CALL BACK N: AMBULAN E C MPANY kYES BULATORY? PATIENT TAKEN TO AMBULANCE: /t�.� ESPONSE ZONE❑,NO ❑ WAL':ED GUERNEY ❑ OTHER fes_ PATIENT CONDITION. DRIVE tj V C'o EMT-1A t TECHNICI �z��� PARAMEDIC Vii:'.\��• 'c9 � � � � ...�(. N AUTHORIZATI OV FOR LSF\ RUN /EMS USE ONLY) `- Ifl, PATIENT REFUSED SERVICES (SIGNATURE) X.______ MEDICAL COVERAGE: INDUSTRIAL 13 YES 11 NO NO. OF PATIENTS: /\ -70 S.S. a_ PRIVATE INS. CO.:J(r. _ '-� —1.1���N BASE RATE: /--KAISER a: - �:-� � ...-_ MULTIPLE PTS. BASE RATE BLUE CROSS a:!7 =�__' �'� 7= L f. f_P1r r 3 TOTAL MILES: a X MEDICARE a: " '1 `E.O.B. ATT. ROUND TRIP: 0 YES 0 NO -•%;! '%<; (,/�,/',t_(� ❑ YES ❑ NO NIGHT: (19:00-07:00) _0• �� ! CCHP/PPHP a: EMERGENCY RUN: LeMEDI�AL a: _ CODE 2�3 �� OTHE OXYGEN: (PER TANK) P.O.E. S ICKER 13 YES ❑ NO NEONATAL: (INCUBATOR) DATES ILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) N AS T RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ��lo/l;�vQ ( DRUGS: (PER ADMIN.) X NAME/�JDl.7i���1 __.-/v/�\/. __. RELATIONSHIP:V. V.__._ E O.A.: (IF NOT REPLACED) ADDRESS:__S0?r—='L. _..--___ __ ORAL AIRWAY: (IF NOT REPLACED) C STATE__ZIP:_ C-COLLAR: (IF NOT REPLACED) J PHONE: __. WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: --- r r� P' A)T r tom( IS. (1t) ) ADDRESS: � __ _ CITY: — ^—. — _._ STATE: ZIP:___ �� 'r� 0 0 F4 COMMENTS:-L?ffc_� A YG TOTAL 7.3.:• Ly VI -- ------. - PATIENT RECEIVED BY:X �(SIG URE) 2- CONTRA CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR flLl INAPPROPRIATE SPACES DAT3,51 E: �- PATIENTS NAME ❑ M ❑ F COMPANY M Ic- 1� / ADDRESS AGE------\V— CITY STATE ZIP DOB O Sn OM OT Ow O Th OF O S DRIVER'S LICENSE N _ PHONE ---- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ p^ INCIDENT LOCATION: J RESPONSE CODE: REQP.D. TIME UESTED BY: TIME- (24 HOUR C,L,O�CK)3�� C 1 O O G> Q Lf1 iC0 if�iJ ' j�yl/���/ TO SCENE- 15"❑ 0.8 RECEIVED 'n PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 —T� ❑ PSAP TIME 10-49 �f'y MILEAGE: ❑ OTHER/PVT TIME 10-7 �� END TIME 10-98 ,DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT. 13 DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER S C' PATIENT CONDITION: DRIVERS EMT-1A TECHNICIAN PARAMEDIC HX: DISPATCHER: Go CHIEF COMPLAINT: DRY RUN: AYES ❑ NO REASON FOR DRY RUN ) D AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (�� ,. . PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.# f l .PRIVATE INS. CO.: BASE RATE: KAISER t1: 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: �1 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: n j TOTAL: t0���• 2 rj PATIENT RECEIVED BY: Pmvidrr ratcin "it* r.Wd f'i'll ,,,,pp . Return Yo'/. q•v t.. �+rc ,I,• _—(SIGNATURE) i n 1i1li'l�r LMS-I CONTRA COSTA COUNTY AMBULANCE I PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M� CHECK OR.FILL IN APPROPRIATE SPACES y DATE:qCl I _ � 1 PATIENTS NAME U- ❑ F COMPANY M ?•`� = �� ADDRESS 1 � AGE 1 1 CITY t4At, STATE ZIP DOB. ( `/ 7 -OS- OM ❑ T ❑ W ❑ Th ❑ F ;S DRIVER'S LICENSE 4 _ PHONE`�5&3-=k3—( NATURE OF DISPATCH Al, .-cl.A TYPE OF TRANSPORT: AMBULANCE 1ptTHER❑ _______ _ STATION 1(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REO OYES BY: CALL RECEIVED R CLOCK) O —� TO SCENE ❑ P.D. TIME 10-8 �7 PATIENT DESTINATION: Y� FROM SCENE-� ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 MILEAGE 11OTHER/PVT TIME 10-7 � ��\\ END TIME 10-98 I• DOCTOR � _— X fl —PMD/(E) START TIME 10-22 HOW CPAN: TOTAL =� - L�+ STANDBY TIME m- REST ❑ FAMILY ❑ TRANSFER WAIT TIME -- TIEN TT ❑ DIRECT ❑ OTHER In,' CALL BACK M AMS{ULAN'CE COMPANY: PT. ULATORY? PATIENT TAKEN O AMBULANCE: RESPONSE ZONE 5� YES ❑ NO ❑ WALKED © GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER31 t l! ! EMT-1A TECHNICIAN S 'cl��� PARAMEDIC _ Hx: DISPATCHER: n''--r A � - L� CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) V(' PATIENT REFUSED SERVICES: (SIGNATURE) X— 'J MEDICAL COVERAGE: INDUSTRIAL ❑ YES DINO NO. OF PATIENTS: S.S. a IVATE�S \11, WOkAy ' BASE RATE: �� 11 KAISER MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X is _-! Iii MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00)� �t,.CCHP/PPRP N: EMERGENCY RUN: c!__.A 'i . > MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) 'EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: "' STATE: ZIP: COMMENTS: _. TOTA PATIENT RECEIVED BY X — I'+ i for rvr i• �a,i i r _ .. ($IfrNATlI1F) ' CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE$PACES DATE: PATIENTS NAME OM OF COMPANY N 40 d2 S ADDRESS AGE r CITY STATE ZIP DOB_ ❑ Sn ❑ M OT OW O Th OF Os DRIVER'S LICENSE N ___—. _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ INCIDENT LOCATION:" RESPONSE CODE: RE UESTED BY: TIME- (24 HOUR CLACK) TO SCENE O. CALL RECEIVED �C—(J : f 1 L C 1j� � ❑ P.D. TIME 10-8 L-LZ- 'cam_+2 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 l ❑ PSAP TIME 10.49 f � A J , MILEA13OTHER/PVT TIME 10.7 r END TIME 10-98 DOCTOR PMD/ER START L- HOW CHOSEN: TOTAL S E ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: _A- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: D RESPONSE ZONE t ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN 5.D�A71A 5 PARAMEDIC Hx: DISPATCHER: 4)i T2 C A1All O D q tiq CHIEF COMPLAINT DRY RUN: F'YES ❑ NO REASON FOR DRY RUN y'Z-2- crq,? AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO N0.OF PATIENTS: l S.S. M > PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL M: CODE 2/3 C 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: I CITY: STATE: ZIP: COMMENTS: C&cft-Lm JCA S -- - - TOTAL JD _.. . ..__ PATIENT RECEIVED BY:X (SIGNATURE) i .. Ii'•.��� CONTRA COSTA COUNTY AMBULANCE y_Cj PRE-HOSPITAL CARE FORM 1 UNIT FPOAUTHORIZATIONIf C��J QfJ J CHECK OR FILL IN APPROPRIATE SPACES DATE: ' ATIENTS NAME � OIL\P QY M F COMPANY M 22 Q cot ' --".E— I 1 ADDRESS �`17 /��) AG���J� ' O � CITY JAUSAL-TC) STATE CA ZIPS_ DOB11'���&J Sn ❑ M OT Ow ❑ Th 13-F IrS ~ DRIVER'S LICENSE N DO 2.22A. /_ PHONE Z25Z �V�ONATURE OF DISPATCH_ AM Dn LAW - TYPE OF TRANSPORT: AMBULANCE QKOTHER 0 _-_-.�__ - _-. STATION 1(A)_2(8)._3(C) 4(D),5(E)_ INCIDENT LOCATION: \/ RESPONSE CODE: REQGESTED BY: TIME— (24 HOUR CLOCK) - CAM I�O U�DCN)P�`� O S' _ ttS.O. CALL RECEIVED > O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE 11 FIRE TIME 10-97 —ice_ :_L-j-- 1 r ` 11� A /�/� ` 1 ❑ PSAP TIME 10-49 1 _ 1i 1'� c 5 MILEAGE: ❑ OTHER/PVT TIME 10.7 _L• C: END 5(t•`-- TIME 10.98 _ DOCTOR PMD/ER START 52, 1 TIME 10-22 HOOSEN: TOTAL _ STANDBY TIME WWI rD� NEAREST. •O FAMILY ❑ TRANSFER WAIT TIME 13 PATIENT 13 DIRECT 13 OTHER y ? CALL BACK M: AMBULANCE Co NY: . PT�MBULATORY? PATIENT TAK�EV TO AMBULANCE: C_ RESPONSE ZONE UK YES O NO 13 WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 02 VC�AL-C- r EMT-tA TECHNICIAN C i ti RAMEDIC 1n F H.: F(ALL- DISPATCHER: A.4 c 4 CHIEF COMPLAINT: bAy& DRY RUN: ❑ YES NO REASON FOR DRY RUN 1 g, AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAG INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: (� L S.S. N 2 F,-q 523 _ 1 PRIVATE INS.CO.:—VIA S� BASE RATE: . t ' KAISER rt: MULTIPLE PTS. BASE.RATE BLUE CROSS M: TOTAL MILES: `f Xd r MEDICARE C d E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) II,, CCHP/PPRP 0: EMERGENCY RUN Q�'Qv f MEDI-CAL M: CODE 21/3 OTHER:_— OXYGEN: (PER TANK) I 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTA'LOOVYW7 ---- - 0630 PATIENT RECEIVED BY. X Pn�uiJir 1ltuin v>,iro ,.n.f r•i:: v,. (SIGNATIIRQ) CMS-I CONTRA COSTA COUNTY AMBULANCE 0f l PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES - DATE: ' PATIENTS NAME P�f 2 - J/7 Kl l�I M ❑ M )WF COMPANY M /r 921Y ) ADDRESS `TE��_�T Q� AGE C4, U V 16 q5 i CITY ,,STATE �A (E ZIP 2Y ° _ DOB �'L. ❑ Sn ❑ M ❑ T 13W O Th ❑ IF ��4 DRIVER'S LICENSE M � _ PHONE ,3.- NATURE OF DISPATCH Sx.iluar- IAJ Fodl— TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOURC CCK) -I TO SCENE - 15a,S.O. — CALL RECEIVED 1r'_ 1j__ // I 17 7 � 5� r: IC�dN� Z ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE -?' ❑ FIRE TIME 10-97 £L ❑ PSAP TIME 10-49 J '/�_LAa�t ,rte�1 Cj&C �r lr0 MILEAGE: I ❑ OTHER/PVT TIME 10-7 END 1. •b TIME 10-98 DOCTOR LCA M 1 C CA PMD/ER STA RT_Z!3 2 TIME 10-22 HOW CHOSEN: TOTAL _l?R STANDBY TIME ❑ NEAREST . ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: s RESPONSE ZONE �- -�. 13 YES O ❑ WALKED GUERNEY ❑ OTHER PATIENT CONDITION: pRIVERF51 L-C ✓!00 EMT-1A ` TECHNICIAN_�Q LA� b 7 PARAMEDIC q?o Hx: DISPATCHER: . IM 7 2��f)10 D l�bU CHIEF COMPLAINT: FI -5 Oo�(1�I (�1�C) DRY RUN: ❑ YES NO REASON FOR DRY RUN r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— iB DICAL COVERAGE: INDUSTRIAL ❑ YES�NO NO. )OF PATIENTS: INS. CO.: // E�_-,a -BfSE RATE: 11 (0S R p: 2 O _ Y t� / i MULTIPLE PTS. BASE RATEE ROSS#: 0,�A L/ ,c �C O TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL u: COD 2_i 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:�A.lIJ�� RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: S• ST ORAL AIRWAY: (IF NOT REPLACED) CITY: 2 G/,J A STA TECL(-,LFZIP: 0 V C-COLLAR: .(IF NOT REPLACED) PHONE:C �=� WORK PHONE: DRY RUN: (AUTHORIZED) wEMPL0YER:(Aplf IL6 A-Ry'vb OCCUPATION: OTHER: [ ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: -7 TOTAL._1 ""i� �•- -.. PATIENT RF.CFIVF(l RY X ( � I n � CONTRA COSTA COUNTY AMBULANCE y(') PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 J I PATIENTS NAME ja OM OF COMPANY N ADDRESS AGE ) CITY STATE ZIP DOB ❑ Sn 0 M 0 T O W O Th 0 F--H) S DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH 41 n,r n uir L r. ,_.cy TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _ i INCIDENT LOCATION: C RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) ` TO SCENE- %S.O._ CALL RECEIVED _C r 7.-- _1 614 1E /e40 r -3 ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 -1 ❑ PSAP TIME 10.49 - f n 1 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 f HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST FAMILY 13 TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT 0 OTHER CALL BACK N: AMBULANCE COMPANY: 4 s PT. AMBULATORY? PATIENT TAKEN AMBULANCE: 0 RESPONSE ZONE ❑ YES NO ❑ WALKED GUERNEY 0 OTHER t PATIENT (TION: DRIVER /.�o.r. 4 �I 6 7_S EMT-tA TECHNICIANPARAMEDIC �( ,SDS -� Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: $ E 0 NO REASON FOR DRY RUN AJ od r'-) AUTHORIZATION FOR DRY RUN(EMS USE ONLY) yyy PATIENT REFUSED SERVICES: (SI URE) X_ f I 95� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO N . OF PATIENTS: S.S. N �• PRIVATE INS.CO.: BASE TE: KAISER N: MULTIPL TS. BASE RATE BLUE CROSS N: TOTAL MILE X MEDICAR E.O.B. ATT. ROUND TRIP: YES 0 NO 0 YES 0 NO NIGHT: (19:00-07:0 ' CCHP/PPRP N: EMERGENCY RUN: ^ MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES NO NEONATAL: (INCUBATOR) i DATES BILLED: STANDBY: (OVER 15 MIN.) ` E.K.G.: (PER EPISODE) t NEAREST RELATIVE/RESPONSIBLPARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) NAME: R ATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STAT ZIP: C-COLLAR: (IF NOT REPLACED) _d_ PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: _ CITY: STATE: ZI COMMENTS: t} - TOTAL: -�v_._r. 00632 PATIENT RFCFIVFD BY X fAmidrr rot CONTRA COSTA COUNTY AMBULANCE \ I� �-�• PRE-HOSPITAL CARE FORM I UNIT � AUTHOWZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: f 3 `r PATIENTS NAME OM ❑ F COMPA/N+Y# ADDRESS AbE CITY STATE ZIP DOB ❑ Sn ❑ M ❑T ❑W ❑Th ❑ F ❑S DRIVER'S LICENSE# PHONE____ NATURE OF DISPATCH f L TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: , , J RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S.O. CALL RECEIVED Jo////v Ila //� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 1,12y 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: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ,,//e eO cq u 0d•Y t EMT-1A TECHNICIAN u L�'�� 1 -PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: @'YES ❑ NO REASON FOR DRY RUN /V "9 fV AUTHORIZATION FOR DRY RUN(EMS USE ONLY) C1 q�j9 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 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDT-CAL C 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: X_ 00633 Provider retain White r-rd M13k on Noturn rp.71•u r,i (SIGNATURE) PY I p tr �I" uhra t i 11 i�yI CMS-1 I CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM 1 UNIT AUT ORIZATION N CHECK OR RLL INAPPROPRIATE SPACE DATE: 3 - )I PATIENTS NAME `` ❑ M OF COMPANY N /t2`�)/J ADDRESSLV�- 1 AGE— CITY GE CITY STATE ZI DOB ❑ Sn ❑ M O T O W 13 Th O F OS ` DRIVER'S LICENSE 0 PHONE NATURE OF DISPATCH H(Af- . TYPE OF TRANSPOR LANCE .OTHER❑ STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: I RESPONSE CODE: RE_OUE TEQ Y: TIME— (24 HOUR CLOCK) _ Y ��\ C 1 � ^ TO SCENE- t9 S.O. L<< CALL RECEIVED TIME 10-8 ! PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 1`4 ❑ PSAP TIME 10-49 �}IL MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 -DOCTOR PMD/ER START �` b TIME 10.22 HOW CHOSEN: ITOTAL STANDBY TIME _ ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK Of: AMBULANCE COMPANY: CA: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SL' RESPONSE ZONE 5 ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER —, Nf- ! PATIENT CONDITION: DRIVER Z MT=1_A_. f TECHNICIAN N 17 3 PARAMEDIC HK: msPATcRm: _11a EL 4 ; CHIEF COMPLAINT: _l YE EASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY)— PATIENT NLY)PATIENT REFUSED SERVICES:(SIGNATURE) X ` MEDICAL COVERAGE: INDUSTRIAL ❑ YES kNO NO.OF PATIENTS: S.S. N I PRIVATE INS.CO.: BASE RATE: k KAISER N: MULTIPLE PTS. BASE RATE r i BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ® NO D YES ONO NIGHT: (19:00-07:00) CCHP/PPRP 0: EMERGENCY RUN: MEDI-CAL*: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ONO NEONATAL: (INCUBATOR) -� DATES BILLED: STANDBY: (OVER 15 MIN.). E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) I CITY: STATE— ZIP: C-COLLAR:.(IF NOT REPLACED) �yODL PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) + EMPLOYER: OCCUPATION: OTHER: ADDRESS: 1 CITY: STATE: ZIP: COMMENTS: TOTAL: 0®634 PATIENT RECEIVED BY: X P�. Irl./e. ..•.. . tn,;,, ..r r:,._ (SIGNAMAE) I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I 1 UNIT AUT14ORIZATION 4 83 I ,1,191 CHECK OR FILL IN APPROPRIATE SPACES DATE: -_1 13 I S3 •���„ PATIENT'S NAME LV r�1�S M 13F COMPANY ADDRESS 11 �`�1 AGE ol.. C n /3 7(4� ' CITY `� u'��- STATE—L] ZIP 008 ❑ Sn ❑ M ❑ T O W ❑ Th 13 F DRIVER'S LICENSE q __—_.—_____ _ PHONE21 Z 1 A � S M c—NATURE OF DISPATCH � � TYPE OF TRANSPORT: AMBULANCE CI OTHER❑ _ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)__-._ . INCIDENT LOCATION: RESPONSE COO REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- ❑ S.O. CALL RECEIVED �S f7F �C(Z-F'-`� ❑ P.D. TIME 10-B _ I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 CC_0A MILEAGE: ❑ OTHER/PVT TIME 10-7 -:0V END � TIME 10-98 DOCTOR PMD/ER START TIME 10-22 =.r--- HOW CHOSEN: TOTAL ( Z- STANDBY TIME U-NEAREST ❑ FAMILY O TRANSFER �-� WAIT TIME �. ATIENT O DIRECT ❑ OTHER CALL BACK k: AMBUpJE COMPANY: -- { AMBULATORY? PATIENT TA TO AMBULANCE: C O' RESPONSE ZONE I ES ❑ NO ❑ WAL'<Eo/yr.UERNEY ❑ OTHER J ` PATIENT CONDITION: DRIVERWy". 5 EMT-1A TECHNICIAN �1 L 2-1` • PARAMEDIC Hx: � DISPATCHER: -7 L_ !00 CHIEF COMPLAINT: � DRY RUN: O YES O REASON FOR DRY RUN LI f�151b 1J " )AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X r MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. - o PRIVATE INS. CO.: BASE RATE: s6' - KAISER R: MULTIPLE PTS.BASE RATE i BLUE CROSS(►: TOTAL MILES: \ �` X C (9 - 1 MEDICARE#: E.O.B. ATT, ROUND TRIP: OYES ❑ NO -. ` ❑ YES ❑ NO NIGHT: (19:00-07:00) 1. CCHP/PPHP M: EMERGENCY RUN: 2+C)' AJbEDI-CAL M: CODE 2/21 �1 OTHER: OXYGEN: ( ER TANK) 11 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) I DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) � NEARS RELATIVE/RESP 1SiGLE P-eRTY: V.: (PER ADMIN.) X LA i Lbt ) DRUGS: (PER ADMIN.) X NAME._ LATIONSNI _ E.O.A.: (IF NOT REPLACED) ADDRESS: / ` ORAL AIRWAY: (IF NOT REPLACED) CITY L STATE__21P: C COLLAR: (IF NOT REPLACED) PHONE: f WORK PHONE: DRY RUN,: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - --- ADDRESS: CITY: STATE: ZIP:- COMMENTS: IP:COMMENTS: - TOTAL' F _ PATIENT RECEIVED BY:X 00635 L Provider mai•. Whttr and /`r•: ror� , Art Yr- ,• .,..., . rw whom Fil:inp (SIGNATURE) OIS-1 �- CONTRA COSTA COUNTY \f` ' AMBULANCE PRE—HOSPITAL CARE FORM I � ' 1 (I UNIT AUTHORIZATION M GoIA /.4— CHECK OR FILL IN APPROPRIATE SPACES I DATE: • - Q 3—R?, - PATIENT'S NAME _1M_Q1 ('�..y� �_- OM ❑ F COMPANY ADDRESS 9 7 y_-JAGE 30 1 13 �0 CITY_- �`1,� ',7.:_ STATE-_-"- ZIP 0 - DOBr ❑ Sn O M ❑ T DW 13 Th O F O S DRIVER'S LICENSE fi _...-_._ . _..__ _-_. PHONE .�33_-_L91 NATURE OF DISPATCH TYPE OF TRANSPORT. AMBULANCE JA OTHER❑ INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME- (24 HOUR CLppK) ~~ TO SCENE- 9S.O. CALL RECEIVED RP -�Dsf� __\ ❑ P D TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _. ❑ TIME 10-49 OTHER/PVT MILEAGE: � ❑ OTHER/PVT TIME 10-7 -7 _ END _! 7 TIME 10-98 .~ DOCTOR _ _ PMD/ER START < TIME 10-22 HOW CHOSEN: TOTAL ).� STANDBY TIME ' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT likOTHER G CALL BACK M: AMBULANCE COMPANY: �'.B2uc�c - • � PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S O RESPONSE ZONE ❑ YES ty-NO ❑ WAL°:ED KGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER.._ 1 I D MT-1A TECHNICIAN ;_e,<& T DIC Hx: — ____.. ______ DISPATCHER: -4 e C Ur n D O CHIEF COMPLAINT: Q__..Q_..______ _ DRY RUN: ❑ YES A NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES- (SIGNATURE) X MEDICAL COVERAGE: IND STRIAE ❑ YES WNO NO. OF PATIENTS: -�^Q -�,a 1 PRIVATE INS. CO.:-___....____-.-- BASE RATE: ` v'csa KAISER a: __ ___ MULTIPLE-PTS, BASE RATE J BLUE CROSS#: TOTAL MILES: X d, ' MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 CCHP'PPHP p:____. _...__ _ EMERGENCY RUN: MEDI-CAL CODE 2/�3 OXYGEN: SP AJANK) 12�Ld1'O r P. ..E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) V DATES BILLED: - STANDBY: (OVER 15 MIN.) i E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ,,QQ LL DRUGS: (PER ADMIN.) X NAME: -Cr b f� mcx,rZii-ALrATIONSHIP: S E O.A.: (IF NOT REPLACED) � rrtern,, ADDRESS:_ p ORAL AIRWAY: (IF NOT REPLACED) _..udGs 3 CITY _____ - - 's .. STATE__ZIP:—_ C-COLLAR: (IF NOT REPLACED) PHONE WORK PHONE__- DRY RUN: (AUTHORIZED) EMPLOYER: _—.__-_.--- ___.__ OCCUPATION: OTHER: ADDRESS: -- -- _ r` �_R )�•CTj) r.: CITY: STATE: ZIP: COMMENTS.— It OMMENTS. ,- -- TOTAL: i /� / l -- --- PATJENT RECEIVED BY: 1rwi,!rr rrtr.'� L4Ifr -.r.l .+^.: •..rc =rf:7+: )'r';:c -�.,; n� r (SIGNATURE) r, f r.•hr� h:''i�:p.- DIS-1 i CONTRA COSTA COUNTYd AMBULAN l PRE-HOSPITAL CARE FORM I UNIT I i�7' AUTHORIZATION CHECK OR FILL IN APPAOPMATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY# ADDRESS AGE I , I 1 CITY STATE ZIP DOB_ ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F . DRIVER'S LICENSE# _ _ PHONE ___ NATURE OF DISPATCH �/-7 TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION: ' RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLfK) n TO SCENE- O. CALL RECEIVED u P.U. TIME 10-8 PATIENT DESTI TION: L7 FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 Gilr,' END TIME 10-98 - DOCTOR PMD/ER START TIME 10-22 7Z4 HOW CHOSEN: TOTAL STANDBY TIME / ❑ NEAREST • ❑ FAMILY ❑ TRANSFER WAIT TIME 11 PATIENT 13 DIRECT 11 OTHER CALL BACK#: AMBULA E O PANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ; I PATIENT CONDITION: DRIVER I -IO At TECHNICglAN PARAMEDIC /0640 �� Hx: / DISPATC CHIEF COMPLAINT: DRY RUN ❑ NO REASON FOR DRY RUN AUTHOROR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X -I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ( l S.S. # t PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: Cl YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/ OTHER: OXYGEN: R TANK) P.O.E. STICKER .❑ YES ❑ NO NEO AL: (INCUBATOR) DATES BILLED: ANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIO IP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: S TE_ ZIP: C-COLLAR: (IF NOT REPLACED) I ww PHONE: WO PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: I TOTAL:— PATIENT OTAL:PATIENT RECEIVED BY: X___._ r�FrynTi,nFl CONTRA COSTA COUNTY j MBULANCE PRE-HOSPITAL. CARE FORM I [ 1NIT AUTHORIZATION q CHECK OR FRl IN APPROPRIATE PACESDATE: PATIENT'S NAME_- ` _ ❑ M 1:1 F COMPANY# /12 I ! rr ADDRESS � - --- -- -- A �� leI� t CITY - _. STATE-_- ZIP DOB-_.-__ ❑ Sn ❑ M ❑ T..C❑ W ❑ Th ❑ FF DRIVER'S LICENSE _ ...__. .__ ...- NATURE OF DISPATCH J l e`5 a-.--. _ _ .. _ PHONE - _ TYPE OF TRANSPORT: AMBULA-NG OTHER❑ -.__._-__-_-.___- ... INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE 3 S.O. _ CALL RECEIVED rX ❑ P.U. --- TIME 10-8 42- PATIENT DESTINATION: 0 . FROM SCENE- ❑ FIRE -__ TIME 10-97 I / - ❑ PSAP TIME 10-49 i MILEA ❑ OTHER/PVT TIME 10-7 : f END _ TIME 10-98 f DOCTOR . __-_-__-_- __-.. PMD/ER START_._ -- TIME 10-22 :L C HOW CHOSEN. TOTAL _- - STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME �- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COK A Y: PT AMBULATORY) PATIENT TAKEN TO AMBULANCE: J U RESPONSE ZONE (� � Cl YES ❑ NO Cl WAL`:ED Cl GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER.No --),,,-3 EMT-1A � r TECHNICIAN _ [�_ 7 ' PARAMEDIC H.x: ------ --- ------ - DISPATCH yv CHIEF COMPLAINT: ___- _-___ ._-_-----__._--. DRY RUN: VY ❑ NO REASON FOR DRY RUN[ ft ______ _ __.--_-_.. __--_- AUTHORIZATION FOR DRY RUN(EMS USE ONLY)-- PATIENT NLY) S PATIENT REFUSED SERVICES. (SIGNATURE) X.____ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: c) S.S. PRIVATE INS. CO.:._ ____.__-_ BASE RATE: I KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS q:---____-._.___--- ____-- TOTAL MILES:- X MEDICARE a: E.0 B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP a:-. _ EMERGENCY RUN: PAE DI-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) i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME. ......_____.. .. ...._.__.__ ___....._.. RELATIONSHIP:.---- E.O.A.: (IF NOT REPLACED) AnDi1ESS .._ __._. __._-._...__.-_ 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:--- COM(�1ENTS: - ---------- -- - -- -- ---- TOTAL: I PATIENT RECEIVED BY:.X /4•r,ci r r• rrr.:r< %:i r. ..,. n:.: ,..•f,, -rrr.r+ Yr':.. pts.. ,.•hr•n ti i'ino (SIGNATURE) / s CONTRA COSTA COUNTY J AMBULANCE �j• 4� PRE-HOSPITAL CARE FORM I �.�)I UNIT '/ AUTHORIZATION M CHECK OR FILL IN APPROPRIATE SPACES DATE: r PATIENT'S NAMEGt F_ � M ❑ F COMPANY« ADDRESS T� ' Q7 lI ��,,, ��y�- AGE L_ CITY C - �� i ,STATELL_ikg^ ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F bt8 DRV FSS, C n _ P'ZN S G - A T U R E OF DISPATCH 3 TY E OF TRANSPORT: AMBULANCEV OTHER❑ -- STATION 1(A)_2(8)_3(C)_4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME- (24 HOUR CLOCK) TO SCENE- VS.O. CALL RECEIVED Liz ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-n ❑ FIRE TIME 10-97 :zZ- i •L-- 11PSAP TIME 10-49 1 MILEAGE ❑ OTHER/PVT TIME 10-7 ?• I END Z TIME 10-98 _ 1 DOCTOR r►��Nb2- PMDeT�START TTIME 10-22 �— 1 HOW CHOSEN: �v TOTAL V STANDBY TIME ' NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _– ❑ PATIENT ❑ DIRECT ❑ OTHER 2.' CALL BACK N: AMBULANCE CO rA PT. AMBU TORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WALKED GUERNEYOTHER SCc�L� PATIENT CONDITION: DRIVER PC m ^�_r' EMT-1A I i I TECHNICIAN .�'�LS�(IL1/t�7��'I .�=�PARAMEDIC _ Hx: DISPATCHER: C'i_,_• E CHIEF COMPLAINT: DAY RUN: ❑ YES NO REASON FOR DRY RUN 1 L AUTHORIZATION FOR DRY RUN(EMS USE ONLY) j l L� PATIENT REFUSED ERVICES: (SIGNATURE) X / I MEDICAL Co V $�aE:�.. INDUSTRIAL OYES b`NO NO. OF PATIENTS: . . N SS PRIVATE INS.CO.: BASE RATE: I KAISER M: MULTIPLE PTS. BASE RATEcz BLUE CROSS N: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 0.OLO CCHP/PPRP M: EMERGENCY RUN: 1 . MEDT-CAL X: CODE 2/3 OTHER: OXYGEN: (PER TANK) 6JI 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 AME: SLC `�" RELATION SHIP:J,,A Aa 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: THER: ADDRESS:— I15iUB . C,Q`1 CITY: STATE: ZIP: fU•A� J COMMENTS: .. __ TOTA - -�flll�.--- ------ I. W _ PATIENT RECEIVED BY' ; CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT . AUTHORIZATION Or CHECK OR FILL IN APPROPRIATE SPACES DATE .. PATIENT S NAME_ ` .1 __L�� _J.._aA /41 ...�- .__.___ _ ❑ M COMPANY K :s ADDRE CseLt ---- AGE'-:) ,v •c CITY._ C' �j'' � STATE._�,_-�-_ ZIP .L.��.�_L=_.._.. DOB,J_'_,^,�_�_/J ❑ Sri ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE p __._-____. _ PHONE /J :/.__ NATURE OF DISPATCH.-_- d TYPE OF TRANSPORT. AMBULANCE CTHER❑ INCIDENT LOCATION. ' RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CLOCK) TO SCENE ❑ so. __.__ _ .._. CALL RECEIVED ■� :L ❑ PD _._._.._. TIME 10-8 L7T - PATIENT DESTINATION- FROM SCENE -� ❑ FIRE __.-_._. TIME 10-97L / ❑ PSAP TIME 10-49 --1-1-1 M rl a G'Ll LE jTND ILEAGE OTHER;PVT TIME 10 7_-'S�_' '_ _ TIME 10-98DOCTOR ►_ _. PM %ER ART -�_� -_ , 1 : TIME 10-22 HOW CHOSEN: TOTAL -�. _; _- STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER j WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ,f ��� CALL BACK#: AMBULANCE C MPANY: kYTAMBULATORY? PATIENT TAKEN TO AMBULANCE i ► RESPONSE ZONEES ❑ NO XWAL"ED ❑ GUERNEY ❑ OTHER -__�_-_ J _ 2.-! i /,j PATIE CONDI�IN. DRIVER___r`_,CJL -_� / EMT=1A TECHNICIAN � Hx: DISPATCHER: � t . � � 7•✓ ( � CVTF COMPL INT: !��701s�_�__`_ DRY RUN: ❑ YES E�.NO REASON FOR DRY RUN — �,[ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) _ PATIENT REFUSED SERVICES (SIGNATURE) X .-- __._-___.__. MEDICAL COVER GE: I D STRIAL ❑ YE �NO NO. OF PATIENTS S.S. a �J PRIVATE INS. CO.: - _ BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE t __ _ 1 7 7 i BLUE CROSS#: TOTAL MILES:. _._ _. X 7k 2> yE ❑ YES ❑ NO 1 1 MEDICARE a:� � 'S � O.B. ATT. ROUND TRIP: j ❑ YES ❑ NO NIGHT: (1900-07:00) CCHP/PPRP ri: EMERGENCY RUN: - rI 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: 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:-..--- - - --- ----- --- ---- - - — -- --- - -- 1 CITY -- - -- ._ STATE'_ --- ZIP:.. COMMENTS .___._-. _. - -" - - - OIAI - - _.._. PAI If NI I(i.('I VI IIIIY I 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I J UNIT AUTHORIZATION 8 f Z Z CHECK OR FILL IN APPROPRIATE SPACES DATE: -� PATIENTS NAME �Y�y P—1 M OM O F COMPANY M i ADDRESS - AGE 1 CITY STATE ZIP DOB—. ❑ Sn O M ❑ T O W ❑ Th .O F O S DRIVER'S LICENSE PHONE__—_—_. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME– (24 HOUR CLOCK) I TO SCENE- 3 j S.O. CALL RECEIVED _ZZ �M I �1 oj=nnc� V%o(16 /� ❑ P.U. TIME 10-8 �Z PATIENT DESTINATION: FROM SCENE- ❑ 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 AT HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE ZONE AYES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER — PATIENT CONDITION: DRIVER W ' `�`y EMT-tA l TECHNICIAN , hPARAMEDIC ` Hx: r J p n DISPATCHER: CHIEF COMPLAIN : DRY RUN: RYES ❑ N EASO FOR DRY RUN Y U i AUTHORIZATION FOR D PATIENT REFUSED ERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO O. OF P TIENTS. S.S.# I PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS p: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP k: EMERGENCY RUN: ` MEDT-CAL k: CODE 2/3 OTHER: OXYGEN: (PER TANK) 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 DRUGS: (PER ADMIN.) X j 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: / P .fly e TOTAL:_ JL PATIFNT RFrFIVFf1 RV X qL CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I qt UNIT ' AUTHORIZATION# J� •' 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: 9 10 �5 PATIENT'S NAME � 1:i� }��}�"-L.���� ❑ M �.F COMPANY ADDRE 5 _ A- �) ���`—f\ Vr_ ��__ AGE /,, �/ 13 ' � � •,r CITY_ 1 C w'r Cir \Z. STATE-..C- ZIP_-I-1 t�Q� DOB 7`O ❑ S. ❑ M ❑ T :❑ W O ThOF DRIVER'S LICENSE # __._.__...._...____.__.—._._ _ PHONE�3 I—?�� NATURE OF DISPATCH 1 I TYPE OF TRANSPORT: AMBULANCE THER❑ INCIDENT.LOCATION: n RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) 44{1 C TO SCENE- � ❑ S.O. CALL RECEIVED Q C� �U 4 ❑ P.D. TIME 10-8 3 '• 1 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 ❑ PSAP TIME 10.49'.1''1 '`; n orYlA Ns MILEAGE: 61 /XpTHER/PVT TIME 10.7 -LQ_ : END f TIME 10.98.` �QQ_'t�'!T DOCTOR _QS�.— L PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL 20STANDBY TIME ❑ NEAREST • ❑ FAMILY RANSFER WAIT TIME �-- -) ❑ PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE COMP T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE YES ❑ NO 1)4,WAL!,ED ❑ GUERNEY ❑ OTHER tt I v r t 1 I PATIENT CONDITION: DRIVER 7 EMT-1A TECHNICIAN 50 PARAMEDIC Hx: DISPATCHER: 04 CHIEF COMPLAINT: U. DRY RUN: ❑ YES 1 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X r� MEDICAL �CAL COV�RA �! Z INDUSIA Dd YES NO NO. OF PATIENTS: u E S.S. PRIVATE INS. CO.: BASE RATE: 1LLl_3S1"'1 KAISER#: MULTIPLE PTS.BASE RATE < i ' 'C ^ f+rt� 1 BLUE CROSS#: __ TOTAL MILES: !S X I I MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r t \/ ❑ YES ❑ NO NIGHT: (19:00-07:00) ` CCHP/PPRP#: EMERGENCY)RUN: .r r,. •s .'Yj �'8 %MEDI-CAL#: COD /3 n U OTHER �� �� OXYGEN: P R TANK) VL I`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.) yX� p DRUGS: (PER ADMIN.) X NAME:. /1. /?C( 4..I -/,�)RELATIONSHIPA�16 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: �t OTHER: - ADDRESS: CITY: STATE: -ZIP.:--- COM ENTS: `./., 5 l ir..r' C"? Z�� � CC�� 1 TOTAL: a Z S70 — PATIENT RECEIVED BY:;vzl - w� . H•nnider reta::r White txd Pin:: ropy heturn Ye,ltm• -Opp t• EVS when bil:imp (SIGN URE) OIS-1 CONTRA COSTA COUNTY 1\ t AMBULANCE d J /� ��to PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION# _23 y "1 �y1 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: ,,,•,�•l ) PATIENT2 S NAME_____-:•�i_'Sd ���`� M ❑ f COMPANY# ADDRESS L _ AGE 0\'^�, l l - CITY STATE ZIP_ DOB �Sn 0 M 0 T O W O Th/0 F 0$_l DRIVER'S LICENSE#" ____. _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER Cl — STATION 1(A)_2(8)_3(CI_4(D)_5Z_ ±� INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - P(S.O. CALL RECEIVED _� •_� �•� � �S�` �i. //'l� /�t� �/V C� D. TIME 10-8 OO =: 2.1 PATIENT DESTINATION: FROM SCENE 0FIRE TIME 10.97 0 PSAP TIME 10-49 r 00 C C' G N MILEAGE-/� 0 OTHER/PVT TIME 10.7 00 : 7- END _ TIME 10-98. ; DOCTOR PMD/ER START 0 1'cI)— TIME 10-22 HOW CHOSEN: TOTAL 1 I STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT DIRECT ❑ OTHER I CALL BACK#: AMBULANCE CO ANY- RT TORY? PATIENT TAKEN TO AMBULANCE: c'/ RESPONSE ZONE ES 0 WAL'CED P,"GUERNEY 0 OTHER / ✓� PATIENT CONDITION: DRIVER Z I FC MT-td F- 1 TECHNICIAN .41d PARAMEDIC Hx: DISPATCHER: 0��F�� T oo4 i CHIEF COMPLAINT:_-2 S Ve 1 4T✓L j e_- DRY RUN; Y REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— J MEDICAL COVERAGE: INDUSTRIAL 0 YES 0<10 NO. OF PATIENTS: - S.S. PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X dJ•_ - MEDICARE#: E.O.B. ATT. ROUND TRIP: 0 YES 0. NO . D 0 YES .0 NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: �� w • -1 MEDICAL#: CODE 2/3 OTHER: OXYGEN-. (PER TANK) * { ..; -rte---- P.O.E. STICKER O YES 0 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: 0 14 q COMMENTS;P� T!�S �� Q ' 1 d TOTAL:_��-7• - PATIENT RECEIVED BY:X Provider Pero-r. whit, ,r.•i li.: •opp 4et�r. Yv'2uu MSL t• SIS uhrn hit'inp (SIGNATURE) -I CONTRA COSTA COUNTY 1 (/ AMBULAN �.� PRE-HOSPITAL CARE FORM I uNlr AUTHORIZATION M «l V ✓ CHECK OR FILL IN APPROPRIATE SPACES DATE: �...L .. PATIENT'S NAME__S C\l-c 1�S /�+�_7� l -M ❑ F COMPA Y# ADDRESS,! G EE Z . _ A A / `i CITY I� ` STATE--A ZIP! DOSn OM OT Ow O Th •O F O DRIVER'S LICENSE b _._ ..____ -_. _..___ PHONFL-�?J_936_/ NATURE OF DISPATC TYPE OF TRANSPORT: AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: ESTED BY: TIME— (24 HOUR CLO K) -I 1� ' TO SCENE- S O. CALL RECEIVED I" ~ / —-- -- -- -- -- ❑ P.U. TIME 10-8 -3 . .. PATIENT DESTINATION: tr FROM SCENE- ❑ FIRE TIME 10-97 / O PSAP TIME 10-49 oll �/ I MILEAGE'�� O OTHER/PVT TIME 10-7 i //_ END!_12,' TIME 10-98 DOCTOR _��o_(aL f ' �--PM /ER START. �— TIME 10-22 _ HOW CHOSEN: TO fSTANDBY TIME N " PATIENT ❑ FAMILY ❑ TRANSFER WAIT TIME - PATIENT ❑ DIRECT 13 OTHER j 1 CALL BACK k: AMBULAN E ANY PT AMB LATORY,) PATIENT TAKE TO AMBULANCE: RESPONSE ZONE E] YES NO 13WAL':ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER W EMT-A I L/� TECHNICIAN*a-4 PARAM DIC Hx: S?UL _1 �--- ��� DISPATCHER: 'r; Q � /� � , 1 D L� I CHIEF COMPLA T: ,_-__._,_ _._ DRY RUN. ❑ YES wo REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ 1 MEDICAL COVERAGE- IN USTRIAL YES NO NO. OF PATIENTS: S.S. a /W O 1 PRIVATE INS. CO.: BASE RATE KAISER a: MULTIPLE PTS. BASE RATE 1,77TU 1 BLUE CROSS#:—,___ _ TOTAL MILES: X - I MEDICARE a: __ E.O.B. ATT. ROUND TRIP: O YES ONO ❑ YES ❑ NO NIGHT: (19:00-07:0( — / CCHP/PPRP 4: EMERGENCY RUN: MEDT-CAL a: CODE 2/3 J OTHER: ^ 1' —. OXYGEN: (PER TAN - l P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR*)' DATES BILLED:_ — STANDBY: (OVER 15 MIN.)T y��yvL E.K.G.: (PER EPISODE) %J NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X NAME S/I��1�7 _ _ RELATIONSHIP:AAF-J E O.A.: (IF NOT REPLACED) _ -// /t/ t/ ADDRESS: _2�7 �9l<G N Y_ __ ORAL AIRWAY: (IF NOT REPLACED) CITY_LeAK� STATE._.ZIP:___ C-COLLAR: (IF.NOT REPLACED) PHONE: !t3— WnRx PHONE:_ DRY RUN:.(AUTHORIZED) EMPLOYER: �IJGlQ2_ l CUPATION: OTIJER: / ADDRESS: �`_OC CITY: _____ STATE:—.—21P:— COMMENTS:_�� 'I _ TOTAL:-! - - uub PATIENT RECEIVED BY:X (SIGNATURE) LKS-t =t / CONTRA COSTA COUNTY AMBULANCE ✓// PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME_ '� ����`� ❑ M F COMPANY ADDRESS L� ?-tom - t� AGE� + I i CITY__. % lL`I STATE-_ ❑ W ❑4Th F ❑S WOf � DRIVERS LICENSE b ___._.__.._....__._ _....._ PHONE 1�34_sf�_(a4j_aKRE OF DISPATC TYPE OF TRANSPORT: AMBULANC OTHER❑ INCIDENT LOCATION: RESPONSE COD BY: TIME- (24 HOUR C (ACK)^' ��^ ) ( � TO SCENE - .O. CALL RECEIVED '1` ---- G/ �E!4STED P.D. TIME 10 8 } PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 _ ❑ PSAP TIME 10-49 MILEAGE: �J,(i ❑ OTHER/PVT TIME 10-7 -1 2 f ! �.Z. END !_IO_`1 TIME 10-98 DOCTOR � P D/ER S T� TIME 10.22 - H W CHOSEN: O STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFE / I WAIT TIME O PATIENT ❑ DIRECT 1:1OTHER CALL BACK#: AMBULA ANY: PT AMB. TORY? PATIENT TAK N AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WAL"ED GU ERNEY ❑ OTHER D PATIENT CON TION DRIVER- __ t 60o ET-1A TECHNICIAN o PARAMEDIC _ ' Hx� _ r '� ` DISPATCHER: / d b CHIEF COMPLAINT: _____-_ DRY RUN: ❑ YES NO EASON F64 DRY RUN AUTHORIZATION OR DRY RUN(EMS USE ONLY) •r PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: I INDUSTRIAL ❑ YES D�CS NO. OF PATIENTS: S.S. PRIVATE INS. CO.' BASE RATE: - (� KAISER #: MULTIPLE PTS. BASE RATE Z�0 1 BLUE CROSS#: -- _---- TOTAL MILES: -X _ MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT,: (19:00-07:00) ,4:26'. C-'U CCHP/PPRP#: EMERGENCY RUN: -301.00 MEDI-CAL#: CODE 2/3 ccl If OTHER: __ OXYGEN: (PER TANK _CS) .�'- -- t 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 L� - DRUGS: (PER ADMIN.) X NAM1. T�. LL►E)NSHIP: .O.A.: (IF NOT REPLACED) ADDRESS: --__ -_ ORAL AIRWAY: (IF NOT REPLACED) CITY STATE___ZIP: C-COLLAR: (IF NOT REPLACED) PHONEL� =�'J-6� ORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: -_._- -_ OCCUPATION: OTHER: ADDRESS CITY: —__—_—_—_ STATE: ZIP:_ COMMENTS: 1 Z•OZ -- -- -- TOTAL: PATIENT RECEIVED BY:X 00645 Se- FT• Pi.!rr trt,::- L�i•r •../ r� ,tnr. Yr•• . (SIGNATURE) n^ chre t:• i •; OIs-1 r •• CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I,Vti'l l AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME LL rr6ZSQA l �/�Ly 1 elM ❑ F COMPANY N -� ADDRESS / C W 7 r �� AGE' � d % V CITYT I C�/►1 STATE ZIP POB / VnM O T.Q,W .0Th ss---��F PJDRIVER'S LICENSE# _ PHONE�U� / 7 NATURATCH d • ,�. -- TYPE OF TRANSPORT: AMBULANCE OTHER 11 _ STATION 1(A) (BI._3(CI_4(D)_SIE).r,�..._J INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY: TIME- (24 HOUR CK) TOSCENE- S.O. CALL RECEIVED �3O P.D. TIME 10 8 i PATIENT DESTINATION: 1' FROM SCEN ❑ FIRE TIME 10-97 ` CI? n ❑ PSAP TIME 1x49:> ..� J♦ � MILEAGE: ❑ OTHER/PVT -TIME 10-7 - �y END I Z TIME 10-98, DOCTOR L/ PMD/ER START TIME 10-22 HOt HOSEN: TOTAL STANDBY TIME 1-...�.J NEAREST O FAMILY O TRANSFER ' WAIT TIME+ PATIENT O DIRECT O OTHER CALL BACK N: AMB ULA 1 .C M NY: PT. AM ORY9 PATIENT TAK N T AMBULANCE: _.. V RESPONSE ZONE - ❑ YES z NO O WAL'<ED ❑VERNEY ❑ OTHER PATIENT CONDITION: DRIVER C' �U ' �"I2Z��n S-/6) EMT-1A TECHNICIAN-T71- ��77o i Fif 70 PARAMEDIC / Hx: IG4P 0lf DISPATCHER: ' . CHIEF COMPLAINT: 4-C2 . DRYRUN. ❑ YES' POND REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) - /(TU! PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES*NO NO. OF PATIENTS: S.S. M ' .- PRIVATE INS. CO.: 13ASE RATE: ''` , KAISER a: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: MEDICARE#: ��/, 'O S'- l .7 7,I -/4 E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) V 1 CC #: EMERGENCY RUN: N EDI-CAL k: -7 G'-V qQV1 7.;'A> CODE 2/3 r OXYGEN: (PAR TANK) P.O.E. STICKER ❑ YES 13 NO NEONATAL: (INCUBATOR) " CJ DATES BILLED: . STANDBY: (OVER 15 MIN.) crG__ 130 ` E.K.G.: (PER EPISODE) \� NEAREST RELATIVE/RESPONSIBLE PARTY: - - I.V.: (.PER ADMIN.) -�+-- DRUGS: (PER ADMIN.) X NAME: 7C- RELATIONSHIP:_ E.O.A.:(IF NOT REPLACED) ADDRESS: 5���)Com' - ORAL AIRWAY: (IF NOT REPLACED) CITY: -STATE ZIP: C-COLLAR: (IF NOT REPLACED)­­­­- PHONE: EPLACED)----•-•--- - - PHONE: WORK PHONE: DRY RUN: {AUTHORIZED) EMPLOYER: .1e,11P OCCUPATIOa' OTHER: - - ----^ - --- ADDRESS: CITY: /STATE: ZIP• - COMMENTS: I", ILI r _.. TOTAL: PATIENT RECEIVED BY:X Yf�rr+irlrr rrto[c Vhitn r-Trt F'1'c: -:+pp votLr++ Yt'(r+W "•r+;� 7• ,7KS uhr" hit"inq (SIGMA URE) DIS-' ' � CONTRA COSTA COUNTY AMBULANCE PREHOSPITAL CARE FORM I UNIT AUTHORIZAAN M c� ... ... .. :. c CHECK 011 flLL INAPPROPRIATE SPACES DATE: —�— PATIENTS NAME ❑ ti ❑ F. COMPANY M ADDRESS'°• `' AGE CITY STATE ZIP DOB - ll Sn ❑ M ❑T O W ❑ Th O F O S 1 DRIVER'S LICENSE 0 _- - -� PHONE NATURE OF DISPATCH Poi-) hell it 4 TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ ' STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT.LOCATION - n 'i 3 RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) I I c '7 ,- P TO SCENE- S.O. CALL RECEIVED W 1 - z ❑ P.D. TIME 10-8 21 :J_ PATIENT DESTINATION: --- ) � V ' FROM SCENE-/j, ❑ FIRE __ TIME 10.97 ❑ PSAP TIME 10-49 I MILEAGE: OTHER/PVT TIME 10-7 END TIME 10-98 J DOCTOR PMD/ERS START TIME 10.22 HOW CHOSEN: _ TOTAL��_ STANDBY TIME 1, _❑ NEAREST;'?? ❑ FAMILY ❑ TRANSFER WAIT TIME ' ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: 2Z E13 , . AMBULATORY? PATIENT TAKEN TO AMBULANCE:: [� RESPONSE ZONE `5YES 13NO ❑ WALKED 11GUERNEY 13OTHER l PATIENT CONDITION: DRIVER ��a L <<�1(_ =,l l) EMT-1 2 7 ►1 i Flii L 1 1 TECHNICIAN 11�lc�,!� �� n -PARAMEDIC Hx: - DISPATCHER: I q CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN 1QLL�#��Fu�rij 111 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) q_f q R. '.:. ::PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: i S.S. N PRIVATE INS.CO.- BASE RATE: KAISER M2 t MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE C. ' a E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:' ' EMERGENCY RUN: MEDT-CAL 0: i CODE 2/3 OTHER: t''' 1 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) ��Cel " EMPLOYER:- OCCUPATION: OTHER: ADDRESS: --CITY: STATE: ZIP: _ tine COMMENTS: -- 77e ,7 TOTAL:•rT.c"-)I _ PATIENT RFCFIVFn 11Y X 1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT i AUTHORIZATION M J . .. ' t CHECK OR FILL IN APPROPRIATE SPACES DATE: �� - •e-- PATIENT'S NAME� a.11�_ � M D F COMPANY N p �- ( L" I ADDRESS 1�_ 42-1 L, `LL MPLa 1 Gl,l_ L AGE -U ��] CIT Ja O 9' 2 f4le- STATE ZIP DOBE 1 O Sn OM OT OW O Th OF O S DRIVER'S LICENSE a __—_,_�__ ___ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC&N OTHER❑ -- STATION 1(A)_2(B)_3(C)_4(D)_5(E)_• INCIDENT LOCATION: RESPONSE COO REQUESTED BY: TIME— (24 HOUR CLOCK) n t lu �- TO SCENE- XS.O. CALL RECEIVED _, , �/ C—LS ❑ P.D. TIME 10-8 PATIENT DESTINATION: a� FROM SCENE- Cl FIRE TIME 10-97 ((�� ❑ PSAP TIME 10-49.,- r MILEAGE: D OTHER/PVT TIME 10-7 -- END TIME 10-98 1 I DOCTOR PMD/ER START TIME 10-22 :_...._ •� HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE C_OMPAt Y: T AMBULATORY? PA ENT TAKEN TO AMBULANCE: RESPONSE ZONE ` ^, YES ❑ NO WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN "� ► f N N l S y tEbIC — r Hx: DISPATC CHIEF COMPLAINT: DRY RUN: NYES D NO REASON FOR DRY RUN ALIT�ORIZAT FOR DRY RUN(EMS USE ONLY) ! PATIENT REFUSED SERVICES: (SIGNATUR X Cg/�n, E,� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: -••�~ S.S. a .-— I PRIVATE INS.CO.: BASE RATE: - KAISER a: MULTIPLE PTS. BASE RATE I I BLUE CROSS a: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: D YES O NO •• "'"' O YES .O NO NIGHT: (19:00-07:00) - CCHP/PPRP a: EMERGENCY RUN: / MEDI-CAL a: 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) �� T• EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: - rnrdl • .Q. ._.. . PATIENT RECEIVED BY:X 0 61 a- C Provider reta!r• White Lr ri..4 rare he[yrn wl.iu ropy t, vm.S uhev bil-iap (SIGNATURE) as-1 CONTRA COSTA COUNTY r,': AMBULLA.NNC� PRE-HOSPITAL CARE FORM I C , UNIT AUTHORIZATION 0 CHECK OR FILL INAPPROPRIATE SPACES DATE: r PATIENTS NAME '?(� "�1 '"1 yJ Cr ZL 0�`1' �r�7Acp M ❑ F COMPANY N ADDRESS �L� �L �,%� r C( AGE CITY _(CC._ol V-.lW d STATE ZIP DOB N3 J , O Sl(, M T O W O Th. O F 0 8 DRIVER'S LICENSE _1�.)— NATURE OF DISPATCH p PHONE__-_—_ TYPE OF TRANSPORT: AMBULANCE�4 OTHER❑ — STATION 1(A)_2(8)_3(C)_4(D)_5(E)�r INCIDENT LOCATION: RESPONSE CODE: EOUESTED BY: TIME— (24 HOUR O K) TO SCENE- S.O. CALL RECEIVED _ ❑ .D. TIME 10-8 _L 1 PATIENT DESTINATION: S FROM SCENE CO3 FIRE TIME 10-97 O PSAP TIME 1049 �--� / �/� r"f MILEAGE: ---777 ❑ OTHER/PVT TIME 10-7 �'' �z END TIME 10-98 12� AL-- DOCTOR 41 PMA START I TIME 10-22 HOW CHOSEN: TO I STANDBY TIME "-- NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _._ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBUL CE O PANY: PT. AM LA ORY7 PATIENT TAK N TO AMBULANCE: 5I0 RESPONSE ZONE ❑ YES NO ❑ WAL':ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER G41Af71 nit 510 EMT-1A I r/� TECHNICIAN�'7 • H1r/r� ID00 PARAMEDIC A - DISPATCHER: 0 1 CHIEF COMPLAINT: DRY RUN: ❑ YE ,IN REASON FOR DRY RUN r61 AUTHORIZATION RY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X / MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: ��� j KAISER MULTIPLE PTS. BASE RATE 14,10LUE CROSS 7 �'J �� A,; ? TOTAL MILES: X E.O.B. : ❑ YES ONO ATTROUND TRIP 4.1 I c� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M: EMERGENCY RUN:" "—U MEDI-CAL 4: CODE 2/3 _ 17 OTHER: OXYGEN: (PER TANK) ����.�..... P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) sd r/ E.K.G.: (PER EPISODE) ] NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ���� iscrj NAME: �'�I �''"I'1ClkRELATIONSHIP: w` 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 4 �f _,.'S . OCCUPATION: `nA er- OTHER: i 7' ADDRESS r -:f /,-, .7 T CITY: (< e."I Gy /1 TATE: ZIP:— COMMENTS: IP: COMMENTS:i�KF✓Yl`E' ;�,��M V � TOTAL: �� J (� ®0649 PATIENT RECEIVED BY:X Provider retp[r. &/hit, vd N, rvl, cotur+ Yo'Iry Mr. t• .M.S when Fif'inp (SIGNATURE) Olf-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M r. � O CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ��CP«T u-� } } ❑ Ml�� COMPANY M L r ADDRESS (,:I W Cs T IM IUd F\1. ICS AGE i. CITY—M-11 STATE—CA zip—':3 10 DOBC?3-c ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE R PHONE — S NATURE OF DISPATCH �?AT{�S L I: TYPE OF TRANSPO 1•: AMBUTANC THER❑ STATION 1(A1x (B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: f• RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK)` - TO SCENE - ., ❑ S.0. _ CALL RECEIVED ! C=rc N 14, /A G?M c( N f Eir D P.D. TIME 10-8 TIME 10-97_ PATIENT DESTINATION: FROM SCENE - D FIRE I ) �= ❑ PSAP TIME 10-49 t 1 �L I 7 1Z MILEAGE: 4 IS OTHER/ VT TIME 10-7 r ,/ I C<< END V TIME 10-98 DOCTOR 1 ; •(- `` } E 'l +; PM ER START—��-Z •• p TIME 10-22 MOW CHOSEN' TOTAL 7 ? STANDBY TIME ❑ NEAREST ❑ FAMILY TRANS WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER ' CALL BACK#: AMBULANCE COMPANY: C'A PT. AMB a Y? PATIENT TAKE RESPONSE ZONE ❑ YES "" ❑ WAL'CED CKGUERNE0 OTHER t PATIENT CONDITION: DRIVER 11202L 11 7) � M7 to ,L_1 TECHNICIAN a 11�,�i Cts 7 ? Z PARAMEDIC HX: At-lRe liO u - po5 V4 oluO DISPATCHER: CHIEF COMPLAIN ' G- -) Ll)SAIC L'1t5S w 6RY RUN: ❑ YES REASON FOR DRY RUN -TO-;()uo0 f� iO slor AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X MEINCAL COVERAGE: INDUSTRIAL ❑ YES VNb, NO OF PATIENTS. S.S. ti 1 - I `i - ?,I T ? PRIVATE INS. CO.: BASE RATE- KAISER s: MULTIPLE PTS BASE HATE BL S x: TOTAL MILES: / X ' I ,/ MEDICARE �1S ( ' (y " 7 E.0 B. ATT. ROUND TRIP: ❑ YES 0 NO ❑ YES ❑ NO NIGHT: (19 00-07:00) ! �) CCHP/PPRP N: EMERGENCY RUN: ' MEDT-CAL>< CODE 2/3 OTHER: '1 OXYGEN: (PER TANK) P.O. . STICKER ❑ YES 16-NO NEONATAL: (INCUBATOR) AT 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: n1y`Al _ 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-0, is `14 TOTAL: 3,00-- PATIENT RECEIVED BY: rL+�t— yq I _ I'm-iddr rotain Nritu .n.lhin: .•..T.P !ol„+i Y.•': q•{ r eer: d„•, fiT inir ( A EMS•I 006 �� 1i r ��.. CON IRA (;0%1A COUNIY L, AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT �. �+ AUTHORIZATION If CHECK OR FILL IN APPROPRIATE SPACES DATE: 11J 1� r PATIENT'S NAME_ .1__�'_._1:'._ � 7:•._'''r_• /0.M % F COMPANY0 ADDRESS !Z--�-P c' S � Y'~� OCrL^ p l )UI'4AGE CITY-- STATE ^*`,Ll ZIP�J `i 7/ DOB -J�1! ❑ Sn �M O T 13 W O Th ❑ F 17 S DRIVER'S LICENSE to ____ __. (n� rr PHONE____.—___.-- NATURE OF DISPATCH Ln1C�n'�i C�•� tC�h1,c TYPE OF TRANSPORT: AMBULANCE0 OTHER❑ . .-___..... STATION 1( —20_30_4(0)_5(E)_' 7. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �� f f II TO SCENE- 3/( K S.O. CALL RECEIVED :_L_ CL`� �' �� �•�Lrl�' — [ ❑ P.D. � TIME 10-8 �Tj :�-ji I PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 /� t.'�7^ to i 13PSAP TIME 10-49 �_ /,Z MILEAGE: ❑ OTHER/PVT TIME 10-7 _,[✓1 END ,r TIME 10-98 Z DOCTOR S 1 ��_ - PM Dlf START_�2• f TIME 10-22 HOW CHOSEN: YYY TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME - - �-PATIENT ❑ DIRECT Cl OTHER CALL BACK M: AMBULANCE COMPANY: - S PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: so RESPONSE ZONE 7 YES ❑ NO ❑ WAL'<ED GUERNEY ❑ OTHER S 1 PATIENT CONDITION: DRIVER )_)C1 �O EMT-1A f 'f ( TECHNICIAN _� F ��>� PARAMEDIC y Hx: _L+Ci�rc�l t� `I li ._t r C DISPATCHER: ' �U ( �. CHIEF COMPAINT: �Lf ���S.�I"I'^' �^ I DRY RUN: ❑ YES RKNO REASON FOR DRY RUN _` ��i�� F—i�__.L c.�C__• AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X—__ J I I MEDICAL COVERAGE, INDUSTRIAL 0 YES 0 NO NO. OF PATIENTS: S.S '1 I PRIVATE INS. CO.: / BASE RATE: Lic_:` KAISER R: '? 5_" _j C' ? C ����1Gc$ ;��1,J S MULTIPLE PTS. BASE RATEI EILUE t;ROS : In0 C -A (?� _ TOTAL MILES: �� X M M O �� E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO 5�' .d�'- �' _'• 7- /j ❑ YES 0 NO NIGHT: (19.00-07:00) / CCHP/PPRP M: EMERGENCY RUN: MEDI-CALM: CODE 2/3 OTHER: OXYGEN: (PER TANK) �>- e 1 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) y 'r DATES BILLED: STANDBY: (OVER 15 MIN.) JI E.K.G.: (PER EPISODE) v I� NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 4 DRUGS: (PER ADMIN.) X j NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _ ORAL AIRWAY: (IF NOT REPLACED) CITY: a STATE-_—ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OT R: -D, ADDRESS: e CITY: STATE: ZIP: COMMENTS: TOTAL �' cl.. P PATIENT RECEIVED BY: X livmvidrrrr••• r (SIGNATURE) - r•. _ r r,.t:� r. .. . UIS-I loor" CONTRA COSTA COUNTY ti; AMBULANCE PRE-HOSPITAL CARE FORM I f UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES - DATE: ' _� PATIENTS NAME ' / Om v F COMPANY M �l1 ( - , r 1--R �( ADDRESS K ( ` ' AGE- — CITY :o ll STATE ZIP DOB � �,5❑ Sn M O T ❑ W,❑ Th ❑ F O S . DRIVER'S LICENSE M r PHONE 2Z(n 2-g4ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE-Er OTHER❑ __ --__. STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ , r INCIDENT LOCATION:' 1 E` RESPONSE CODE: R ESTED BY: TIME- (24 HOUR CLOCK). 5 _ t - TO SCENE- � S.O. CALL RECEIVED I f� S 3 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 y ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 f 2 //�� � END TIME 10-98 L 1�1�kf6VSTART- TIME DOCTOR � � PM /ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER f_ f 1 CALL BACK#: AMBULANC COM ANY: PT/CMBULATORY? PATIENT TAKENRESPONSE ZONE.,TO AMBULANCE: I YES 1) NO ❑ WAL'<ED GUERNEY ❑ OTHER 7 F PATIENT CONDITION: DRIVER� � L L���I `1)r t EMT-1A �)r TECHNICIA6 , ��!& ��'l�(_�C_0 PARAMEDIC L� Hx: fJ q( r DISPATCHER: 1 � r CHIEF COMPLAINT: ���, DRY RUN: 11YES ,Q NO REASON FOR DRY RUN AUTHORIZATION FOR 1.DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: I D STRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS r.O C�(_IG BASE RATE: KAISER R; MULTIPLE PTS. BASE RATE B E CR SS N: TOTAL MILES: ' X MEDIC E - - E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP-M:� f EMERGENCY RUN: / MEDT-CAL R: 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 1 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:��7 r� �4-ntj=1L I c-_1 21.) - --- TOTAL: PAIIENT RECEIVED BY. X ----_-___-.. Prallidar retain Whit, I,— (SIGNATIME) h. r � LMS-I CONTRA COSTA COUNTY AMBULANCE 7 t PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 813 13 ` • r tt CHECK OR FILL INAPPROPRIATE SPACES DATE: S; _ 1 I PATIENTS NAME ` L C E M ❑ M F COMPANY - ADDRESS YOK MAt %��QJ t _ ST.y,,� AGE CITY R)Ch AOOD STATE ✓' ZIP 9 " L- DO(Bs_22 ❑ Sn [? M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE M - PHONE Z 3 5 `e 3_� NATURE OF DISPATCH --- TYPE OF TRANSPORT: AMBULANC OTHER❑ -- STATION 1(A)_2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE. REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- ❑ S.O. — CALL RECEIVED LL 1 )� I LA 0-'fords k—tKS I AL HE e_ K Z_ ❑ P.D. TIME 10-6 PATIENT DESTINATION: FROM SCENE Z ❑ FIRE TIME 10-97 I[� _ 13PSAP TIME 10-49 1 VA LL t�"0 ZR-oAD ,->! y L,7�t l 1 MILEAGE. XPTHER/PVT TIME 10-7 _1 r / 9 (,S 7. END 3 TIME 10-98 /) DOCTOR�4 l PMD/ER START /t�0 5.1 12 L TIME 10-22 HOW CHOSEN: TOTA_L.) 7 STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER , . �,� WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER ( 1 ) CALL BACK R: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE $ YES ❑ NO ❑ WALKED AGUERNEY ❑ OTHER r 'r PATIENT CONDITION: DRIVER JFN T-1A t, _ TECHNICIAN W 1 L S Y>:V �'I . PAR EDIC 1 , HX: x t N TA L DISORDER, DISPATCHER: CHIEF COMPLAINT. S( S U DRY RUN: ❑ YES' NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X M pICAL COVERAGE: INDUSTRIAL ❑ YES kNO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RTE: lit KAISER R: MULTIPLE PTS. BASE RATE T- - BLUE CROSS R: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPH M: EMERGENCY RUN: 3L = of 07 (91 --d5o CODE 2/3 OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES 10 NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X R�A�JJ _ DRUGS: (PER ADMIN.) X NAME: " '��Lwiy I OL LI t RELATIONSHIP: LAI E.O.A.: (IF NOT REPLACED) ADDRESS: �T'`t'E`(� 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• -)D o L D Aj r- S, (;N fj•o _.... - --- 00653 ----•-- TOTAL:.- - --y --- - - _._..__.. PATIENT HECEIVED BY X CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM f ` , UNIT ® AUTHORIZATION 4 _�3cm CHECK OR FILL IN APPROPRIA11 SPA CIS _ DATE: 4PATIENT'S NAME �+ �`-� ` +`mow O I� D F COMPANY A ` ADDRESS;--- y�:S; AGE CITY STATE-___.,.-_,.,-,ZIP DOB ❑ Sn U O T ❑W ❑Th O F (3 3 } DRIVER'S LICENSE A ! - PHONE ��.._ NATURE OF DISPATCH 1 ) TYPE OF TRANSPORT:' AMBULANCE OTHERO STATION 11A)._21B)_31C)_4(D)^5(E).lc C.'t INCIDENT L CATION: _ RESPONSE CODE,- REQUESTED 8Y: TIME— (24 HOUR CLOCK) L4,Tz. TO SCENE- S.O. CALL RECEIVED W L ❑ P.D. TIME 10-8 1 _ PATTEN DESTINATION: J FROM SCENEc ❑ FIRE TIME 10-97 - _ ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 7 �I END TIME 10.98 _- r DOCTOR `-2 r PMD/ER STARTTIMETIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME s+^ O NEAREST- ❑ FAMILY ❑ TRANSFER - WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK k: AMBULANCE COMP�NY:� EPT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ( � O YES ❑ NO _ I ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER 'L��c � I o -,A TECHNICIAN �►�� � y5 AAAMEDiC Mx: r DISPATCHER: t50os 022 lob CHIEF COMPLAINT: DRY RUN: V�YES ❑ NO REASON FOR DRY RUN 102Z IJ QOLAW- AUTHORIZATION FOR DRY RUN(EMS USE ONLY) Iti S U' I�`1 1):PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: . _ INDUSTRIAL ❑ YES.❑ NO NO.OF PATIENTS: S.S.0 1 I PRIVATE INS. CO.: BASE RATE: KAI MULTIPLE PTS. BASE RATE B UE CROSS K: TOTAL MILES: X MEDICARE C, ' E.O.B. ATT. ROUND TRIP: D YES ❑ NO ❑ YES NO NIGHT: (19:00-07:00) CCHP/PPRP M:'' ' EMERGENCY RUN: MEDI-CAL 4: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER D YE ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) l ' E.K.G.: (PER EPISODE) NEAREST RELATIVE/R SPONS)BLE 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) �e ' EMPLOYER:-- - OCCUPATION: OTHER: ' ADDRESS: "CITY:` STATE: ZIP: (II . I -COMMENTS- - '� f "-- TOTAL:— CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ' _�( AUTHORIZATION NES CHECK OR FILL IN APPROPRIATE SPACES DATE: `�1 PATIENT'S NAME �L'`� Im ❑ F COMPANY M �) ADDRESS 1'( ( A 1�I O t -r �f_k= AGE S ^ , *-- CITY n�' (-ANG STATE C�� ZIPCLI�=-GZ..J_ DOB �_(-3L❑ Sn xm OT O W ❑ Th OF b S DRIVER'S LICENSE N V�_�''`�.�"�^ - PHONE_ ? NATURE OF DISPATCH �'� I A R_( 1 TYPE OF TRANSPORT: AMBULANCEA OTHER❑ — _--- STATION 1(A)_2(B)_3(C)_4(0)-5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE 3 S.O.— _ CALL RECEIVED L ❑ P.U. TIME 10-8 4 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �',/!. MILEAGE: ❑ OTHER/PVT TIME 10-7 END Q ( `,� TIME 10-98 ~� DOCTOR r—47 1/1 r 2 PMDCO STARTTIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST O FAMILY ❑ TRANSFER WAIT TIME (PATIENT ❑ DIRECT ❑ OTHER ( CALL BACK N: AMBULANCE COMPANY CAS PET PATIENT TAKE TO AMBULANCE: I RESPONSE ZONE ry YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER . I PATIENT CONDITION: DRIVER `_IVar �"�� L��� `� EMT-1A As TECHNICIAN_ ({-�—�— ` PARAMEDIC �- Hx. �5-11-1 r-- DISPATCHER: - CHIEF COMPLAINT: -i�-k� �- I N �- DRY RUN: ❑ YES '�NO REASON FOR DRY RUN A C? IT 11-1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY PATIENT REFUSED SERVICES: (SIGNATURE) X_ ) MEDICAL COVERAGE: INDUSTRIAL ❑ YES NNO. OF PATIENTS: PRIVATE INS. 90.. G2� BASE RATE: KAISER N: vh�L✓�ul. .-. T MULTIPLE PTS. BASE RATE BLUE CROSS It. TOTAL MILES: X �j MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-CAL M:f'1 OhC� CODE 2/3 OTHER: OXYGEN: (PER TANK) S� U 7 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 D _ u DRUGS: (PER ADMIN.)_ X NAM EVA L-EI L C/L Lam- RELATIONSHIP�� 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: SSI`J 1 S 1l DRY RUN: (AUTHORIZED) EMPLOYEk E eP STAR 6?CbPAT.10N:DR 1 v eR OTHER: ADDRESS:�5 0 C ti e__5 N .T CITY: 0 A.K LA h+D STATE: CA ZIP: COMMENTS: ���' �� �'��L,tel( H/✓S 41-r 2Li) .STAi2 N tH1niti= s — - HE HAS /n/S.i/jAN !S'�. ._ TOTAL .cr%u_l-c! -_ -- - ----.•S - 06 PATIENT RECEIVED BY X (SIGNAL URQ) ~-------I�, . CONTRA COSTA COUNTY AMBO NCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# r CHECK OR FILL INAPPROPRIATE SPACES DATE: v PATIENTS NAME ❑ M ❑ F COMPANY M ADDRESS AGE CITY STAIE-* ZIP DOB _ 0__-_. M OT OW O Th OF ❑ S DRIVER'S LICENSE M ___... PHONE NATURE OF DISPATC . TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDjENNTT t�OCATI 1 RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR LOOK) !�% � L TO SCENE .O. CALL RECEIVED n i __ ❑ P.U. TIME 10-8 PATIENT DESTI 4 TION: FROM SCE ❑ FIRE TIME 10-97t ❑ PSAP TIME 10•-49 T 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 R: AMBULANCE PT AMBULATO ? PATIENT TAKEN TO AMBULANCE: So RESPONSE ZONE -\=-- ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CO DITION: DRIVER 7p_ 1� EMT-tA TECHNICIA Iv�►�_ PARAMEDIC Hx: DISPATCH R: v /� 0 '7 ( CHIEF COh1PL INT: DRY RULES ❑ NO REASON FOR DRY RUN tQ- �- � PATIENT NS EO SERVICES: (SIGNATURE) X-AUTHORIZATION FOR DRY RUN(EMS USE ONLY)^- -5_,�_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: E S.S. # PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) CCHP/PPRP M; EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER YES ONO NEONATAL' (INCUBATO DATES BILLED: STANDBY: (OVER 15 MI .) E.K.G.: (PER EPISODE) NEAREST 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 REPL CED) CITY: _ STATE--ZIP: C-COLLAR (IF NOT REPLAC ) PHONE: _ WORK PHONE: DRY RUN. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: i TOTAL: _ 00656 0656 , PATIENT RECEIVED BY: X_ _- (SIGNATURE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 0 3 / 3 3 3 CHECK OR FILL W APPROPRIATE SPACES DATE: `PATIENTS NA' EI ❑ M ❑ F COMPANY N ADDRESS;i`-'" ) - _ I ` AGE4 CITY - STATE_ ZIP_._.�______•DOB ❑ Sn O T O W O Th ❑ F O S DRIVER'S LICENSE 0 L I PHONE NATURE OF DISPATCH _ J V 7G T►wA TYPE OF TRANSPORT:,AMBULANCE OTHER❑ — " — STATION 1(A)_2(B)_3(C)._4(D)_S(E) INCIDENT LOCATIONf --, = RESPONSE CODE': REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED G / 33 2c aAfiR 1-1 :,.,ttA l'Q'f)A,G O P.D. TIME 10-8 PATIENT DESTINATION: - FROM SCENE- ❑ FIRE TIME 10-97 V v p '—'� O PSAP TIME 10-49 - Q MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 PMD/ER START J TIME 10-22 _ HOW CHOSEN: TOTAL STANDBY TIME C3 NEAREST;''; ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMP Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES,.❑ NO. I O WALKED ❑ GUERNEY ❑ OTHER . PATIENT CONDITION: DRIVER H1 J L L f A M S 9 U hl EMT-1A r Ulgj . ! TECHNICIAN t�C116IFR AR C2 Hx:_ DISPATCHER: l CHIEF COMPLAINT: i DRY RU YE NO REASON FOR DRY RUN PT•_ R t 1'V JA C_ ALIT O FO R RUN(EMS USE ONLY) •,.I'.;::'PATIENT REFUSED SERVICES: (SIGNATURE) X— I�v MEDICAL COVERAGE- 1 INDUSTRIAL ❑ YES ❑ N NO. OF PATIENTS: I S.S.0 Al PRIVATE INS.CO.: BASE RATE: KAISER N: 7 I MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE C t E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:' ' ! EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 OTHER: -T=' 1 OXYGEN: (PER TANK) 1 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: TOTAL: �r CIL. PATIENT RECEIVED BY: X 006 .. .. ISIryN�1 i inpl CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT a AUTHORIZATION N .2=1 � CHECK OR FILL IN APPROPRIATE SPACES DATE: / `PATIENTS NAME ❑ M ❑ F COMPANY ADDRESS AGES. CITY STATE ZIP DOB Q Sn ❑ M T ❑ W O Th 13F OS DRIVER'S LICENSE N _ ' PHONE —� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ — -- STATION 1(A)_2(B)_3(C)X4(D)_5(E)_ r INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK !9 v " uo1S I 'J• TO SCENE- 13 P O. CALL D. TIME a8 RECEIVED PATIENT DESTINATION: N U FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 V END TIME 10-98 DOCTOR 7 a Z PMD/ER START x TIME 10-22 HOW CHOSEN: f TOTAL T STANDBY TIME Z ❑ NEARESTI .! ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT. ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: _, ^ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �� RESPONSE ZONE c-� ❑ YES ❑ NO..., ❑ WALKED ❑ GUERNEY ❑ OTHER r PATIENT CONDITION: 1 DRIVER EMT-1A ! TECHNICIAN ��`'�� PARAMEDIC HX: ! DISPATCHER: CHIEF COMPLAINT: DRY RUN�.XYES ❑ NO REASON FOR DRY RUN 24 AJ It C4 LL_ /QQ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. M . I 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: ZIP:— COMMENTS:- -Mi- IP: COMMENTS: f- S 1 wOr- On ,� SS L v2 AIJ f)t--,C�UI(_AKJC Lnl PI h `C -�N LKIF TOTAL: _• �� C_ PATIENT RECEIVED BY: X Pn:i.{rr rvti . Vhi rr ,«/ I'i•:: (SIGNATURE) `Y CONTRA COSTA COUNTY ''c AMBULANCE PRE-HOSPITAL CARE FORM I \ UNIT AUTHORIZATION N CHECK OR!IL IN APPROPRIATE SPA CIS PATE: .�h PATIENTS NAME LA ❑ M ❑ F COMPANY N lr; l / (e ADDRESS"1' AGES I E CITY STATE ZIP DOB ❑ Sn O M QST O W O Th •O F S DRIVER'S LICENSE N PHONE NATURE OF DISPATCH " TYPE OF TRANSPORT: AMBULANCE D OTHER 0 _ -- STATION 1(A)_2(B)_3(C)_4(D)_5(E), INCIDENT LOCATION:. RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK)'3& TO SCENE S.O. CALL RECEIVED '- �� L� ��y� 66- er,4,ywC� �-5 ❑ P.D. TIME 10-8 •,• : PATIENT DESTINATION:�7 /AJSP� �v"l FROM SCENE- ❑ FIRE TIME 10-97' ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR L`` L ' I PMD/ER START E 1 HOW CHOSEN: TOTAL STA IME ?: ❑ NEAREST.;` ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY. PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: t� RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 7.) ( PATIENT CONDITION: DRIVERS - ' EMT-lA TECHNICIAN PARAMEDIC Hx: DISPATCHER: D--{ . S. LC C /1 b qo JE'J CHIEF COMPLAI T: DRY RUN: YES ❑ NO REASON FOR DRY RUN A.2I Z-Z W 40---TV-- (( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT EFUS D SER ICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S"�: 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: 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: 1c)_-L L -9 TOTAL:__v_J�_-_-- _. ®061;()c __. PATIENT RECEIVED BY' X._ ,. ..:i. . (SMNATunr) .-1 CONTRA COSTA COUNTY AMBULANCE -1 I PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION a S 3 3 CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑-M ❑ F COMPANY a f ADDRESS AGE CITY STATE ZIP DOB—. ❑ Sn ❑ M OWO Th OF O S. Q DRIVER'S LICENSE N _ _ PHONE_ __.�-- NATURE OF DISPATCH "`'`1 O TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ STATION 1(A)_2(8)_3(C)_4(D)_5(E)_. INCIDENT LOCATION: RESPONSE CODE: R ESTEO BY: TIME - (24 HOUR CLOCK)) r �. TO SCENE- CALL RECEIVED L f L ? y( ( TP-�NTOt ) ��,f v..�. _ I - P.D. TIME 10-8 tL 7 PATIENT DESTINATION: ) FROM SCENE - ❑ FIRE TIME 16-97 ❑ PSAP TIME 10.49 Ti-�!' ILEAGE: ❑ OTHER/PVT TIME 10-7 !(1 f NO _—�, % TIME 10-96 DOCTOR PMD/ER TART ^ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK a: AMBULAN E COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL!tED ❑ GUERNEY ❑ OTHER i ` 1 PATIENT CONDITION: DRIVER I )N EMT-tA / r TECHNICIAN `-�C_ PARAMEDIC Hx: J - ��' N'J 1 DISPAT HER: 1 CHIEF COMPLAINT: DRY RUN. S ❑ NO REASON FOR DRY RUN A T A I N FO RU (EMS USE!U Y) (f `/ PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YEA1O NO NO. OF PATIENTS: S.S. a PRIVATE INS. CO.: BASE RATE: E KAISER a: MULTIPLE PTS.BASE A1E t BLUE CROSS N: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ES ❑ O 1 ❑ YES ❑ NO NIGHT: (19:00- 7:0' n CCHP/PPRP M: EMERGE , UN: I MEDI-CAL a: CO2,2/3 OTHER: OXYGE . (PER TANK) P.O.E. STICKER ❑ YES ❑ NEO TAIL: (INCUBATOR) DATES BILLED. `� STp DBY: (OVER 15 MIN.) K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY:,, I.V.: WER ADMIN.) X DRUGS: (PER ADMIN.) X I NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLAC D) 3 CITY: STATE_ IP: C-COLLAR: (IF NOT REPLACED) ' PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUP ION: OTHER: ADDRESS: CITY: STATE: ZIP: r COMMENTS: -- ----- TOTAL: - --- - — 00660 PATIENT RECEIVED BY: X Provider retain, White ar.d Pir., ;,)pL .4et�r )'r•:.o- •.•;,, t nr when 1:1-i.1,7 (SIGNATUR4) F�. CONTRA COSTA COUNTY AMBULANCE �q PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N p3 32 40 CHECK OR FILL IN APPROPRIATE SPACE DATE: / PATIENT'§ NAME ❑ M ❑ F COMPANY N ADDRESS.-=;,'i�I AGE a• Oiv CITY '~-STATE ��ZIP POB _ ❑ Sn 13M ❑ T ❑ W ❑ Th 13 F ❑ S DRIVER'S LICENSE N - PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE 11 OTHER❑ - STATION 1(A)-2(B)_3(C)_4(D)._5(E)_ ' t. r S•.. /1 INCIDENT LOCATION:i y �1 RESPONSE CODE.' REQUESTED BY: TIME- (24 HOUR C�LpCK) TO SCENE --7 S.O. CALL RECEIVED 1 ❑ P.D. TIME 10-8 ' PATIENT DESTINATION:• ) FROM SCEN ❑ FIRE TIME 10-97 _T ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 :�- J _ 11 . END TIME "OOC'fORts)�•�� ( � PMD/ER START - IM 10- E -- - HOW CHOSEN: TOTAL STANDBY TIME I i'I' .:❑.NEAREST' ! ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT 11 DIRECT ❑ OTHER J�C;ALLBACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE .❑.YES ,❑ NO, ❑ WALKED ❑ GUERNEY ❑ OTHER ; :i I JATIENT CONDITION: DRIVER EMT-1A a� TECHNICIAN ` • ' (} PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN I J AUTHORIZAITION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 95 -- y% MEDICAL COVERAGE-.• INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N - r PRIVATE INS. CO.: - BASE RATE: KAISER If: i MULTIPLE PTS.BASE RATE BLUE CROSS N: _ TOTAL MILES: X MEDICARE C I E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:Ll ' 1 EMERGENCY RUN: MEDT-CAL N: CODE 2/3 /7 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/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: TATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK ONE: DRY RUN: (AUTHORIZED) `EMPLOYER: OCCUPATION: OTHER: 1 ADDRESS: - CITY:* STATEN ZIP: - COMMENTS' JA- 10- TOTAL:- PATIENT TOTAL:PATIENT RECEIVED BY: X ,... IClrNe,I inn CONTRA COSTA COUNTY AMBU NCE ' PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION Merl CHECK OR Flll IN APPROPRIATE SPACES DATE: t 2 1 PATIENTS NAME ❑ M. ❑ F COMPANY M ADDRESS AGE • pie nel I CITY STATE ZIP DOB ❑ Sn_ ❑ M ❑ W ❑ Th ❑ F 13-s DRIVER'S LICENSE M _ PHONE ___.—_ — NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: / RESPONSE COD REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE ❑ P.D.— TIME 0-8 RECEIVED I ; t / PATIENT DESTINATION: FROM SCE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 t� Q �L1 MILEAG ❑ OTHER/PVT TIME 10-7 ENDTIME 10-98 >, DO"T -L PMD/ER STAR TIME 10-22 `'�• HOW CHOSEN: TOTAL \ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE COA�1(Y! PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE/ ❑ YES ❑ NO ❑ WAL`CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVE � )�l EMT-1A TECHNICIA 13 f PARAMEDIC -�� Hx: DISPATCHER: / n/� CHIEF COMPLAINT: DRY RU�S El NO REASON FOR DRY RUN C,0 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERV CES: (SIGNATURE) X— MEDICAL COVERAGE: 7 INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 1��L— S.S. p x PRIVATE INS. CO.: BASE RATE: t KAISER p: MULTIPLE PTS. BASE RATE / BLUE CROSS#: TOTAL MILES: X e MEDICARE p: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO r ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL p: CODE 2/3 �y OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) C DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE P RTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) l PHONE: WOR PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OC ATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY: X_—_ Provider retair White -,.d Pink ropy hetur.: Fr':.0 rnp: t , p+l.' uhrr t41'ing (SIGNATURE) EMS-1 � CONIRA COSTA COUNTY I,., AMDULANCE �( PRE-HOSPITAL CARE FORM I UNIT ,-Z ( AUTHORIZATIONM �� -1-•, $ - � - � 3 �.. .r CHECK OR FILL IN APPROttPRIATE SPACES DATE: PATIENT'S NAME t'J_L_1��Il �� �O'� N1 i��e( ( e`-+ O M m F COMPANY N `S^�,+O I ADDRESS _t3`��L/ '(� 14 ��t� AGE`14 ' CITYI �.� 1 " �"/l � STATE ZIP ? 1 G 7 ZS� OOB��q❑ Sn ❑ M OT.❑ W ❑ Th. .OF O I • DRIVER'S LICENSE a ___N�'_N `-__ PHONE31SL��SS Ns RE OF DISPATCH I ( •,,� TYPE OF TRANSPORT: AMBULANcO OTHER❑ ______ — .__ STATION 1(A)_.2(B)_3(CI_4(D)_5(E)�- INCIDENT LOCATION: C .RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CC CK) ," TO SCENE- 9 S.O. CALL RECEIVED —� ❑ P.O. TIME 108 I `I: 1 PATIENT DESTINATION: ,7 FROM SCENE - ❑ FIRE TIME 10-97 �• � ; O PSAP TIME 10-49 f ;'' �7 .X v ✓� MILEAGES q ❑ OTHER/PVT TIME 10-7 END�•!� TIME 10.98: DOCTOR 1--�L`-' ( N PM /E START_, 'Z- TIME 10.22 ----- HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIMEjpl 1. PATIENT ❑ DIRECT ❑ OTHER :Z2 CALL BACK 0: AMBULANCE COMPANY: I Eo AMBULATORY? PATIENT TAKE TOAMBULANCE. G RESPONSE ZON YES A NO ❑ WAU,ED TAKEN UERNEY ❑ OTHER v v PATIENT CONDITION: DRIVER " O T-IA TECHNICIAN PARAMEDIC r Hx: __ DISPATCHER: ' j CHIEF COMPLAINT: k!�' — DRY RUN: ❑ YESNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X-- -J 4 � -" MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: �'' - S.S. PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X --/ 1 MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO CICS O YES ❑ NO NIGHT: (19:00-07:00; -� - - CCHP/PPRP q: EMERGENCY g --T MEDT-CAL N: CODE 7/3/ j OTHER: OXYGEN: (PER TANM J � v P.O.E. STICKER ❑ YES ❑ NO NEONATAL (1NCUBATO 353.cL�• �' "� DATES BILLED: STANDBY: (OVER 15 MIN.) /,:-r E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) '- /d j.. /� (7 S TG_ DRUGS: (PER ADMIN.) X NAME: t,� c -W\K RELATIONSHIP:_P�' 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) 7Fti(iF-V_5EMPLOYER: OCCUPATION @ OTHER: I�p101 C ADDRESS: i �� •,....., /� (��: CITY: 17'k STATVPT ZIP: �J- -- COMMENTS: N AV TD eLi A ;�l .Z •Y 7q 77 TOTAL:"-,--, PATIENT RECEIVED BY:X Provider retail Ykitr .,rd " rp etn Ye'?,•i• - , ni• (SIGNATURE) c4•n hil'in,T OIS-1 .r V J - „If CONTRA COSTA COUNTY AMBULANCE 0 - PRE-HOSPITAL CARE FORM I UNIT _ AUTHORIZATION#-b J ._ np �~• CHECK OR FILL INAPPROPRIATE SPACES DATE: -el / I .( PATIENTS NAME L22� 5=`J.� — ❑ M Q(F COMPANY# In/I'L' I ADDRESS ��� 1J fU AGE CITY STATE ZIP=1`� °Q b D0B?_jJ ❑ Sn ❑ M M T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE# PHONE NATURE OF DISPATCH Cke4 TYPE OF TRANSPORT: AMBULANtEl2rCTHERD _._....____. . .___.._.__._.. &CO ���a�w`� #C y S. ►�. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR LOCK) �� TO SCENE- fX S.O. -_ CALL RECEIVED z _ rte" ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE.1 ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 1- MILEAGE: ❑ OTHER/PVT TIME 10-7 f END_ S_ Z� TIME 10-98 DOCTOR -- r �PMq/ER START--D TIME 10.22 ` HOW CHOSEN: �/ TOTAL STANDBY TIME >. I W NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPON E ZONE AYES ❑ NO ❑ WALKED a GUERNEY ❑ OTHER - A` PATIENT CONDITION: DRIVER " r� G_Q0 EMT-1A TECHNICIAN PARAMEDIC Hz: ( y�� — DISPATCHER: �.1.^ ^I r CHIEF COMPLAINT: �.+�- — 1l�'SS DRY RUN: ❑ YES R NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X�7 —_ l MEDICAL COVERAGE: INDUSTRIAL ❑ YES 13 NO NO. OF PATIENTS: J}j S.S. # f'?7 PRIVATE INS. CO.: BASE RATE: f KAISER#: MULTIPLE PTS. BASE RATE r BLUE CROSS#: Qu/° TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO o CU 05- 0 5-❑ YES ❑ NO NIGHT: (19:00-07:00) PPHP#: �o'5 96 / EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) — 77 J c)/7 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 5 DATES BILLED: STANDBY: (OVER 15 MIN.) �� %�•' �"-f� E.K.G.: (PER EPISODE) NJ REST RELATIVE/ ESPONSIBLE PARTY: I.V.: (PER ADMIN.)_ X 7! 11 DRUGS: (PER ADMIN.) X NAME:� �L1d�LC21!NQjELATIONSHIP: �U E.O.A.: (IF NOT REPLACED) ADDRESS. _ ORAL AIRWAY: (IF NOT REPLACED) CITY: ______ STATE__—ZIP:_—._..- C-COLLAR: (IF NOT REPLACED) PHONE: 3 0 WORK PHONE. _ DRY RUN. (AUTHORIZED) L(LI_CD GQ EMPLOYER: OCCUPATION: OTHER: ADDRESS: J� • ^' CITY: STATE: ZIP: COMMENTS: OA #-2 7 - - sas TOTAL:_�! 5;_ ---- - - -_---_--_ --.•----- -- .__-.__ ..._-•--. PATIENT RECFIVEn BY X Pr,midor rehab. Iniifr ,.a1 Pi.:: i„ (Slr`iNAT1INE) ,•..ISM i fi��•. .. � �� ..q.p f � FMI .��u�: f is •� ►.M6-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N s CHECK.OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME-3)1S� 1) 1� _ ❑ M ❑ F COMPANY N C. 1� ,? . W U A-)ADDRESS,,:• 1 AGE CITY .S{TATE ZIP DOB ❑ Sn ❑ M T ❑ W O Th O F O S DRIVER'S LICENSE N J PHONE - -- NATURE OF DISPATCH 61 4s ' TYPE OF TRANSPORT: AMBULANCE OTHER O STATION 1(A)_2(B)-3(C)_4(D)_5(E)_ I INCIDENT LOCATION r- - `t.) RESPONSE CODE: REESTED BY: TIME— (24 HOUR CLOCK) -- ' TO SCENE- 5.0. CALL RECEIVED �� :�3 ,jp� t. c) Al,rF%nn + Z ❑ P.D. TIME 10 8 PATIENT DESTINATION: .• ... FROM SCENE 13 FIRE �� TIME 10-97 :` � • - I}���Z. � ❑ PSAP TIME 10.49 T)�� MILEAGE: 11OTHER/PVT TIME 10-7 _L_ :� END TIME TIME 10.98 .bOCTOW +'� �� PMD/ER START " - TIME 10.22 e� HOW CHOSEN: t TOTAL STANDBY TIME NEAREST;-, FAMILY 11TRANSFER WAIT TIME t_— ❑ PATIENT . ❑ DIRECT ❑ OTHER CALL BACK C AMBULANC CO PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPO SE ZONE ❑. YES 0 NO I ❑ WALKED ❑ GUERNEY ❑ OTHER - �l PATIENT CONDITIONI DRIVER aMT—lA TECHNICIAN PARAMEDIC HK: 1 DISPATCHER: ) I t 55 CHIEF COMPLAINT ) DRY RUN: ES ❑ N REA O -FOR DRY RUN 1 U AU HO Z ION fOR RY RU �, ,1, USE ONIYA �7 1 jaPATIENT REFUSED SERVICES:(SIGNATURE)X 42 MEDICAL COVERAGE; - INDUSTRIAL 13 YES ❑ NO NO.OF PATIENTS:/ S.S.N I . . . �} 1 PRIVATE INS.CO.: BASE RATE-- - r 4 KAISER Co MULTIPLE PTS.BASE RATE t BLUE CROSS N: TOTAL MILES: X MEDICARE Ny ' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES -O NO NIGHT: (19:00-07:00) CCHP/PPHP 0:4-;-- EMERGENCY RUN: MEDT-CAL N: ' ' I CODE 2/3 OTHER:— ,.. OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES 13X NEONATAL: (INCUBATOR) c 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) t —EMPLOYER: CCUPATION: OTHER: , ADDRESS: r " CITY:- - - STATE: ZIP: COMMENTS:- TOTAL: V.. l. C!Z 665' -- - — --- PATIENT RECEIVED BY:X Penni dsr r.f.oin N,i li ,...1 rr•:I (SIGNATURE) ,pl, V•fun• I. ... I �' 4�� !i 1 i•.+ bf5-1 1 ' CONTRA COSTA COUNTY I S AMBULANCE �j PRE-HOSPITAL CARE FORM I - UNIT AUTHORIZATION N U -3 1 S/ CHECK OR FILL IN APPROPRIATE SPACES DATE: [ l — (05 - PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS AGE CITY STATE ZIP---- DOB— _ ❑ Sn ❑ M aT ❑ W ❑ Th ❑ F O S DRIVER'S LICENSE N __—.^_____.._—_—_ PHONE___.— . ___..__—_.— NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER ___________-__ --- STATION I(A)12(B)_3(C)_4(D)_5(E)— INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE - flS.O.— CALL RECEIVED f ' ' lk LJ '� .� X /l 7_ t{ Z ❑ P.D. TIME 10-8 PATIENT DESTINATION. FROM SCENE - ❑ FIRE _ TIME 10-97 <� ❑ PSAP TIME 10-49 \ c -� MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START-----,/7 \ TIME 10-22 HOW CHOSEN' TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: C.Fl,�•L��c PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE'ZONE ❑ YES ❑ NO ❑ WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER--1 .�Lr ' I EARA101FMT-tA f TECHNICIAN - PDIC Hx: �."-' kjc� 0A DISPATCHER: —..L._I( ( ,/ CHIEF COMPLAINT: DRY RUN: ® YES ❑ NO REASON FOR DRY RUNnA/F�.�tiF AUTHORIZATION FOR DRY RUN(EMS USE ONLY) f 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:, E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: 09:00-07:00) CCHP/PPRP N: EMERGENCY RUN' MEDT-CAL N: 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: I.V.: (PER ADMIN) X DRUGS: (PER ADMIN.)____ X _ NAME: RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 1 STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: _ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: T CITY: STATE: ZIP: COMMENTS: _ --- —- _ TOTAL. — --- ---------.._.... _. PATIENT RECEIVED BY X . .---_----•-.-- /b•ri(rr �rri;. c�., ..� ,. . . _ ... (SIGNA fURE) CONTRA COSTA COUNTY ( AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION M •�' ).\�q CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME._ (.J) IC. Li , ( l l R /n . .-. . . __—___ 48 M ❑ F COMPANY _ ADDRESS j-/ -?--ii•L�'.L.A'-:_l/.�I �_-- — AGE — �.Cp I �. CITY_._.._(_d_F __ STATE__C-/'l._— ZIP cyLj__[_c/_ DOB ❑ Sn OM/11 M/11 T o W ❑ Th ❑ F [IS f DRIVER'S LICENSE a _. PHONE _2. 3 NATURE OF DISPATCH / - NTC_ _ TYPE OF TRANSPORT. AMBULANCE OTHER O INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME — (24 HOUR CLOCK) D - r TO SCENE- XS.O. CALL RECEIVED 4" _3E.�-- ❑ P.U. TIME 10-8 . .. ) I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 �--Q MILEAGE:� ❑ OTHER/PVT TIME 10.7 END.._____b_^:____._ TIME 10-98 _ DOCTOR _.//1Jc,��'.,� _.__.-.__..__ PM !ER-) START_7L,_)r,.__ __ TIME 10-22 NOW CHOSEN: TOTAL STANDBY TIME i ❑ NEAREST ❑ AMILY ❑ TRANSFER WAIT TIME ❑ PATIENT DIRECT Cl OTHER (� L, ) CALL BACK N: AMBULANCE COMPANY:. " C AJ LZ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE `�C, RESPONSE ZONE YES ❑ NO KWAL"ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER _LLi r� ,]0 �) EMT-1A �L TECHNICIAN -A/L ' RAMEDIC ! Hx ./P. n'L[.-L_—_..C:J:-tel._-._I ;_, �/�1 u..it_(.__-i7dCh�_ DISPATCHER: __I:- __ �+1� CHIEF COMPLAINT /i_l.lc,»r?J DRY RUN: ❑ YES XNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES- (SIGNATURE . r � MEDICAL COVERAGE INDUSTRIAL ❑ YES' yCNO NO. OF PATIENTS: c PRIVATE INS. CO.: —_.. BASE RATE: /w " KAISER x: _ — MULTIPLE PTS. BASE RATE BLUE CROSS $V_ TOTAL MILES: X !2/0-2 MEDICARE #: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO �! ❑ YES ❑ NO NIGHT: (19:00-07:00) �O CCHP,'PPRP q: _ —_ EMERGENCY RUN: . (JPO MEDI-CAL It: —._—.___--- -- CODE 2/3 OTHER:—_.— _—______. _ _ _. OXYGEN:-(PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL- (INCUBATOR) DATES BILLED:—_.._.— __._. ._ _ ---_ .—_ —_- -. STANDBY: (OVER 15 MIN.) ���•' "S'� Q5 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:1�___:. i 066 — -- -- ---- - .-..-.. ,30/ ) S L - --------- -- TOTAL: PATIENT RECEIVED BY: X 1T'td,7rr ri �'. .. L:.r' , •.,. uh:•: bilirp (SIGNAT E) L115-1 i CONTRA COSTA COUNTY AMBULANCE / PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION K ��`1 U CHECK OR ML INAPPROPRIATE SPACES DATE: PATIENTS NAME ❑ M ❑ F COMPANY N / ADDRESS AGE OleU ' , CITY STATE__ ZIP DOB --❑ Sn ❑ MOT ❑ W Th ❑ Ft ❑ S t DRIVER'S LICENSE N ! PHONE NATURE OF DISPATCH - . TYPE OF TRANSPORT: AMBULANCE OTHER❑ -- STATION 1(A)_-2(B)_3(C)_4(D)_5(E)_ SS( KO x awn-Q- w L . INCIDENT LOCATION: / "` RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- CALL RECEIVED L� : _e7 ❑ P.D. TIME 10-8 yam- —3 PATIENT DESTINATION:- FROM SCENE - ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ti END TIME 10-98 DOCTOR '' 1 PMD/ER START TIME 10 22 � HOW CHOSEN: TOTAL STANDBY TIME i . :. ❑ NEAREST. ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: �l CHS PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER 1 PATIENT CONDITION: I DRIVER SL r �`�`� = EMT-tA 1 TECHNICIAN I� /K PARAMEDIC X 5- Hx: �U F ^� DISPATCHER: 1i1J� �(, - / I��I CHIEF COMPLAINT: DRY RUN: XlYES ❑ NO REASON FOR DRY RUN U'Z t \J-;C- C%7 �I/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) FG SC CC. PATIENT REFUSED SERVICES: (SIGNATURE) X C1��MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.0 I PRIVATE INS.CO.: BASE RATE: KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE M:' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N:n ' EMERGENCY RUN: MEDI-CAL N: 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) PIEAREST 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: �+p _ 68 TOTAL: �?_•l{' -- PATIENT RECEIVED BY: X r., ., .. .. •�. MIONA1UgQ) CONIRA COSTA COUNTY AM(IULANCE PRE-HOSPITAL CARE FORM I ( UNIT AUTHORIZATION N �'_ G, •, 3 CHECK ON FI(iM APPROPRIATE SPACES GATE: PATIENT'S NAME `..:F-_`o'I .1 k- to ro I o 0 _ O MCOMPANY N 7 L > - 1 ADDRESS _X5_ll� 1_�_�C•c `klbL�. _— C�� r�-` AGE L /, ll R 7 Z_ STATE ZIP__ DOB E!J O Sn O M OT O W QTh OF OS QQ� �j DRIVER'S LICENSE ,,-_____..__.._ PHONEC V._,,�2,L�I_ NATURE OF DISPATCH ,o, "j TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ ______ _-.._ STATION 1(A)_2(B) 3(C) (D)_5(E)_ :` 5 tCJr,/V,tlNt.;IDENT LOCATION: / RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ALL ! Ll TO SCENE - Z S.O. CALL RECEIVED 11� ( tT7- \J Tor_.//-1 11),t {_ (� ❑ P.U. TIME 10.8 PATIENT DESTINATION: FROM SCENE ----7 ❑ FIRE TIME 10.97 C �\�l ❑ PSAP TIME 10.49 p� - --c _ MILEAGE: ❑ OTHER/PVT TIME 10.7 ENDS TIME 10-98 �L Z DOCTOR 1/ �__._._ PMD R START__ TIME 10-22 HOW CHOSEN: TOTAL Z STANDBY TIME ,O'NEAREST D FAMILY ❑ TRANSFE '/ WAIT TIME _. ❑ PATIENT O DIRECT ❑ OTHER `� CALL BACK N; AMBULANCE COMPANY: - t^ v , EPT AMBULATORY) PADENT TAKEN TO AMBULANCE: SU RESPONSE ZONE YES ❑ NO WAL':ED ❑ GUERNEY D OTHER ,J PATTEN CONDITION: DRIVER 3 EMT-1A �a - TECHNICIAN �� �>U PARAMEDIC I _ ` Li. _ DISPATCHER: r ' CHIEF COMPLAINT: ,S �_ DRY RUN: O YES :d�NO REASON FOR DRY RUN t. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (1 PATIENT REFUSED SERVICES: (SIGNATURE) X—_ MEDIC COVERAGE: INDUSTRIAL D YES kNO NO. OF PATIENTS: S.S. N =i I_1{ (/\ ', PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE /1 BLUE CROSS N: TOTAL MILES: X MEDICARE N: CIN I\ )E E.O.B. ATT. ROUND TRIP: O YES O NO T O YES ❑ NO NIGHT: (19:00-07:00) �o OD �J (CCHP/PPRP N: EMERGENCY RUN: Q,(J7)Q�4' �� MEDI-CAL N: CODE 2/3 - �?1 OTHER: _- OXYGEN: (PER TANK) P.O.E. STICKER D 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:1? �1.\LL_ �Q 1V '__ RELATIONSHIP: I�1 E O.A.: (IF NOT REPLACED) ADDRESS: _ ___ ORAL-AIRWAY: (IF NOT REPLACED) CITY: STATE___ZIP:__— C•COLLAR: (IF NOT REPLACED) PHONE: '�l� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS:— TOTAL: IP:COMMENTS: TOTAL: 1,5771 _ PATIENT RECEIVED BY: X (SIGNATURE) - rw , 11 YY CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME lL�c!� ❑ M O F COMPANY f Z fo✓ 3 ' ' ADDRESS AGE. 12Kr...1 CITY STATE ZIP DOB O Sn O M O T, ;KW' O Th ,0 F O S-1 DRIVER'S LICENSE p ___ — PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER❑ ATION 11A) 2(B)_3(C)_4(D)_5(E)l7f] INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) TO SCENE- 21 ❑ P.D. TIME 0-8 RECEIVED :Y3 1 PATIENT DESTINATION: FROM SCENE- IRE TIME 10-97 �1 ❑ SAP TIME 10-49, n 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 : 1 AMBULANCE COMP9,NY- PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER c PATIENT CONDITION: DRIVER 2 EMT+1A TECHNICIAN PARAMEDIC VI Hx: DISPATCHER: E-I E L D C r CHIEF COMPLAINT: DRY RUNES ❑ NO REASON FOR DRY RUN 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE)'X MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: - S.S. PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS.BASE RATE . I ,.�" !=l BLUE CROSS N: TOTAL MILES: X -- MEDICARE N: E.O.B.ATT. ROUND TRIP: O YES ❑ NO 6S ,. ��, ,• r "j ❑ YES ❑ NO NIGHT: (19:00-07:00) _-_r---J 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.O.: (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: 4 STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - �'L1A PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) p EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP. t COMMENTS: TATAI• 00 —---�� 6 7011. PATIENT RECEIVED BY:X Provider retei*. Vhite •-..d Pin-% rorr .Ratur+ Ye•2cw Mpy t• DFS when bil:inp (SIGNATURE) �1, CON I IIA C.0f,I A COUN I Y AMIILILANCF PRE-HOSPITAL CARE FORM 1 UNIT Z AUTHORIZATIONS SK L-3� CHECK OR FILL IN APPROPRIATE SPACES DATE: v _ iy - PATIENT'S NAME_.L1:i.Tli j.: -� i--_-__,c_t`n.►:� _ JkM ❑ F COMPANY M/__/_' ADDRESS �7 { ,�iLL_4s.�/<_�.._k C c_d-- - —Q----- AGE CITY__LL L ------_. STATE_L ^.`_—_ ZIP�L�L�`/:' - DOB_jZ_Z _ZI ❑ Sn ❑ M OT XW D Th D F O S - DRIVER'S LICENSE a _.__...._.__ __ PHONE_9 j 3_Z`�Z L _ NATURE OF DISPATCH ( hl V-W u , Itted TYPE OF TRANSPORT. AMBULANCE OTHER❑ _. STATION 1(A)_2(8)-3(C)_4(0)_5(E)_ • ' r a INCIDENT LOCATION: RESPONSE COOE: 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 ❑ PSAP TIME 10-49 :�3 N5� 3 MILEAGE: Cl OTHER/PVT TIME 10-7 ,I END TIME 10-98 DOCTOR _ ►1 L4� r PMD/6) STARTTIME 10-22 HOW CHOSEN: TOTALS STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME - ' ® PATIENT ❑ DIRECT ❑ OTHER C>j CALL BACK a: AMBULANCE COMPANY: y CA PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: s O RESPONSE ZONE . YES ❑ NO ❑ WALKED GUERNEY ❑ OTHER i PATIENT CONDITION: DRIVER_ .�yi - EMT-tA ^ TECHNICIAN __ PARAMEDIC X Hx: I ` ��y�LL1•i;��_— DISPATCHER: JLf�L I C_Xi�� f CHIEF COMPLAINT: r��c�L�t— r 1_C�ti� DRY RUN: ❑ YES ANO REASON FOR DRY RUN f AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ^� I PATIENT REFUSED SERVICES: (SIGNATURE) X__ ' f 4.• r MEDICAL COVERAGE: INDUSTRIAL ❑ YES P NO NO. OF PATIENTS: 40 PRIVATE INS. CO.: BASE RATE: "o' ' KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS r X 0 1 MEDICARE a: `�`1 ' Z Z - 3 4 (�•`� E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NO i I ❑ YES ❑ NO NIGHT: (19:00-07:00) ( � i CCHP/PPHP N: _ EMERGENCY RUN: _<_Mtb1-CAL+t: hr Ct• ir( cl a AxVAe__ 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) r J NEAREST RELATIVE/RESPONSIBLE PARTY: I V.: (PER ADMIN.) X '�j'! I II (( DRUGS: (PER ADMIN.) X NAME: J_ RELATIONSHIP:hfC`I1lk� E.O.A.: (IF NOT REPLACED) ADDRESS:J L C �L:.v�i� �r��'1 _ ORAL AIRWAY: (IF NOT REPLACED) CITY: --. I —_`__.___...____ STATED =ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: __ __ OCCUPATION: OTHER: ADDRESS: ��_ ,2 /D•U7J f rT r CITY: STATE: ZIP: COMMENTS: — TOTAL —_ _— PATIENT RECEIVED BY:X 00671 (� + ;n , (SIGNATURE) `...• ► Provider rrt;r'� I L- r . . . i�t:.r� I:'„�• Rr- L-hp, ['r T .•a DIS-1 CON1f1A COSTA COUNTY AmnULANCE �j 2 PRE-HOSPITAL CARE FORM I uNlr r AUTHORIZATION0 � 1 �1 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME C—, ❑-M ❑ F COMPANY M %/ ADDRESS (c2 UU -_J C;/-'t�- AGE 3'' 11�`` l_ O �J CITY_M __ STATE S-_ ZIP—____ DOB�-� ❑ Sn ❑ M ❑ T P/W O Th OF U$%. DRIVER'S LICENSE q ___..__. . ___.___ ._.. PHONEI_"'-��._____.�_ NATURE OF DISPATCHnL.CS�1S TYPE OF TRANSPORT: AMBULANCE 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 - j S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-n 11 FIRE TIME 90-97 /�� : A 1 l / / o� ❑ PSAP TIME 10-49: �`�'� MILEAGE: n / ❑ OTHER/PVT TIME 10-7 ---' �7 END 1 l-0 TIME 10-98 DOCTOR PMDR STARTS TIME 10-22 HOW CHOSEN: TOTAL �� (I STANDBY TIME T NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT .❑ OTHER CALL BACK N: AMBULANCE COMPAjtiY, PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: J U [RESPONSE ZONE ❑ YES NO ❑ WAL"EDO'GUERNEY ❑ OTHER 1 ,- s j PATIENT CONDITION: DRIVER • �?V 7✓1 { �.Y► hS�o EMT-1A 1 TECHNICIAN Ci c AMEDIC Hx: �]j S �� 1 1'� USS DISPATCHER: -I)13 E��T�C - 1 L� CHIEF COMPLAINT: L U �� DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 1 //�� I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (/L-}1 PATIENT REFUSED SERVICES: (SIGNATURE) X (!('� MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: f 1 ��•-..�)� S.S. >< / PRIVATE INS. CO.: BASE RATE: Cl.� KAISER x: MULTIPLE PTS. BASE RATE / C^ 1 / BLUE CROSS p: TOTAL MILES: _3 X MEDICARE M: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP p: EMERGENCY RUN: MEDI-CAL N: CODE 2 3 �\ OTHER: OXYGEN: (PE F 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: DRY RUN: (AUTHORIZED) EMPLOYER: __ OCCUPATION: OTHER: ADDRESS: _ CITY: STATE: ZIP: COMMENT 111 • 'Nl Pl UN 1 O TOTAL: �y. ._... PATIENT RECEIVED BY: X u7 2, Providrr rria:• Ai•. •'r} ir•,.- pr•' . RI' F„•n ( URE) �. � h�i"i••� 015-! v{" CONTRA COSTA COUNTY AMBULANCEINA PRE-HOSPITAL CARE FORM I UNITZr AUTHORIZATION M t I CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME L k.,; 'j OM OF COMPANY* r L - ADDRESS: AGE p V l� CITY - STATE ZIP DOB -0 Sn O M O T t%W O Th O F O S DRIVER'S LICENSEIt L PHONE —� NATURE OF DISPATCH_) — r TYPE OFTRANSPORT:LAMBULANCE 0 OTHER 0 _ STATION 11A)_2(B)_3(C 4(0)_6(E).s - .j INCIDENT LOCATIONS { S;Zi RESPONSE CODE. iIIEOUESTED BY: TIME— (24 HOUR CIQCK) TO SCENE- ? {❑�P.D. TIME 0 g RECEIVED F'ATIE T DESTI ATION:. .\._._) FROM SCENE.- ❑ FIRE TIME 10.97 PSAP TIME 10-49 20ir ('�' �/s� MILEAGE: O OTHER/PVT TIME 10.7 ur END_�_,_____._ TIME 10-98• .FrDOCTOR r I fl-!''2 + - PMD/ER START�. - TIME 10.2 v --.I HOW CHOSEN: r ..___ TOTAL - STANDBY TIME - ) eTr.,13 NEAREST 7 Q FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK M: AMBULA CO, Al PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 19�� [RESPONSE ZO O YES;•O NO O WALKED O GUERNEY O OTHER. PATIENT CONDITION: '--- DRIVER F` ( d EMT-IA TECHNICIAN S S Q L_ 9w, RM PARAMEDIC Hx: DISPATCHER: Solrti?l 4 ( (4 U r �Q, CHIEF COMPLAINT: ' DRY RUN: 15,eIE-15 O NO REASON FOR DRY RUN C CF� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) A;!,) .)t PATIENT REIFUSED SERVICES:(SIGNATURE) X - MEDICAL COVERAGE: _ INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S.0 PRIVATE INS. CO.: j BASE RATE- ! KAISER K: I MULTIPLE PTS. BASE RATE BLUE CROSS M; TOTAL MILES: t X r MEDICARE 0; E.O.B. ATT. ROUND TRIP: O YES O NO I O YES •O NO NIGHT: (19:00-07:00) ` CCHP/PPHP M: 1 EMERGENCY RUN: I MEDI-CAL 0: CODE 2/3 OTHER: "� i OXYGEN:; (PER TANK) P.O.E. STICKER O YES O O 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: fel BIZ' 6 3 1- PATIENT RECEIVED BY:X (SIQNATUHE) l Pmuldfr rteain Aito and Pi.A r Pr' .A.•.. 1,. •:,, r-c-i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ,, '� AUTHORIZATION N S3-13 Y-5--r.. r CHECK OR iltl IN APP O IA TE le-3SPACES DATE: � PATIENT'S NA A f ❑ M ❑ F COMPANY 0 ADDRESS " AGE n A� , let.)A j CITY STATE ZIP — DOB ❑ Sn ❑ M 13T W W ❑ Th 13 F O S DRIVER'S LICENSE b PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT:; AMBULANCE 0 OTHER❑ — STATION 1(A_2(8)_3(C)_4(0)_5(E), INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOURCLOCK)� 1 TO SCENE- S.O. CALL RECEIVED ❑ P.D. TIME 10.8 PATIENT DESTINATION: ( C b � FROM SCENE- ❑ FIRE TIME 10-97 I 13OTH TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 14.7 ` END TIME 10-98 n DOCTOR T rr I PMD/ER START TIME 10-22 HOW CHOSE TOTAL STANDBY TIME l ❑ NEAREST: ❑ FAMILY ❑ TRANSFER I WAIT TIME —_ ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK C AMBULANCE COMPANY: PT. A�URY4 PATIENT TAKEN TO LANCE: Q RESPONSE ZONE ❑ YE ❑ WAIL<ED UERNEY ❑ OTHER �, PATIENT CONDITION: DRIVERI EMT-tA TECHNICIAN PARAMEDIC Hx: DISPATCHER: r' (y U (ff1 CHIEF COMPLAINT: I DRY RUN: KYES ❑ NO REASON FOR DRY RUN (( V AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1'►J )C,�y PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: r KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS tt: TOTAL MILES: X MEDICARE N: ' E.O.B. ATT. ROUND TRIP:. ❑ YES ❑ NO ❑ YES 13 NO NIGHT: (19:00-07:00) CCHP/PPRP X: EMERGENCY RUN: MEDT-CAL ef: CODE 2/3 OTHER: OXYGEN: (PER TANK) C P.O.E. STICKER ❑ YES ❑ NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ; E.K.G.: (PEA)EPISODk) i NEAREST RELATIVE/RESPO IBLE PARTY: I.V.: (PER AbMIN.) 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; C 7 '� PATIENT RECEIVED BY:XPr4 �j ider retain Vhite Lmd Pink oopk . keturn Ye'!vw oopy t, EMS when bi 1:inp (SIGNATURE) EMS-1 2 i CONT A COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 Rill UNIT AUTHORIZATIONT101 1� ~, CHECK 011 FILL IN ACP 1Are SPACES DATE: r ' PAtIENTS NAME. ❑ M ❑ F COMPANY 0 ADDRESS AGE__l �``•- CITY STATE ZIP DOB -O Sn O M OT OW O Th ❑ F O S DRIVER'S LICENSE4 PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:;AMBULANCE❑ OTHER❑ -- STATION 1(A)_2(B)_3(C)_4(D)_6(E)_ INCIDENT LOCATION:) RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLO� K) TO SCEN 1 — CALL❑ P.D. TIME D-8 EIVEO T 0 PATIENT DESTINATION::. FROM ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 A` MILEAGE: 13OTHER/PVT TIME 10.7 END TIME 10-98 S DOCTOR'r�-7r' T f PMD/ER STARTTIME 10-22 HOW CHOSEN: 1 TOTAL L� STANDBY TIME c~.tL❑ NEAREST; ;'. ❑ FAMILY ❑`TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANIy�� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S RESPONSE ZONE .3 O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER NIPATIENT CONDITION:. DRIVER L) EMT-1A TECHNICIAN PARAMEDIC Hx: DISPATCH R' �/U I rut) CHIEF COMPLAINT: _ DRY RUN: YES ❑ NO REASON FOR DRY RUN AUTHOR ZATION FOR DRY RUN(EMS USE ONLY) 9t7p 1 � PATIENT REFUSED SERVICES: (SIGNATURE) X 15� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: / S.S.III rL� ► L.I PRIVATE INS. CO.: BASE RATE: KAISER K: 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. MEDT-CAL N: CODE 2/3 OTHER: OXYGEN:, (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) cDATES 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: '(AUTHORIZE D) _'EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL:. l"i S R _. PATIFNT nFr.F1VFn nv x JOMNTRCOSTA COUNTY AMBULANCE A'� ` PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION NJ `l' • - `CHECK OR FILL IM APPROPRIATE SPACES 1 DATE: fPAT1ENT'S NAME 1, O M'10 F COMPANY N ADDRESS AGE N.- r CITY ST TE—.� ..ZIP - DOB ❑ Sn OM O T Ow 13Th ❑ F. O S - DRIVE • LICENSE N f PHONE T- NATURE OF DISPATCH" -1 -F TYPE OF TRANSPORT:: AMBULANCEbe OTHER O STATION 1(A)_2(B),3(C) 4(D)_5(E)_..;. INCIDENT LOCATION:- _ I %4� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR COCK) r _ I I TO SCENE- S.O. CALL RECEIVED G • 3� , I L 1-Cl n n�MCI It ; .-_--.-�_-�-�[/ O P.O. TIME 10-8 PATIENT DESTINATION FROM SCENE- O FIRE TIME 10-97 PSAP TIME 10-49 MILEAGE: O OTHER/PVT TIME 10.7 •� END TIME 10.98 ,� ' ci"DOCTOR T'c t��' r PMD/Etat` START — TIME 10 22 i �_'' HOW CHOSEN: TOTAL STANDBY TIME - r yY0 NEAREST;" ❑ FAMIL� Cl TRANSFER ( WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE_COMMPY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ : C_.,U RESPONSE ZONE ❑ YES. ❑ NO O WALKED ❑ GUERNEY O OTHER ? PATIENT CONDITION: DRIVER�'t��F r Q70 EMT-1A>l TECHNICIAN���,b"�'l� (SC) PARAMEDIC Hx: - - DISPATCHER: 1 146 CHIEF COMPLAINT: DRY RUN: RYES ❑ NO REASON FOR DRY RUN U J-Z2 'n AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qq . . PATIENT REFUSED SERVICES: (SIGNATURE) X 9s� MEDICAL COVERAGE:___.__ INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: r BASE RATE:- ."', KAISER*: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N:' E.0.8,ATT. ROUND TRIP: ❑ YES O NO r ❑ YES fl NO NIGHT: (19:00.07:00) CCHP/PPRP N: ( EMERGENCY RUN: MEDT-CAL N: ': F. : CODE 2/3 OTHER: ''-" I OXYGEN:I (PER TANK) y P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEIRESPONSIBLE PARTY: --- - - - I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X "'-NAME:• RELATIONSHIP: E.O.A.:(IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) -CITY: STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) v ti -EMPLOYER: OCCUPATION: OTHER: ADDRESS: "'-CITY: STATE' ZIP. -COMMENTS: TOTAL:--X"� e • __ PATIENT RECEIVED BY:X-_ l 19i0NA r11PF1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM i UNIT 2 AUTHORIZATION cHccK OR FILL IN fA010PRIArf srAcn DATE: 1" PATIENTS NAME ❑ M 13 ;F COMPANY M ADDRESS - - ( „ . AGE— CITY GE CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T_0 W ❑ Th ❑ F OS i DRIVER'S LICENSE M PHONE NATURE OF DISPATCH ^g l ` TYPE OF TRANSPORT:; AMBULANCE 0 OTHER 0 — — STATION 1(A)_2(B)_3(CI_4(D)_5(E)_ INCIDENTIOCATION�w ! %t : RESPONSE CODE-, REQUESTED BY: TIME—(24 HOUR CLOCK) } 1 TO SCENE `2 S� 4t�olq � 1 CALL RECEIVED( /, IJ P.D.Y_ TIME 10-8 PATIENT.D INATION: _ FROM SCENE ❑ FIRE TIME 10.97 -i ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 ( _. END TIME 10.98 ."DOCTOR' ' PMD/ER STAR 1� TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME t•y- ❑ NEAREST O FAMILY ' ❑ TRANSFER' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY- 00 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: S+ c) [RESPONSE ZONE ❑ YES �❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: ' DRIVER /y �) EMT-1A ` TECHNICIAN / PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN:/ly\YES ❑ NO REASON FOR DRY RUN v� 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 N: MULTIPLE PTS. BASE RATE BLUE CROSS A: t ` TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ 140 NIGHT: (19:00-07:00) 1 CCHP/PPRP N:• I EMERGENCY RUN: MEDI-CAL 0: '' I `'" CODE 2 13 I OTHER: OXYGEN: (PER TANK) .I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) i C 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) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: 1 CITY: STATE: ZIP: . COMMENTS: TOTAL: ►'J' 7 ( , PATIENT RECEIVED BY: X (SIGNA•1URE) CONTRA COSTA COUNTY AMBULANCE 2 f PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 6 DT ...• •� CNECK OR ML IN OPRIATE SPACES DATE: 1 ,f PATIENTS NAME �� V'�.�1 ❑ M ❑ F COMPANY K • l ADDRESS AGE O CITY STATE ZIP DOB -❑ Sn ❑ M ❑ T ❑t W ❑Th O F O S DRIVER'S LICENSE 0 _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:.AMBULANCE 0 OTHER❑ _ — STATION 1(A)_2(B)_3(C)_4(DI_5(E)_ INCIDENT LOCATION1 1 RESPONSE CODE: RESTED BY: TIME- (24 HOUR CLOCK) 2 A-j TO SCENE- S.O. CALL RECEIVED J VV � C3- ❑ P.O. TIME 10 8 6i PATIENT DESTINATION: FROM SCE N ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 N MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98. 'DOCTOR t 1 PMD/ER STAR a7TIME 10-22 HOW CHOSEN: -- TOTAL STANDBY TIME i ?j`.' ❑ NEAREST: ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY:��� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SU RESPONSE ZONE G.= ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER j PATIENT CONDITION: DRIVER I EMT-IA / 1 TECHNICIAN PARAMEDIC Hx: DISPATCHER: U CHIEF COMPLAINT: DRY RUN: ES 13NO REASON FOR DRY RU qv� 5-4F:c: AUTHOR? TION FOR DRY RUN (EMS USE ONLY) C/,/,/ •�• PATIENT REFUSED SERVICE'S145IGNATURE) X MEDICAL COVERAGE, I INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: ff S.S. M j PRIVATE INS.CO.---N BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X - MEDICARE N: E.0 B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0: ' ' EMERGENCY RUN: MEDI-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/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) * 11 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 8C PATIENT RECEIVED BY: X (SIGNATURE) - 1 � r v� CONTRA COSTA COUNTY AMBULANCE III PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 0 CHECK ON FILL INAPPROPRIATE SPACES DATE: lip ' F3 PATIENT'S NAME�iL��.�. 1J /S5'1 f 4 0-M VrF COMPANY M I J ADDRE,5�_ " Y t /L� /7 Al 2 CITY �</('/ )'1 r / _ �,� STATE-_�.��_ ZIP 1 � .> , c� D"O�B O Sn O M O.T )f IN ❑ Th O F O$'�'� DRIVER'S LICENSE a PHONE-22 r NATURE OF DISPATCH 14u F0� TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ — STATION 1(A) 2(0)_3(C)_4(D)_5(E)--.'& INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK TO SCENE- �7 '0S.O. CALL RECEIVED l� A.r� rill(� 1 rn ' o 3 O P.D. TIME 10-8 -- PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97. c ❑ PSAP TIME 10-49. `Ao _ MILEAGE: 13OTHER/PVT TIME 10-7 1 / �� END TIME 10-98 DOCTOR `-, PMD(�RJ STA' 2 TIME 10-22 -� HOW CHOSEN: �/ TOTAL <- STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER 1 WAIT TIME O PATIENT ❑ DIRECT O OTHER p.� CALL BACK a: AMBO E MPANY: .-. =AMBULATORY? PATIENT TAKEN TO AMBULANCE: C O RESPONSE ZONE❑ WAL'<EDGUERNEY 11 OTHER J j PATIENT CONDITION: DRIVER (/ illC'q �8 EMT-tA j t TECHNICIA PARAMEDIC Hx: 0 C DISPATCHER: Li 6' 1 j COMPLAINT: / —!_��1�211 L ' aRY RUN: ❑ YES �'NO REASON FOR DRY RUN ^��� F _�� - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAG INDTR L 13 '� YESNO NO. OF PATIENTS: �7 S.S. PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: �- X 7- J-3� a MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO -� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP k: 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 RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: t RELATIONSHIP: �� E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: 7 Y rh�C STATE—e-A ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: - (U 1 �_ V�ORK PHONE:-,?�' "•? `�� DRY RUN: (AUTHORIZED) EMPLOVER �'('`J� RJB OCCUPATION: OTHER: ADDRESS: ` ✓:; CITY: STATE:LAL ZIP: - COMMENTS: TOTAL: GA lell-I 661D f-9 PATIENT RECEIVED BY:X SIGNATURE) Provider tYta:r. whit, ,r•i !'i r,: rnr1, 4otvr+, Yr';,•e• �npy t• 9Wubn hiI'inp 01f-1 J•^� CONTRA COSTA COUNTY ;' AMBULANCE PRE-HOSPITAL CARE FORM I uNn AUTHORIZA'fION�_ ' • 0 1 �3 •" CHECK OR FILL IN APPROPRIATE SPACES DATE PATIENT'S NAME ��iSI 1.15�C -' �{ ❑ M F COMPANY a . (r ADDRESS — _il �tcS`JCI'- `�L' ---- ----- - --.-- AGE _ 11 1 :. ��,; STATE.-C+ _ ZIP _ _ .. _. .. _ DOB(P�3l Cl ' 11 S O M 0.`lw_•��1-Th O F O S DRIVER'S LICENSE a .__.. .._ PHONE-3 1 Z� !!!!!!NATURE OF DISPATCH.1411_ _AA TYPEOFTRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION-,•_., RESPONSE CODE: REQUESTED BY TIME — (24 HOUR CLOCK) r TO-� SCENE so, _. .._ __ CALL RECEIVED .�_ :" .,_ IL- P D. _.________ TIME 10-8 PATIENT DESTINATION ( )"1 T�}( r� �> FROM SCENE ❑ FIRE _____ ___ TIME 10-97 _ ra _._ ❑ PSAP TIME 10-49 ~• 1 L J I]—_ MILEAGE. 0 OTHERi PVT TIME 10-7 ti END .. •-�-- _ _ _ _ _ TIME 10-98 -� r _--_ DOCTOR 'ER START____ ( Y ---------- TIME 10-22 f r HOW HOSEN TOTAL --�1,. __ --_.__,_ STANDBY TIME EAREST ❑ FAMILY ❑ TRANSFER Y _—_— WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER z,I } CALL BACK a: AMBULANCE COMPANY: EcJ AMBULATORY? PATIENT TAKEN TO AMBULANCE. RESPONSE ZONEYES O ❑ 1NAL'(EO YGUERNEY ❑ OTHER PATIENT CONDIT N. DRIVER.--.—N AT-IA___ _ (� TECHNICIAN _ __ YIIV `.11_5 .__— EDIC ' HK --f—� - DISPATCHER. .: CHIEF COMPLAINT: _3"i`�.� 3+1 —___—_ DRY RUN: ❑ YES ONO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY)-- _. PATIENT REFUSED SERVICES. (SIGNATURE) " r MEDICAL COVERAGEINDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S a - --- - ----- ----- PRIVATE INS CO.: __— BASE RATE: KAISE -- --_. MULTIPLE PTS. BASE RATE S r" /;l TOTAL MILES:----- - — X ICAR �_�� (�—,_;�1�� E.O B. ATT. ' /ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (1900-07:00) I CCHP/PPHP a: _ EMERGENCY RUN: MEDI-CAL a:.- __.^______ _— CODE 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 ADM(N.)_—.—_—_ X DRUGS: (PER ADMIN.)_ X NAME: RELATIONSHIP - E.O.A.: (IF NOT REPLACED) ADDRESS:— _ _ � ._ ORAL AIRWAY: OF 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 7_, C 006�on PA 1 11 NI H +:I U I+Y X + 1•r n�i.ldr ri hIi w�. .. ' .I IVI,. .I;. " CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N ��� i „_. ... -.tom..•". ; I r'" p ,,); 1 •••• CHECK OR FILL IN APPROPRIATE SPACES DATE: _... � ATIENTS�NAME`i ) _ ❑ M.-O t COMPANY Nnn [� J ADDRESS; , ( ' AGES_ C1/R �'_U _1 - CITY- y -STATE ZIP DOBE_ O Sn OM OT OW O Th O F O S DRIVER'S LICENSE.N ► J PHONE _ NATURE OF DISPATCH 0.✓ c �17 TYPE,OF•TRANSPORT:!AMBULANCEY OTHER❑ — --. ( STATION 1(A)_2(B)_3(CK4(D)_5(E)_ ! i INCIDENT_4QgATION, Vii'! RltS'PONSE CbOE: �R,E�QUESTED BY: TIME- (24 HOUR CLOCK)^ I L --- TO SCENE lk 5.0. CALL RECEIVED _.L/1�1 L� ►— P.D. TIME 10-8 PATIENT DESTINATION:. FROM SCENE ❑ FIRE TIME 10-97 Q_Q_ 51 ❑ PSAP TIME 10-49 °', I MILEAGE: ❑ OTHER/PVT TIME 10-7 : i .) END TIME 10-98 I `, SIDbC:TOA tT"'fi'�' PMD/ER START TIME 10-22 HOW CHOSEN: _+ TOTAL STANDBY TIME - 7j3.0 NEARESTp FAMILY ❑ TRANSFER ' WAIT TIME -- I O PATIENT O DIREGtT ❑ OTHER CALL BACK N: AMBULANCE CO PANY;Z P T.,AMBULATORY? 1 PATIENT TAKEN TO AMBULANCE: �t RESPONSE ZON �1. ❑ NO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: DRIVER S L2 EMT-1A D►1I8U TECHNICIAN Q�� / PARAMEDIC Hx: t - _ DISPAT EAS ' CHIEF COMPLAINT: DRY RUN'�ES ❑ NO RE �OWFO A FO DRY i .111%,7":).PATIENT REFUSED SERVICES: (SIGNATURE) X i ��y y1�1 MEDICAL COVERAGE_ INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: � 1 !+�� S.S.k PRIVATE INS.CO.: BASE RATE: `.:`. KAISER k: 1 MULTIPLE PTS. BASE RATE -, `7 BLUE CROSS k: r i 1 P I I TOTAL MILES: X s •' MEDICARE N:' E.O.B. ATT. ROUND TRIP: ❑ YES O NO YES ❑ NO NIGHT: (19.00-07:00) ' '. CCHP/PPRP Nr _ - EMERGENCY RUN: MEDT-CAL N: ` " :r: CODE 2/3 , t r OTHER: *. OXYGEN: (PER TANK) t� P.O.E. STICKER ❑ YES ❑TNO r' NEONATAL:. (INCUBATOR) 4 DATES BILLED: STANDBY: (OVER 15 MIN.) 1 E.K.G.: (PER EPISODE) ''—NEAREST RELATIVE/RESPONSIBLE PARTY: — I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X —NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) 'CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) C "-`EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:- - TOTAL: '� GE (,0;16L :s - -- PATIENT RECEIVED BY: X (SIONATI IRE) CONTRA COSTA COUNTY AMBULANCE (;�/ •j�/�� PRE-HOSPITAL CARE FORM I C ' UNIT �' AUTHORIZATION 4 d r �. CNECK OR FILL INAPPROPRIATE SPACES - DATE: 'PATIENTS NAME u- ��aC/' S P-Iv1 ❑ �F COMPANY B ( ) ) ADORE AGE-7 CITY I✓ �� E'//�i STATE ZIP DOB� � � ^' ❑ Sn ❑ M ❑ T ❑ W'7-(Th ❑ F ❑ S DRIVER'S LICENSE 4 __ ___.__—_ PHONE 2 SL__. _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCi-Z OTHER❑ _._- _-._-_____ __ STATION 1(A).a,._2(B)_3(C)-4(D)_5(E)_ INCIDENT LOCATIQ RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,, TO SCENE- S.O. CALL RECEIVED C><, /� C'[/� D P.D. TIME 10-81j `f ' PATIENT DESTINATION: FROM SCENE 2 ❑ FIRE TIME 10 97 i .:!_ `1 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 c d END TIME 10-98 DOCTOR �i -��� PMD/® START TIME 10-22 , HOW CHOSEN: TOTAL STANDBY TIME 13NEAREST `FAMILY 13TRANSFER WAIT TIME -- ❑ PATIENT D DIRECT ❑ OTHER (�>j CALL BACK 4: AMBULANCE C MPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ,'ZONE ❑ YES 4-NO D WALKED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER � �Y)�; l7 _ EMT-1A TECHNICIA, /%✓L P�I /S(��/� - PARAMEDIC I Hx: ` nLSYI} l F7` nIR�. lJ� DISPATCHER: CHIEF COMPLAINT: p DRY RUN: ❑ YES ANO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE. � -)NDUSTRIAL ❑ YES�3rNO NO. OF PATIENTS: S.S. 4 c/J D — PRIVATE INS. CO.: BASE RATE: KAISER 4: MULTIPLE PTS. BASE RATE BLUE CROSS 4: TOTAL MILES: X r A d _ E.O.B. ATT. ROUND TRIP: D YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP 4: EMERGENCY RUN: ( MEDI-CAL 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 NAM l�AS Pmkotl`�Q RELATIONSHIP:" C"r E.O.A.: (IF NOT REPLACED) _ ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) C)TY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: � ) OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL . . 7' 00 PATIENT HECEIVLD BY. X _.___ '0.0'6 8 'T ,,lOr Mhu Nn!. � ( i.. .f 1• ✓l,.r w b­ 1 1 , ) IMS. I i-10 CONTRA COSTA COUNTY o 1 AMBULANCE PRE-HOSPITAL CARE FORM I u �• UNIT 21 AUTHORIZATION CHECK OA FILL INAPPROPRIATE SPACES DATE:. _ PATIENT'S NAME ❑ M IKIF COMPANY N4 FP ADDRESS I AGE D i j CITY "STATE ZIP DOB ❑ Sn 13M O T O W k—Th ❑ F ❑ S 1 DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER 0 _ -- STATION 1(A)_2(B)_3(C(j-_CD)_5(E)_ INCIDENT LOCATION:r -� RESPONSE CODE:- �REQUESTED BY: TIME— (24 HOUR C TK) ( ,M�, Z N TO SCENE- S.O. CALL RECEIVED 00 ,,l` 1 , 'i`— ��?�'_ ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCEN ❑ FIRE TIME 10-97 PSAi TIME 10-49 OTHER/PVT ; r MILEAGE: ❑ OTHER/PVT TIME 10-7 - -• + •. ENO TIME 10-98 DO',67 +�t ( 1 PMD/ER START TIME 10-22 HOW CHOSEN: ITOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CQ Al1Y2 ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON F� 7�•i, ES ❑ NO. , : O WALKED ❑ GUERNEY ❑ OTHER �. PATIENT CONDITION:' `• DRIVER S �' ' �- EMT-tA . I ^^ TECHNICIAN ti� J PARAMEDIC Hx: r1i 1✓1 O /'t + C C Id Q h�DISPATCHER: F7 ` Llf CHIEF COMPLAINT: a <'-s �InL DRY RUN: ES ❑ NO REASON FOR DRY RUN S ��� j n .I a!'i T U ATION F D UN(EMS USE ONLY) J _ PATIENT REFUSED SERVICES:(SIGNATURE) X� `1y MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.K 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/PPHP C' ' EMERGENCY RUN: MEDI-CAL N; CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X `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 ,C � _ . 6"Es, _ PATIENT RECEIVED BY X P•-,,r.l... �.R,,r- v�rr. ,.,r ... ... .•._ IS+(1NAl11RE! .M�-� CONTRA COST COUNTY ^1 AMBULANCE PRE-HOSPITAL CARE FORM I _ UNIT AUTHORIZATION M ` CHECK OR FILL INAPPROPRIATE SPACES GATE: S , ,_.• 20 �1 G PATIENTS NAME $L COMPANY K I _ ADDRESS '. AGE 1 CITY STATE_ ZIP DOB a Sn ❑ M O T O W kfTh ❑ F ❑ S DRIVER'S LICENSE N: PHONE _— NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE 0 OTHER O _ —.__ STATION I(A)-2(B)_3(C)_4(D)_51E)_ INCIDENT LOCATION:. RESPONSE CODE: REQUESTED BY: TIME- (24 HOURC OCK)� 1 i'l�i ✓1 � 2 nc-� � ��C,/C;. � TO SCENE - � S.O. CALL RECEIVED � • ❑ P.D. TIME 10-8 - PATIENT DESTINATION: FROM SCENE 13 FIRE TIME 10-97 V p O PSAP TIME 10-49 MILEAGE. ❑ OTHER/PVT TIME 10.7 END TIME 10-98 DOCTOR 11` ` t PMD/ER START TIME 10-22. HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL.BACK N: AMBULANCE C50TP!l;JN4,f / PT. MBULATORY7 PATIENT TAKEN TO AMBULANCE: ;& RESPONSE ZON �. YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER' �1 PATIENT CONDITION: 1 DRIVER SO L" EMT-1A //11 TECHNICIAN L S N PARAMEDIC If Hz: M I Yto (� /t.��� , G- S C P f��+ DISPATCHER: LC �C Q �.C 9 n 1(_ CHIEF COMPLAINT: �e hl_� t�I ✓� �+ DRY RUN: �S NO R ON FOR D Y RUN t� t V-x 4�/f i C� AUT Y R VVEA U L Yf I/ I '1• = PATIENT REFUSED SERVICES: (SIGNATURE) X_ VZ I j 2 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 ; J PRIVATE INS.CO.: BASE RATE: k KAISER or MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE R: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP%PPHP M: ' r EMERGENCY RUN: MEDT-CAL C CODE 2/3 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) 6sl EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: -"COMMENTS: I -` TOTAL: _ PATIENT RECEIVED BY: X_ e Pn•vi N lar -rr.. ,i•- •! (SIGNATUIVI �� c CONTRA COSTA COUNTY ` AMBULANCE ' j PRE-HOSPITAL CARE FORM 1 UNIT ,,�� AUTHORIZATIONR ��� CHECK OR FILL IN APPROPRIATE SPACES - _ - DATE: j ! lv 1 i, PATIENTS NAME ��'%'}+' r� ❑ M`D F COMPANY R { ADDRESS : N F/.'=L AGE.� L.> CITY STATE ZIP. 008 ❑ Sn ❑ M ❑ T ❑ W 13'Th ❑ F ❑S DRIVER'S LICENSE"# _ PHONE �.1 1�l NATURE OF DISPATCHI%"?'• TYPE OF TRANSPORT: AMBULANCE.M OTHER❑ STATION 1(A1-_2(B)-31C1_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) / J <1 , TO SCENE- © S.O. CALL RECEIVED ' ❑ P.D. TIME 10-8 4_4 ! 7 O FIRE TIME 10 97 - •_77 I PATIENT DESTINATION: FROM SCENE- �, . ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END f j TIME 10-98 .DOCTOR-->'`^`-�r 7 , PMDEg START TIME 10-22 HOW CHOSEN: TOTAL t — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _— ❑ PATIENT ❑ DIRECT ❑ OTHER ( ? CALL BACK k: AMBULANCE-COMPANY: PT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE 11YES ❑ NO ❑ WALKEGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER'• �'/'�t j,ll. EMT-1A _ TECHNICIAN ��/'4',< a PARAMEDIC Hx: r'�C f� rE•c?f c'a r..� DISPATCHER: CHIEF COMPLAINT: C)?I I/ DRY RUN: ❑ YES 1,?.NO REASON FOR DRY RUN I. L/ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) n PATIENT REFUSED SERVICES: (SIGNATURE)X— MEDICAL COVERAGENDUSTRIAL 13 YES ❑ NO NO, OF PATIENTS: S.S. III -1 ,-,-,PRIVATE INS. CO. t IC I �'/'L 1/2 Y L� 1 BASE RATE: .l I KAISER R: l I� '` ` 1 MULTIPLE PTS. BASE RATE BLUE CROSS A TOTAL MILES: X 1 MEDICARE It:_-,�/ - ' - �` � r 7 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO It( I ❑ YES ❑ NO NIGHT: (19:00-07:00) /4 CHP/t PHP M: EMERGENCY RUN: M {71,CAL R: 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 // � I NAME1 b yXT1 �K/S RELATIONSHIP:, T C/S7r E.O.A.: (IF NOT REPLACED) ADDRESS: r, ORAL AIRWAY: (IF NOT REPLACED) _ CITY: -I 17t STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: '(AUTHORIZED) EMPLOYER: r X i OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: 4. COMMENTS: — —. ---— - —$2 5.00 TOTAL. ----.---.- - Q PATIENT RECEIVED fJY X __.. CON I IIA 0081 A COUN I Y (r I t AMBULANCE �2 PRE-HOSPITAL CARE FORM I C UNIT [n ti AUTHORIZATION N 923 3 CHECK OR FILL IN APPROPRIATE SPACES �! ,��7 I �! I f jI DATE: - 1 / f PATIENT'S NAME__ _��Jt. ;�� C! .L�-.1 �,[Q _ M D F COMPANY M - (, . ; y-- ( n ADDRESS — _--.f _ �� ' �L — ( AGE .i r CITY_fh4ilz?_ STATE ZIP Dl_j_Ll' q O Sn OM OT O W P'Th ❑ F L1 n L DRIVER'S LICENSE N _._.____.__._.__.___ ___ _.___ PHONE NATURE OF DISPATCH F) " p )TYPE OF TRANSPORT: AMBULANCE OTHER O ___.. _ STATION 1(A)_2(B)^3(C)_4(D)_5(E)# ' I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) } � TO SCENE- p S.O. CALL RECEIVED t O P.D. TIME 10.8 .L,r7 T:��...� I PATIENT DESTINATION:' FROM SCENE- ❑ FIRE TIME 10-97 _5X_ - r 2- O PSAP TIME 10-49 5, S/ j r1 MILEAG O OTHER/PVT TIME 10.7 J END_ D TIME 10-98 i DOCTOR � �� `� PMDe START CM! TIME 10-22 I. • HOW CHOSEN: TOTAL L 113 STANDBY TIME T O NEAREST FAMILY ❑ TRANSFER �- WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER �� .) CALL BACK N: AMBULANCE COMP NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ::jLb ❑ YES INO ❑ WAL'<ED GUERNEY O OTHER — j i PATIENT CONDITION: DRIVER. (1 EMT-1A 1 TECHNICIAN ,' ' PARAMEDIC_tL Hx: L].� M' ---- DISPATCHER: 1_I.t. ( t �, r;. -- ' 1 ' CHIEF COMPLAINT: —s.u�Kf G� DRY RUN: 11 YES NO REASON FOR DRY RUN ! AUTHORIZATION FOR DRY RUN (EMS USE ONLY) f PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES �•NO NO. OF PATIENTS: 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 O NO -- i I,.,_7 O YES '❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: 4 MEDT-C CODE 2/3 .i. 11 OTHE { )nP_ OXYGEN; (PER TANK) P.O.E. STICKER ❑ VES ❑ NO NEONATAL: (INCUBATOR) I �^ DATES BILLED: STANDBY: (OVER 15 MIN.) i ff E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X -- DRUGS: (PER ADMIN.) X NAME: YC< < �• �t� RELATIONSHIP: E.O.A.: (IF NOT REPLACED) -- -_ I ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STAYE______ZIP:__ C-COLLAR: (IF NOT REPLACED) kz� PHONE: c�,_ ]� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:���QA��nnGLSLt>zhOCCUPATION: 4Q&fjtC OTHER: ca_w ADDRESS: .1,IIl('Y1f llyc' I.SuCJ��` L I CITY: Lc, 1 nc.:( STATE: ZIP:LL r COMMENTS:SUMS 1.1 t�.,� t���e,0111 ► 4 MN cls CAL Kedl 4.�SC.Lt1� TOTAL: c-Zy-J v PATIENT RECEIVED BY:X OW e�r c (SIGNATURE) '�) Flvvict'r rrwin L4;i', �_r`! r'V; CJI'L �CCun Ye".s , . f• L*tt when t -ink UIS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION R I ` Tit T� •-i d' CHECK OR FILL INAPPROPRIATE SPACES GATE: ��•//,� �.�;,�. "' I PATIENT'S NAME ISM ❑ F COMPANY M n 1 t ADDRESS ;9 �-5'12 CITY I ..� STATE ZIP Dopy—�z v /❑ Sn ❑ M ❑T ❑W �Th O F 0$;; . DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH � - TYPE OF TRANSPORT: AMBULANCE Et3THER❑ ilTiE;UFf;4 J INCIDENT LOCATION: RESPONSE CODE: ' . EOUESTED BY: TIME- (24 HOUFJ C K)t L T TO SCENE- 2 .0. CALL RECEIVED ❑ P.D. TIME 10-8 �t '.4 PATIENT DESTINATION: FROM SCENE 13 FIRE TIME 10-97 �'r R I ❑ PSAP TIME 1049, I, T ID a } MILEAGE: ❑ OTHER/PVT TIME 10-7 1 END �-S / TIME 10-98 ) DOCTOR PMDrE START TIME 10-22 -_��� ..Z� •�' HOW CHOSEN: ITOTAL 2- • STANDBY TIME . $i ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAITTIME it1 6e;. O PATIENT ❑ DIRECT /`��THER 3 CALL BACK#: AMBULANCE CO ANY'Y• PST/AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5 RESPONSE ZONE �-Y�ES ❑ NO ALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER - TECHNICIAN PARAMEDIC Hx:L-LLT' t DISPATCHER: n CHIEF OMPL 'INT: -�� _ DRY RUN: ❑ YES ANO REASON FOR DRY RUN . AUTHORIZATION FOR DRY RUN(EMS USE ONLY) t Y (31 n., _ ATIENT REFUSED StRVICES:(SIGNATURE) X MEDICAL C VERAGE: INDUSTRIAL YES •I NO NO. OF PATIENTS: •�% .. �Ur .f; . S.S. # _U 13 �.> PRIVATE INS. CO.: BASE RATE: 1 6 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). LT,' CCHP/PPHP#: EMERGENCY RUN: 1 ydL�SL MEDI-CAL#: COD2)/3 I c (i IJGV H Rf1TX3 -fi` OTHER: OXYGEN: ( RTANK) P.O.E. STICKER ❑ YES P, NO NEONATAL: (INCUBATOR) IUD raw •'AL2? DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.O.: (PER EPISODE) r�{`�`• 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) L' CITY: 1 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 retain White cid Pink copy Return YoNow co,y w -( O URE)-• .►.+..+.w ' to MS when billing t CONTRA COSTA COUNTY `;-�� AMBULANCE I PRE-HOSPITAL CARE FORM I ( UNIT � �j AUTHORIZATION N ,) CHECK OR FILL IN APPROPRIATE SPACES \ DATE: 1 I J PATIENTS NAMEL!'-_�� -L- ❑ M ❑ F COMPANY N ADDRESS ^ � AGE CITY �, U L�C� � �?Ae_VES —_ DOB__ ❑ Sn ❑ M ❑ T ❑ W P<b 0 F S DRIVER'S LICENSE N __.__.__. _.. _. . __ PHONE .------ __._ .,---- NATURE OF DISPATCH S_ls) 1 TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: I � '_( RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL K) i TO SCENE- S.O. CALL RECEIVED 5 ~ " ❑ P.D. --_ TIME 10 8 ~ J PATIENT DESTINATION: FROM SCE E ❑ FIRE -- TIME 10-97 ❑ PSAP TIME 10-49 _ MILEAGE. ❑ OTHER/PVT TIME 10-7 END —_ TIME 10-98 " DOCTOR PMD/ER START___ ___ TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME ` ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ J ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: S RESPONSE ZONE ❑ YES ❑ NO ❑ WAL"ED ❑ GUERNEY ❑ OTHER -_ PATIENT CONDITION: DRIVER M / t .�.� E T-11A `' t TECHNICIAN SH RAMEDIC y Hx: �.! --- -y-^-�, ----- DISPATCHER: A AA LJ1f i K1 t l C! ( � CHIEF COMPLAINT:--y.`'"� �S_7 DRY RUN: ❑ YES X NO REASON FOR DRY RUN \11U HO' ATION Oq Y R (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) XwJ�, QA II' 1 MEDICAL COVERAGE: INDUSTRIAL ❑ YESeNO NO. OF PATIENTS: — :`•S'O?�r S.S. N n PRIVATE INS. CO.: BASE RATE: 1 KAISER a: MULTIPLE PTS. BASE RATE 1 BLUE CROSS N: —_ TOTAL MILES: X v MEDICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPHPN: 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: Y _ ORAL AIRWAY: (IF NOT REPLACED) CITY: __.___.__ STATE--ZIP: C-COLLAR: (IF NOT REPLACED) AL PHONE:. WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: _.. __. OCCUPATION' _ OTHER: ADDRESS: CITY: STATE ZIP: COMMENTS: -------- —_ TOTAL --------------- PATIENT RECEIVED BY:X (SIGNATURE) LMS-1 CONIIIA ('OSTIA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IN APPROPRIATE SPACES DATE: Y 3 PATIENT'S NAMML1 UE-S.-_ C�S!LOM .blF COMPANY ADDRESS �','I J'LfJ(-V C_i1//d.,,t��1r AGE CITYSTATEZIP_ DOB b l/ O Sn O M E3T W ❑ Th O F O S DRIVER'S LICENSE a ___ .-_._ PHONE ZbO� `r NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER❑ _____.__.._—._. STATION I fA)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOC TION: RESPONSE CODE: RESTED BY: TIME— (24 HOUR CLOCK) ' TO SCENE �j S.O.— CALL RECEIVED 1� ►1—� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 + , ❑ PSAP TIME 10-49 'L t�..1 l�✓ MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 �: DOCTOR S_?Y'y�. > ; u P START__ TIME 10-22 HOW CHOSEN: .-- TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME (PATIENT ❑ DIRECT ❑ OTHER CALL BACK N' AMBULANCE COMP Y. - PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 3 ) t,TYES ❑ NO ❑ WAL"ED Eg�,GUERNEY ❑ OTHER _ PATIENT CONDITION: DRIVER EMT-1A I (� 7 TECHNICIAN _ -�' PARAMEDIC - Hv 1'..LC_a P-r —v( � DISPATCHER: ""7.. I I. ~- -T,. ,.:! I I CHIEF COMPLAINT:(���; .t_ :'1 C�M_-,Mi `DORY RUN: ❑ YES "Id 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. N PRIVATE INS. CO.: BASE RATE: ,cc —cri-- KAISER>•: MULTIPLE PTS. BASE RATE + r. rl i .: E CROS� S�31- u� 'y",r.,/1 TOTAL MILES: X �J ft,U MEDICARE',f-..1InS '),J ( ' T E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ r YES O NO NIGHT: (19:00-07:00) U 1rI CCHP/PPHP N: EMERGENCY RUN: 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) J'• NEAREST RELATIVE/RESPONSIBLE PARTY: I.V. (PER ADMIN.) X DRUGS: (PER ADMIN.) NAME. � RELATIONSHIP: U.A.: (IF NOT REPLACED) ADDRESS: �CA ORAL AIRWAY: (IF NOT REPLACED) CITY: —_ STATE—_ZIP: C-COLLAR' (IF NOT REPLACED) •��� PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: '/� r- i7 CITY: SlITAATE: ZIP: COMMENTS: TOTAL: S PATIENT RECEIVED BY:X =L Pmvidar rrta:r Vh:I, ,.•.I _ - r•.: -cTp Yv':,�• -n,, t RS uhrn bi2'ing (SIGNATUE► OIS-1 CONTRA COSTA COUNTY AMBULANCE PRE- HOSPITAL CARE FORM i UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: CI ' PATIENTS NAME ( ❑'M ❑"F COMPANY M ADDRESS r ' , �17 e1:� v �/ Lp ! AGES CITY- STATE_._.. .TS ZIP.,1_.___. -DOB O Sn O M Q,T O W ALM O F 0 S7. L' + lit DRIVER'S LICENSE 4 + ) PHONE —.NATURE OF DISPATCH A)LU r}Ir'�f�r lf�L-i<�R71'� TYPE OF TRANSPORT:f AMBULANCE OTHER 0 _ STATION 11A)_2(8)_3(C)_41D1_51E1_ I. INCIDENT LOCATION:; - ) S: RESPONSE CODE! REQUESTED BY: TIME— (24 HOUR CLOCK) t .(7 1 TO SCENE- ❑ P.O. TIME a8 RECEIVEDCALL 40� PATIENT DESTINATION: -—) FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 1D-49 ��/ `4�►%' °'� .'Is �� — `� MILEAGE: ❑ OTHER/PVT TIME 10.7 ' END TIME 10.98 — f-DOCfO�1 `� _ PMD/ER START TOTAL----- TIME 10-22' r�� �' ' HOW CHOSEN: 11Y-- ' STANDBY TIME ' p NEARESTp( O FAMIL� O TRANSFER WAIT TIME __ J O PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY; -� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _>U RESPONSE ZONE O YES,iO NO: , . O WALKED 11GUERNEY 11 OTHER J PATIENT CONDITIONY " ' + DRIVER + + MT-1 J 71$t1:' '.:.1.t • " .) _1 TECHNICIAN. PARAMEDIC -�z Hx: _ - a� r )~ DISPATCHER: YODCHIEF COMPLAINT: DRY RUN:�ES �lr_ REASON FOR DRY RU__ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) •1 .IqqR tet:I U,.-PATIENT REFUSED SERVICES: (SIGNATURE) X /I .1 MEDICAL COVERAGE:___ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M s: PRIVATE INS.CO--___r_ BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE l BLUE CROSS 8: I TOTAL MILES: X MEDICARE R: E.O.B. ATT. ROUND TRIP: OYES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP Il:' ,r T, , EMERGENCY RUN: MEDT-CAL M: ` 1 T I CODE 2/3 OTHER: I OXYGEN% (PER TANK) ------- P.O.E. 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: w E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ZIP: C-COLLAR: (IF NOT REPLACED) - ., PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) � 4°."-EMPLOYER: OCCUPATION: w OTHER: ' ADDRESS: --CITY: - STATE'w ZIP:- -COMMENTS: IP:—"COMMENTS: TOTAL: PATIENT RECEIVED BY: X _ p....I r..• �:.. ..r (9lnNAl11nF) CONTRA COSTA COUNTYt-i. AMBULANCE t L PRE-HOSPITAL CARE FORM I jj ; UNIT _ AUTHORIZATION M Y CHECK OR FILL IN APPROPRIATE SPACES ` DATE: U PATIENTS NAME V Cy 'Vh ❑ M ❑ F COMPANY M ADDRESS _ AGE CITY STATE ZIP DOB _ O Sn OM ❑ T O W P�Th OF ❑ S C E -- r DRIVER'S LICENSE Mz ^_-_ PHONE--------- NATURE OF DISPATCH N_ ` TYPE OF TRANSPORT: AMBULANCEID OTHER❑ __ ____—.__.-_.__. STATION I(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 !✓ ncu-' / �if&!s ❑ P U. TIME 10-8 1 1 PATIENT DESTINATION: FROM SCENE-( ❑ FIRE -- TIME 10-97 T ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 ' HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK M: AMBULANCE COMPANY: C A PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE t. ❑ YES ONO ❑ WAL`CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER– �i��t� EMT-1A TECHNICIAN PARAMEDIC 14 Hz: y Z 314 C DISPATCHER: I l CHIEF COMPLAINT: DRY RUN: AYES ❑'NO REASON FOR DRY RUN f02 r ` L AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— _)�y MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. M 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: r MEDI-CALM: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES D NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: 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) may. PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: j CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: _ TOTAL-f ' 69 ' 00 PATIENT RECEIVED BY: X_ - (SIGNAT')RE) r CONTRA COSTA COUNTY \ 1 AMBULANCE �( PRE-HOSPITAL CARE FORM I ( UNIT ® AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE' It PATIENT'S NAME ❑ M �jF�` COMPANY# �t ADDRESS AGE. �✓ —— -- ----T�..— — CITY-��� GSTATE_11.2__._^ ZIP. _ -1D DOB �{� ..��S ❑ Sn 11M ❑ T ❑ W TQh O F � S DRIVER'S LICENSE a _-_ _._. . _. PHONEI-32-90 O ...... NATURE OF DISPATCH-__.��_ r - TYPE OF TRANSPORT AMBULANC�4 OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY TIME - (24 HOUR CLOCK) \ G TO SCENE - eS.O. __-_.____" CALL RECEIVED " ) �! v�-r �__'-4'-f ----- --------- " ----- ❑ P.D.-------__ TIME 10-8 •. i � - PATIENT DESTINATION: FROM SCENE - 2 ❑ FIRE -_..--. TIME 10-97 ❑ PSAP TIME 10-491- `,(% MILEAGE. J. Cl OTHERIPVT TIME 10-7 END. ,=7 _'_.U. TIME 10-98 DOCTOR _ lL � PMDi START__-L.I _J_ -_-_--.-__ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST Cl FAMILY ❑ TRANSFER / WAIT TIME -_ d PATIENT Cl DIRECT ❑ OTHER i CALL BACK#. AMBULANCE CO QAI� N PT.AMBULATORY? PA TENT TAKEN TO AMBULANCE: RESPONSE ZONE___ YES ❑ NO l':ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION. DRIVER_ ►�v.�(ti` J.-�~--_- EMT-1A TECHNICIAN -_ _il!=�� ILS PARAMEDIC U KPI! DISPATCHER: O 4-� CHIEF COMPLAINT: Lr`1 -/^++��!�, -1-::: `-GY DRY RUN: Cl YES Q NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVE AGE: INDUSTRIAL ❑ YES O NO. OF PATIENTS: S.S. R �1 �-2 T—T i PRIVATE INS. COI 0 r�'-� '11 r.'" -f' �L d - BASE RATE: I FCA1SEFi MULTIPLE PTS. BASE RATE BLUE CROSS# t ITS' Z �y TOTAL MILES: -___.. X MEDICARE v: y:�i � �'''� �"I'�. �� � "'S;NE.O.B. ATT ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT (19:00-07:00) - i CCHP/PPRP#: - EMERGENCY RUN: ' i MED'-CAL a: -y CODE 2/3 l/ OT HER: Wb�ft �LL ,-`�- ll�� OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) TES 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.0 A.: (IF NOT REPLACED) ADDRESS _' --_. ORAL AIRWAY: (IF NOT REPT ACED) _ CITY: _ STATE-,ZIP:_-__. C-COLLAR: (IF NOT REPLACED) - PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) _ EMPLOYER: _. OCCUPATION:_--___.- OTHER: ADDRESS: CITY: STATE: ZIP:- COMMENTS: IP:COMMENTS: IF *--,-- TOTAL - -- ------ -_ - -- - TOTAL 00692 PATIENT RECFIVFn BY X _ 3 CONTRA COSTA COUNTY AMBULANC `�• PRE-HOSPITAL CARE FORM I 11NIT AUTHORIZATION p 7 / ✓�->V `-' CMECK OR FILL IM APPAOPR/ATE SPACES DATE: _ PATIENTS NAME___ �f hG- 1 «.��'___ . . ClM ❑ F COMPANY a �- .. , -7 ADDRESS '' L� / —_-L.�1�i1_"e-------t'-//-- -- AGE//.�-- -LL,, '• � '. CITY STATE STATE__._—_.___ ZIP.C� Y DOB .b.J� .7�❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ S J DRIVER'S LICENSE a -- _.._. _ .. PHONE g'�7- N TUNE OF DISPATCH :v l_C ' ,P.r , r-.J - TYPEOFTRANSPORT AMBULANCE0 OTHER❑ INCIDENT LOCATION: RESPONSE CODE. x OUESTED BY. TIME - (24 HOUR CLOCK)1 0 ,9 �- TO SCENE - S O. ._.__.__.__ CALL RECEIVED �L :L Jt/ ❑ P.D. _ .. --.._. TIME 10-8k L f 1 PATIENT DESTINATION: n n FROM SCENE- ❑ FIRE _____- TIME 10-97 f r Cl PSAP TIME 10-49 /4� j ( T / MILEAGES_._ - Cl OTHER'PVT TIME 10-7 ' END. _/__ .._ _ TIME 10-98 DOCTOR __. PMD R START -7.1--7- - -- TIME 10-22 HOW C OSEN: TOTAL -_!,. __ _._-_.__-__-_ STANDBY TIME NEAREST ❑ FAMILY Cl TRANSFER _ -_._. WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER l CALL BACK a: AMBULANCE CO P NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. J (' RESPONSE ZONE YES ❑ NO w/.L°:ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER- 7 t r�2 .r- ._� r_L EMT-1A TECHNICIAN PARAMEDIC _- .�L 1 � ' 1 _ 1 f(• ? Hx: .��L1�'1 _� _ (i` _t'�_ . DISPATCHER. _.�__ / CHIEF COMPLAINT: �i�1P.. DRY RUN: ❑ YES NO REASON FOR CRY RUN ( t C �S[dde-kmat=(tiP� yr_l.�l S- _ AUTHORIZATION FO Y RUN (EMS USE ONLY) 1t1<� l PATIENT REFUSED SERVICES (SIGNATURE) X-.._.___.._-__-__..._____.__-_ MEDICAL COVERAGE: INDUSTRIAL ❑ YE N NO. OF PATIENTS: S.S. It NO PRIVATE INS. C07 K.c,,cL�S1�1_- BASE RATE: t KALE-R#: q - ' 1--/, MULTIPLE PTS. BASE RATE -- (�` BWE.CROSS k:' 4-.-�z TOTAL MILES: _ X v� MEDICARE a: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO J !'� ❑ YES ❑ NO NIGHT: (19'00- 07:00) /- CCHP/PPRP#: EMERGENCY RUN: aY 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 - » �� l�1y4t� „ C4>✓ DRUGS: (PER ADMIN.) X --__ AME: LY�►1 L'1i._. _ RELATIONSHIP:_- _. E.O.A : (IF NOT REPLACED) PRISS:_ _-. -.Ma �'ZtI'f rk_Ln_____..-_ ._._.---.. ORAL AIRWAY: (IF NOT REPLACED) - CITY: STATE_C- ,*-ZIP:___ C COLLAR: (IF NOT REPLACED) _- PHONE:'2,3-1 I jb- WORK PHONE: - DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE:--ZIP:--.- COMMENTS: IP: -._COMMENTS: 4,93 - - - TOTAL-. - =J --- PATIENt Fit CFIVI I) BY X V ,� .. `- I r,.,rLl.•r• rrrr .. ur.r r• ( ttitL 111111) -- . . ... r . . . IMs-1 VCONTRA COSTA COUNTY AMBULANCE <� PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 J ® 8 /lel 7 CHECK OR FILL IN APPROPRIATE SPACES DATE: / r lLJ ❑ M ❑ F COMPANY PATIENTS NAME.-.. . ' ADDRESS AGE w CITY STATE ZIP___ DOB_—_ ❑ Sn ❑ M ❑ T ❑ W VM ❑ F '❑`S DRIVER'S LICENSE M __ _ PHONE---.------ NATURE OF DISPATCH�Ct 12LJ UyK L TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION:' r�I civ RESPONSE CODE: RE9JJESTED BY: TIME — (24 HOUR CLOCK) TO SCENE- 7a S.O.—_— CALL RECEIVED � ��v I 13P.U. TIME 10-8 0//0 i PATIENT DESTINATION: FROM S ENE ❑ FIRE TIME 10-97 12I_ l I ❑ PSAP TIME 10-49 J11 10 Z- 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 p: AMBULANCE COMPANY: CA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5•L RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER I —L'L� IkMT-1A_ ` TECHNICIAN— ell IPARAMEOIC� Hx: DISPATC f_/f t�lU CHIEF COMPLAINT: _ DRY RU YES 8 NO REASON FOR DRY RUN S C� AUTHORI FOR DRY RUN(EMS USE ONLY) IGG�� PATIENT REFUSED SERVICES: (SIGNATURE) X_ 1"Joh- MEDICAL COVERAGE: INDUSTRIAL ❑ YES rNO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE ; BLUE CROSS 4: TOTAL MILES: X MEDICARE 4: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP q: EMERGENCY RUN: MEDI-CAL p: CODE 2/3 OTHER: k 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'✓ —. •— —_._____ _. PATIENT RECEIVED BY: X-.-.-.— i inF1 CONTRA COSTA COUNTY AMBULANCE �� x PRE5-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IM APPROPRIATE SPACES DATE: yPATIENTS NAME ❑ M ❑ F COMPANY ADDRESS AGE IN CITY STATE -- ZIP DOB ❑-Sn ❑ M O T ❑ W ❑Th ❑ F ❑ S DRIVER'S LICENSE N;_ PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER _ _—.... STATION 1(A)_2(B)_3lC)_4(D)_ (E)_ 4 INCIDENT LOCATION:, - RESPONSE C E: RE STED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED P.D. TIME 10-8 IENT DEST N: FROM SCEN ❑ FIRE TIME 10-97 I O PSAP TIME 10-49 �— MILEAGE: ❑ OTHER/PVT TIME 10-7 " r END TIME 10-98 rDOCTOR `I } _ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME PrM ❑ NEAREST!rl El FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP�AIY^� PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: J .`� RESPONSE ZONE rSi 13 YES 13NO 13WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:' I DRIVER � C EMT-1A 1�r1$ TECHNICIAN�— 7 PARAMEDIC Hx: D I SSPAT�C 50; CHIEF COMPLAINT: YR RUN: YES ❑ O REASON FOR DRY RUN (r OR DRY RUN(EMS USE ONLY) o3'�-J 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: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHO 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: COMMENTS: TOTAL:1�17I-Cr) U PATIENT RECEIVED BY:X hrmi Irr vr.. .; LA0' . ! r.i,: .r.1 y-h. - ,., , . r ISIGNATUnE 00694 CONTRA COSTA COUNTY AMBULANCE .� H> PRE-HOSPITAL CARE FORM I UNIT -Z� AUTHORIZATION N ' CN[CK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME TsqzocIIto "CUcge WM ❑ F COMPANYM ADDRESS titi���t�ti�c AGE ( 'v ► CITY—�d ��w1 C) STATE CCA ZIP�SC�Q_7 DOB_,/j- _ _�3 ❑ S"n ❑ M ElT ElW 13Th F C3 S 1 DRIVER'S LICENSE*401--) 2��.L2 PHONE___93 --l-n-2— NATURE OF DISPATCH -� - TYPE OF TRANSPORT: AMBULANCE'- THER❑ _.^ STATION I(A)-_2(B)_3(C)._4(D)_5(E)_, INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL(?CK) " t � TO SCENE- 2 XS.O. — CALL RECEIVED T� J c'L L.�1 l� JkP l LA 4- It'll Q L►,�� J ❑ 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 - L TIME 10-98 •DOCTOR e PMD START if'`i - TIME 10-22 HOW CHOSEN: TOTAL — STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: cra !� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE DYES ❑ NO O WALKED XGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_- ( EMT-IA Al 1 TECHNICIAN�` PARAMEDIC ,)C Hx: sL Ll^ DISPATCHER: (v CHIEF COMPLAINT: fl� DRY RUN: ❑ YES NO REASON FOR DRY RUN 4 0 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) /r'} PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. 0 PRIVATE INS.CO.: BASE RATE: SER MULTIPLE PTS. BASE RATE BL E CROSS W TOTAL MILES: X I MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) Z -,/ I -) '� CCHP/PPHP 0: EMERGENCY RUN: L 1' ) MEDT-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) -� DATES BILLED:- STANDBY: (OVER 15 MIN.)._ I�� e E.K.G.: (PER EPISODE) "'NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) NAME:(_Ar,T;E/? G EO R G c X RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: u .64t - TG 17 ORAL AIRWAY: (IF NOT REPLACED) CITY: m ✓ 5 ^� I`")STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: -�— WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:DYI11L-_UIL OTHER: r' ADDRESS: �SZ a r/Z.4�O/1 r.•,t tJ ..:�� /�; ' ! ✓', 1 --CITY: IL, STATE: ZIP: -'COMMENTS: h 0 crna l a u ,�l. U E' -- _ TOTAL:_-.— 00696 PA TIENT RECEIVED BY X _ _ Pmvidir mtair. Vhi tP ,.rd Pi,:; pp },!rh,-n 1; (SIGNATUREI TM•. \U V CONTRA COSTA COUNTY C,.. AMBULANCE C ` PRE-HOSPITAL CARE FORM I UNIT 1 AUTHORIZATION A s} CMfC![OR fllL IM APPA O►AIATf SPACES DATE: U PATIENTS NAME ry S Lt 1 M } I`a r jA ❑ F COMPANY f 1" ADDRESS-7—'-4q-l-' � AGE-5 CITY C�11�[2Ogi STATECI).cG01 ZIP—c� �/.--- DOBLJ. 5+ ❑ Sn ❑ M ❑ T ❑W ❑ Th F ❑ S tj- CL DRIVER'S LICENSE N _ �'�' L,,, PHONE_4 S.z=`{I NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ .__ STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY. TIME – (24 HOUR CLOCK) TO SCENEvS.O. CALL RECEIVED ❑ P.U. TIME 10.8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE:•• ❑ OTHER/PVT TIME 10-7 C,�N END�L '� TIME 10-98 DOCTOR PM ER START' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST. ❑ FAMILY ❑ TRANSFER WAIT TIME -- PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY: /1 P . AMBULATORY? PATIENT TAKEN TO AMBULANCE: NO ❑ RESPONSE ZONE-�— YES ❑ WAL'<ED�GUERNEY O OTHER — ( ) PATIENT CONDITION: DRIVER S�^C �C`'`�� �^ )' EMT-1A r TECHNICIAN A-j''L PARAMEDIC Hx: 1 DISPATCHER: _ �I(`) z �►-)(t,� 1 lit` i ' CHIEF COMPLAINT: N DRY RUN: ❑ YES JNO REASON FOR DRY RUN u AUTHORIZATION FO DRY RUN(EMS USE ONLY) 17 y PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES KNO NO. OF PATIENTS: 1 �.. r S.S. R 7 b'T- Z3'S? 3o PRIVATE INS.CO.: NOF- - BASE RATE: ' • n� KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS R: TOTAL MILES: � X `� > 1 MEDICARE+►: E.O.B. ATT ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP R.' _ EMERGENCY RUN: MEDI-CAL R:- NC' CODE 2/3 I OTHER: OXYGEN: (PEAR TANK) P.O.E. STICKER ❑ YES ANO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: IV.: (PER ADMIN.) X CJS DRUGS: (PER ADMIN.) X NAME: (I"�r1 5 I, RELATIONSHIP: LJ 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) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:i`T• h{!� kU 1 ^S ✓q 6y c2 1;0rv ^ i ` Art t�Z TOTAL e c )0069:`7 -- _ - PATIENT FRL('LIVFD HY X ' (SIGNATURE) fms_l I , 1 a CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME�� /_� —T_� ' � M ❑ F COMPANY N �� 1 1 1 ADDRESS /v AGE CITY STATE �A ZIP_Lta DOB �O❑ Sn ❑ M ❑ T ❑ W ❑Th F ❑ S DRIVER'S LICENSE M _ PHONE L -� __ ATURE OF DISPATCH C - TYPEOFTRANSPORT: AMBULANCE 91 OTHER STATION 1(A)-_2(8)_3(C)_4(D)_51E)_ INCIDENT LOCATION: RESPONSE CODE: RE ESTED BY: TIME— (24 HOUR CLOCK) TO SCENE ►1 S.O. CALL RECEIVED � ��� • ❑ P.D. TIME 10-8 y PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 / -� ❑ PSAP TIME 10-49 �s �" 77 MILEAGE: ❑ OTHER/PVT TIME 10-7 I' END TIME 10-98 DOCTOR ��L� ��` PMD ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST 0 FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER �I CALL BACK C AMBULANC§COMPANY: PT. BULATORY? PATIENT TAKE,N13AMBULANCE: 1 RESPONSE ZONE El13 � YES NO WALKED �GUERNEY OTHER I PATIENT CONDITION: DRIVE I ( EMT-tA I TECHNICIAN l hWEDIC DISPATCHER: " ? 1�f - �I) f CHIEF COMPLAINT: DRY RUN: ❑ YES b NO REASON FOR DRY RUN + PATIENT REFUSED SERVICES: (SIGNATURE) X AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I ,� � MEDICAL C V R GE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: l �, S.S. « r �5 5� PRIVATE INS. CO.. L I G BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE Btt)E-CROSS Nn ?_ li h. L1:t >y=4•[''� 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: ( MEDI-CAL x; •-3G " ,� `� ✓• •r� 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 `.�//T.__fff 4+-? -SZ- �q4 DRUGS: (PER ADMIN.) X NAA � '�IC!ZZL-1.4ELATIONSHIR MQQ E.O.A.: (IF NOT REPLACED) ADDRESS: - ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) -PHONE: WORK P i N DRY RUN: (AUTHORIZED) / EMPLOYER�i _ OCCUP I OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: --- TOTAL.- 00698. ( �069 -- _ (� Q l.J8. ( ----- ISA I IT NT RFCF IV[n IIY % _--. ... I .,'.PIAL-,IFI CONTRA COSTA COUNTY AMBULANCE �� �Q PRE-HOSPITAL CARE FORM 1 UNIT -Z f AUTHORIZATION A CHECK OR FILL IN APPROPRIATE 3PACE3 DATE: PATIENTS NAME _ t , ❑`M ❑ F COMPANY M ADDRESS + '` AGE — ),A-/ CITYSTATE_.,,ZIP_r___ � DOB 13 S 13M ❑ T ❑W ❑ Th a F 13S ` 71 DRIVER'S LICENSE M PHONE _ NATURE OF DISPATCHf5�'s1fC—h �./io S TYPE OF TRANSPORT: AMBULANCE OTHER '— STATION 1(A)_2(8)_3(C)_4(D)_5(E)._ INCIDENT LOCATION: j `1.j RESPONSE COOE'. REQ1dESTED BY: TIME- (24 HOUR CLOCK) j� TO SCENE - 3 S.O. CALL RECEIVED '} C C ❑ P.D. TIME 10-8 PATIENT DESTINATION: -._... FROM SCENE-Q ❑ FIRE TIME 10-97 I, ❑ PSAP TIME 10.49. ` ��4 'V- 2'� MILEAGE: ❑ OTHER/PVT TIME 10-7 : END T —_ TIME 10-98 �� — Ye DOCTOR' ` I PMD/ER START TIME 10-22 HOW CHOSEN: , TOTAL �_ STANDBY TIME • O NEAREST :�p 13FAMILY 13TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK R: AMBULANCE COMPANY PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: i U RESPONSE ZONE 4c� ❑ YES ❑ NO � ❑ WAL KED ❑ GUERNEY ❑ OTHER ' ' / ��7 �/ ( :T'.ir c PATIENT CONDITION: DRIVER gQ` `,� EMT-1A ��'.I R ._ TECHNICIAN �'� r �c ARAMEDfC Pix: DISPATCH R: t OS CHIEF COMPLAINT: 1 DRY RUN: YES ❑ NO REASON FOR DRY RUN 4-664h a t� AUTHO IZA ON FOR DRY RUN(EMS USE ONYL )C-OG�'1 e- V/L T/ L/( q Si PATIENT REFUSED SERVICES: (SIGNATURE) X. AGI h G el,(Ll rJ� MEDICAL COVERAGE: _ . INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: % ! S.S.M 1 PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE E BLUE CROSS 0: TOTAL MILES: X MEDICARE R:' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: ` ' ( EMERGENCY RUN. MEDT-CAL M: t ''I 'i CODE 2/3 OTHER: OXYGEN:. (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ) 4 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: — I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 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: i ADDRESS: CITY: STATE' ZIP: COMMENTS:— —= - TOTAL: y PATIENT RECEIVED BY:X "0 6 v z CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT n AUTHORIZATION 0 Od :. CHECK OR FILL IN APPROPRIATE SPACES DATE: 2 IE r' NAME 1' S S �7 1 / / C )E M ❑ F COMPANY 0 DRESS -T ` z cC& AGE G -1 3' 1 CITY y�• ;. STATELLt ZIP D Sn ❑W ❑ fF^DOBJE3 S , DRIVER'StICENSE x - PHONE_ St`��.«_ NATURE OF DISPATCH1'L► TYPE OF TRANSPORT: AMBULANCE Q OTHER O __ __ STATION 1(A)_218)_3(C)_4(0)_5(E)„_ INCIDENT LOCATION: I' - RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)`1/ TO SCENE S.O. CALL RECEIVED _T 1 •`� ` �a�ttitP ❑ P.D. _ TIME 1D-8 j PATIENT DESTINATION: FROM SCENE- 2 ❑ FIRE __ TIME 10-97 RR } _ PSAP TIME 10-49 �� 1Js 13 MILEAGE: ❑ OTHER/PVT TIME 10-7 ' END TIME 10-98 PMD TIME 10.22DOCTOR HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 13PATIENT 13 DIRECT 13 OTHER I ! CALL BACK a AM$U E�OMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1 RESPONSE ZONE YES O NO O WALKED kGUERNEY ❑ OTHER — r� 1PATIENT CONDITION: DRIVER V �' ` `� T-1A r 7,— TECHNICIAN r�H1_ ' PARAMEDIC Hxl 't / DISPATCHER: CHI E OMPLAINT: DRY RUN: ❑ YES A NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X fL•Lv MEDICAL COVERAGE: IND TRIAL O YESN4 NO NO. OF PATIENTS: S.S. R �2 - �i� - Q r -5 PRIVATE INS. CO.: BASE RATE: I ' d o.61) ,1 KAISER K: MULTIPLE PTS. BASE RATE LUE CROSS N: A TOTAL MILES: X A R �_ . - - -/7 S E.O.B. ATT. ROUND TRIP: O YES D NO r ❑ YES ONO NIGHT: (19:00-07:00) EMERGENCY RUN: CODE 2/3 l 11 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 C� J DRUGS: (PER ADMIN.) X NAME: nj e-Ed >%�Hf�e RELATIONSHIP:so" 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) CI EMPLOYER: ^=1 OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: a sy o0 ' ------..--_--- --- -.. TOTAL. ------- --- PATIENT RECEIVED BY X � .y` Lr1� l Ynui•lor nr.r.'. Nir r. ..n! I i•i q-1 — l`•!NATU I V 'l.1' ur . 7 CONTRA COSTA COUNTY AMBULANCE Q �/ r✓1 PRE-HOSPITAL CARE FORM I UNIT (� AUTHORIZATION N •t„ I F.T I CHECK OII MLL IN APPROil11A7E SPACES DATE: , �•-��� 2 PATIENT S NAME ❑ m"❑ F COMPANY N ADDRESS AGE 1 CITY -STATE ZIP DOB ❑ Sn ❑ M T ❑W ❑ Th ❑ F S DRIVER'S LICENSE N C I PHONE NATURE OF DISPATCH TYPE OFTRANSPORT`jAMBULANCE OTHER 0 _ STATION 11A) B)_3(C)_4(D)_5(E)_ INCIDENT.LOCATION 1<�, fIJ RESPONSE CODE: I R UESTED BY: TIME-(24 HOUR CLACK) / TO SCENE- 0. CALL RECEIVED `y i `,� � � 10 �• C tel'. . ' i P.D. TIME 10-8 ~/ PATIENT DESTINATION: - FROM SCENE- ❑ FIRE TIME 10-97 > : C) G ❑ PSAP TIME 10-49 MILEAsk. ❑ OTHER/PVT TIME 10.7 ✓ END TIME 14-98 � ,! G DOCTOR'.l1�' PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME Z71 ❑ NEAREST,-.: ❑ FAMII Y ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE i ❑.YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER �•t r PATIENT CONDITION: DRIVER'-' w-Tc an EMT-tA TECHNICIAN M CKICE na-7 5 t ,PARAMEDIC Hx: DISPATCHER: ,[; Q l C P �7 {yC� CHIEF COMPLAINT: DRY RUN: kYES ❑ NO REASON FOR DRY RUN ^�^ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL 11YES ClNO NO. OF PATIENTS: 14' '. I S.S. K a PRIVATE INS.CO.: BASE RATE: KAISER N: 1 MULTIPLE PTS.BASE RATE BLUE CROSS M: ` TOTAL MILES: X MEDICARE#:' E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑,YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:" EMERGENCY RUN: MEDI-CAL 0: 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: TOTALM PATIENT RECEIVED BY: X , 701 �i^.rtn �mcg r•i�; 1• CONTRA COSTA COUNTY AMBULANCE Q 3 11 PRE-HOSPITAL CARE FORM I UNIT Dei 1 AUTHORIZATION M ( � J CNECR OR FILL IN APPROPRIATE SPACES \ - DATE: PATIENTS NAME ❑ M ❑ F COMPANY M - ADDRESS AGE— CITY GE CITY STATE ZIP— DOB_ _ ❑ Sn ❑ M ❑ T ❑ W O Th O FS DRIVER'S LICENSE M ___ _ __..__.__.._._.._..___--- PHONE_- _____.-_-___.__ NATURE OF DISPATCH— 1 I TYPE OF TRANSPORT: AMBULANCE CI OTHER❑ ___- _ STATION 1(A)_2(8I_31C1_4(D)_51E)_ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) rYtA; / TO SCENE- S.O. _OCC_ CALL RECEIVED nL' : % v 1 w / lv %2-c-- Q/L c►�/� _ P.D._ TIME 10-8 _ , y PATIE T DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 J� ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 :—� DOCTOR PMD/ER START TIME 10 22 C C• -3� HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: , PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �y� RESPONSE ZONE�� ❑ YES ❑ NO ❑ WAL!CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: j DRIVER_ EMT-1A TECHNICIAN '�L7Lcir� 5 1��PARAMEDIC Hx: / DISPATCHER: �_i• -t< li) '� CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUN 12L k"(-� 1140""' AUTHORIZRION FOR DRY RUN(EMS USE ONLY) i PATIENT REFUSED SirR ES. SIGNATURE) X— j MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO, OF PATIENTS: S.S. a } PRIVATE INS. CO.: BASE RATE: KAISER>r: - MULTIPLE PTS. BASE RATE BLUE CROSS k: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES 0 NO NIGHT: (19:00-07:00) CCHP/PPRP K: EMERGENCY RUN: MEDT-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) 1 DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:. OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -- -- — --- - TOTAL:-� _ — --- - PATIENTS NAME: Lisa Kay Eldred AKA: Amy Lee Mayes ADDRESS: No Address DATE OF SERVICE: 08-13-83 AUTHORIZATION NUMBER:83-13538 AMOUNT DUE: $235.00 INCIDENT LOCATION: Port & Wanda, Crockett PATIENT DESTINATION: Contra Costa County Hospital s ;.rr:' ` � . ,. i :' < * d� t r. 1 �.B �r. Jb£: 'fir � �♦�;� �rti,�. �a �`�!?�. '1126'740 I Auc 13 3 4? AH '83 Auc 13 3 44 AN 13 Auc 13 3 46 AN '83 SO NUMBER d -�S GFX CALL RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 108 CALLED BY- PATIENT INFORMATION N D o NAME: 3m AGENCY: = L' _- CUSTOMER p(PT. 1): DOB: ItITttE4 crz c Z f7 U DEPT/FLOORjROOM N: I NAME: _ z a W CALLBACK N^ __ INS. TYPE: PVT MCA M�Ct l KHP PHP VA IND CHAMPUS U INCIDENT LOC: �L�. _ _ /�/��-� POLICY/MCAL 4: m MCAR#: _ m } to CROSS STREET: _ VERBAL PRIOR � : Q JURIS: City: —�//��Q - DOCTOR: &1-?-f v •� -- ----- DESTINATION: PT. a2 NAME: DOB: clop NATURE: .. ___-. CUST. p w --- -"-------- o0 _�-- ---- - ---"-- c PT. #3 NAME: DOB: o ... Z d TYPE Of CAL . TRANS TIME UNIT p - CUST. N m a� CREW: _ - I WAIT TIME: YES NO REASON: Z Gp I� O UNIT TYPE: ALSBl WC RESPONSE E: 0 1 (9 3 4I REASON FOR 10-22: A g w INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 3 4 CANCELLED BY: m BY: END MILEAGE: _ -7, COMMENTS: ` � 'r' p z !^ TIME: BEG MILEAGE: Q�`� /►vCa/�'�f �-r 1-� m DISPATCHER: ' ? V Q --- ^�✓ / - _ TOTAL MILES: XL-01 NOIIVIS IV 3:)NVlT18wv 61.01 ONIN11T113b 3:)Nv1T18wv 86"01 319V11VAV 3:)Nv1118wv L-01 1v11dSOH 1V 3:)Nvinowv a E8, q 9s b £I onn E8, Nn 6E 9na w-::..gal a;L. .x:;11;=.�• Ttp :;•. y t V •�w�, r 3 �, -„�llt� qT r� OT di tii 1 t KJ� a r�,,tti''j�', a �L7. r rip 04 d4t•t :r� i •�' '�: T '.{s} 5 Wit, ,,...' •.i ' `.-�!`. `.7►=�• � ?Ir `d*�+7!'tie3�x �y '•j;, - .• +,. .i•4e '•^vh.. . ,'i X i � ifs, j r-i i '�ha� •}���A�-�.� �1 �,�,, � . 4. ' ti - ,.�`�j• 't ��•� •/n'.MF�u.��•'Hl{t�4�`�T4 �yVf•G.K..'�Lf• . TT:� � u 00-7 0 1 CONTRA COSTA COUNTY AMBULANCE Na j 1� PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME I(Z l I S i�Y��C-g �(M ❑ ,F� COMPANY N ADDRESS 7-) -I 1�1I'l /1 l , AGE �a CITY J� lz �/'YY��STATE� ZIP `I L,Q) DOB_L�a 5cI O Sn ❑ M OT OW O Th OF �1S DRIVER'S LICENSE M ______ _ _ PHON&�:% 5ICAt_0 -NATURE OF DISPATCH Q WL&J TYPE OF TRANSPORT: AMBULANCr THER O __ __- -- STATION l W_L1fB)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: ;QUESTED BY: TIME- (24 HOUR COCK) S.O. CALL RECEIVED L. P.D.- TIME 10-8 tTY : PATIENT DESTINATION: /• FIRE TIME 10-97 PSAP TIME 10 49 0 OTHER/PVT TIME 10-7 �S �/ TIME 10-98 1; t DOCTOR KI V G S F TIME 10-22 HOW CHOSEN: STANDBY TIME '94SEAREST O FAMILY O TR,...,.. WAIT TIME 6 �. PATIENT ❑ DIRECT ❑ OTHER j CALL BACK N: AMBULANCE COlu1P�NY: ��11 ,S _ TEA PATIENT TAKEN TO AMBULANCE: _5 U RESPONSE ZONE ES 11 NO ❑ WAL'CED W,�SUERNEY O OTHERZ ; PATIENT CONDITION: DRIVER c.) 7,3 EMT-11A TECHNICIAN 0 ZZ �~ PARAMEDIC HJ4T tj 4 V cc j I DISPATCHER: V G(71-1' CHIEFCOMPLAINT: f'�) 1 DRY RUN: ❑ YES 4610 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ MEDICAL COVERAGE: INDUSTRIAL ❑ YES' NO NO.OF PATIENTS: C� I PRIVATE INS. CO.: BASE RATE: �{ KAISER R: MULTIPLE PTS. BASE RATE l BLUE CROSS M: TOTAL MILES: X ' MEDICARE C E.O.B. ATT. ROUND TRIP: OYES ❑ NO 1 �/ - _ O YES ❑ NO NIGHT: (19:00-07:00) P/PPH R:j 7 ) �1� ' EMERGENCY RUN: M DI-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:�J2T)%- Oki-, S RELATIONSHIP. ou r E.O.A.: (IF NOT REPLACED) ADDRESS: a u C -SORAL AIRWAY: (IF NOT REPLACED) CITY:�� STATE CA ZI 01 C-COLLAR: (IF NOT REPLACED) PHONE: �' C� �� WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: Tru TOTAL: O ( 1 ._ PATIENT RECEIVED BY:X_ � Provider retain. Lthitr ,.rd Pin; ,� � icl;.r+� Yn'I.�c -np: � � n� (SIGNATUHEI EMS-1 •' P. t chrn Dil`ina } ONT A COSTA COUNTY AMBULANCE v '.PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION H ,3 S ro OA RLL IN APPROPRIA E SPACES DATE: — 5 1JAME �►y�k. Q,ao F UT)1 O M F COMPANY III /- Q , � } MEnSS .,.�QCJ O VIeL.I)�n _ AGE _ O} ITY /�i CHr'1�3Y�1 p STATEL ZIP DOBL�� ✓ �.,l�I ❑ Sn ❑ M ❑ T ❑ W ❑ Th ❑ F tS DRIVER'S LICENSE N-_ PHONE NATURE OF DISPATCH S023 TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ __ _ _.—____ STATION 1(A),2(8),3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: EOUES TED BY: TIME— (24 HOUR(;LK) . 5� 1D08 t�) TO SCENE- S.O. CALL RECEIVED �vA7 V �� �! ,j ❑ P.D. TIME 10-8 t; PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 14.97 �! ❑ PSAP TIME 10-49 i MILEAGE: ❑ OTHER/PVT TIME 10.7 y Q'Sr. TIME 10-98 END �.DOCTOR I)I PM ED START TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER 1 CALL BACK K: AMBULANCE COMPANY: E . AMBULATORY? PATIENT TAKEN TO AMBULANCE: !,', RESPONSE ZONE YES O NO ❑ WALKED GUERNEY ❑ OTHER �y PATIENT CONDITION: DRIVER—S 1 EMT-tA I TECHNICIAN j .2— PARAMEDIC Hx: CA bu-%- 11► r.��Q ZC.fY �5t" DISPATCHER: r� CHIEF COMPLAINT: DRY RUN: ❑ YES )�(NO REASON FOR DRY RUN I�OAUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X, C'v MEDICAL COVERAGE: INDUSTRIAL ❑ YESXNO NO. OF PATIENTS: S.S. N I PRIVATE INS. CO.: BASE RATE: =/� KAISER x: MULTIPLE PTS. BASE RATE BLUE CROSSN: TOTAL MILES: X '9 —, MEDICARE II: f73 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) L L, j CCHP/PPRPC EMERGENCY RUN: -A MEDI-CAL M: �� c� "['�, ��r.3 G' 3 CODE 2/3 J OTHER: . OXYGEN: (PER TANK) 1 J P,O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEARES/T�RELATIVE/RESlPONSIBLE PARTY: I.V.: (PER ADMIN.) X l C'kA {/.X�( 154-Y In ' L� : zJ (IDA) DRUGS: (PER ADMIN.) X - NAME �hOLt RELATIONSHIP: SO E.O.A.: (IF NOT REPLACED) ADDRESS: SCLAI-r— Cl, _412,WW ORAL AIRWAY: (IF NOT REPLACED) i CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) - EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: — COMMENTS: 1C?D / �KCLL;�� (if iQuR_- TOTAL' I U706 n III 1 III (l Ivl 1 I4� x� I . 1 �Y__.... n IJ ' I � V CONTRA COSTA COUNTY AMBULANCE Z / PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION# ' "�ly � CHECK OR ML IN APPROPRIATE SPACES GATE: �", f PATIENT'S NAME1 ❑ M ❑ F COMPANY p / ADDRESS r- I AGE r n t),�1.' CITY STATE- - =R ZIP T_ DOB ❑ Sn OM ❑T OW O Th OF OS DRIVER"S LICENSE N I PHONE NATURE OF DISPATCH /6 S'l TYPE OF.TRANSPORT: AMBULANCE 0 OTHER❑ -- STATION 1{A)_2(B)_3iC)_4i0l_5(E)` t INCIDENT LOCATION: RE50614SE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) 4 r� 7 x / � �..r TO SCENE- © S.O. CALL RECEIVED �E ; [Zp{ ✓ . G ❑ P.D. TIME 10••8 PATIiNT DESTINATION:-- FROM SCEN)nr D FIRE TIME 10-97 - 1 ❑ PSAP TIME 10-49 I- � l MILEAGE: ❑ OTHER/PVT TIME 10-7 ► `' :r. :l.,r j. ( •f END TIME 10-98 OCTOR I , PMD/ER START TIME 10-22 HOW CHOSEN: ( TOTAL STANDBY TIME -b E r..2,❑ NEAREST ,' ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT D OTHER CALL BACK 0: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE f. t 13 YESONO ❑ WALKED ❑ GUERNEY O OTHER PATIENT CONDITION:i DRIVER Pli'JO-A/ EMT-1A - ? - TECHNICIAN r PARAMEDIC Hx: — ,..S; , DISPATCHER: i rq� CHIEF COMPLAINT: { DRY RUN: YES ❑ N EASON FOR DRY RUN 1Q Ste` "( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) I 1 ! PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: - INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: KAISER x; ' MULTIPLE PTS.BASE RATE BLUE CROSS k: I TOTAL MILES: X MEDICARE M:' E.O.B..ATT. ROUND TRIP, D YES ❑ NO "t O YES O NO NIGHT:(19:00-07:00) CCHP/PPRP N: _ r i`, EMERGENCY RUN: 1 MEDI-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) G-1 ~`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 w ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK HONE: vv DRY RUN: (AUTHORIZED) a�fG__ f EMPLOYER: OCC PATION: OTHER: ADDRESS: CITY: STA : ZIP: 770, If COMMENTS: aos , CONTRA COSTA COUNTY AMBULANCE ¢ PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION CHECK OR fill IN APPROPRIATE SPACES DATE: t3 —�s3 t PATIENTS NAME a 9 O tvF,O F COMPANY R ` 4 ADDRESS 's + AGE p r CITY_ STATE. ZIP DOq _ O Sn O M O T O W O Th O F ? , j DRIVER'S LICENSER 1 PHONE �T NATURE.OF DISPATCH O�"�N TYPE OF TRANSPORT:,AMBULANCE OTHER O _ STATION 1(A)!2(B)_3(C) 4(D)_5(E)...._ j INCIDENT LOCATION:' _ RESPONSE CODE: ; REO TED BY: TIME— (24 HOUR CLOCK) ���� ^ �V�T O�t n QCs TO SCENE ❑ P.D. TIME 0-8 RECEIVEDtbS.0. CALL PATIENT DE �INATION:r..... FROM SCENE • D FIRE TIME 10.97 �,-A— :0-T D PSAP .TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 "1 { .[=TOR 11 -2``-' ( � � PMD/ERS START TIME 10-22 HOW CHOSEN: TOTAL. STANDBY TIME O NEAREST,,� O FAMIL� O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK R: AMBULANCE 4M A�Y:,Z ' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONS 1 j O YES O NO D WALKED O GUERNEY D OTHER PATIENT CONDITION; — } DRIVE SS`�� �'S MT 11 TECHNICIAN � �l`� t^d PARAMEDIC Hx: DISPATCHER: jL - ((�� CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUd AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X t .., MEDICAL COVERAGE, _ INDUSTRIAL O YES O NO NO.OF PATIENTS: !_/ .t .S.S.R LI .._` 1 } PRIVATE INS.CO.: BASE RATE:— ' KAISER R� MULTIPLE PTS. BASE RATE BLUE CROSS R: ' " ` a TOTAL MILES: X' �i. MEDICARE R;' I E.O.B.ATT. ROUND TRIP: O YES ❑ NO ❑ YES O'NO NIGHT: (19:00-07:00) CCHP/PPHP R:' f EMERGENCY RUN: MEDT-CAL 0: " CODE 2/3 ` OTHER: t OXYGEN: (PER.TANK) n.l'. 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 a ' DRUGS: (PER ADMIN.) X "'NAME-- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) "'-CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) ++` PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) :`_z EMPLOYER: OCCUPATION: •OTHER: ADDRESS: ,""CITY: STATE: ZIP:- -COMMENTS: IP:--COMMENTS: r } PATIFNT n! rn ny v CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I UNIT AUTHORI TION NT 3 / 3 6`S MM OR FILL IN APPROPRIATE SPACES DATE: 4ATIENTS NA -1 ❑ M O F COMPANY N ADDRESS - AGES n (J CITY S ATEZIP DOB - 11S� 13M ❑T O W 13Th 13F S " I .DRIVER'S LICENSE M f PHONE _� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEF OTHER❑ STATION 1(A)_2(8)_31C1_4(D)_5(E)_ I , INCIDENT LOCATION- RESPONSE CODE! REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE S.O. CALL RECEIVED G s �-� ❑ P.D. TIME 10-8 PATIENT DESTINATION:....- _' FROM SCENE- ❑ FIRE TIME 10-97 �l ❑ PSAP TIME 10.49 i MILEAGE: ❑ OTHER/PVT TIME 10-7 ' r�•, END TIME 10-98 }.•- ,; DOCTOR�'� TL' ' v~_ t PMD/ER START � TIME 10-22 a HOW CHOSEN: _ TOTAL STANDBY TIME ❑ NEAREST-.-i O FAMILY O TRANSFER WAIT TIME ❑ PATIENT J 13-DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: 1 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO. . ❑ WALKED O GUERNEY ❑ OTHER PATIENT CONDITION:--' - DRIVER S 3 ^��� � EMT•1A� d` •�°gr�� '' 1 i __. } TECHNICIAN �L.S_L� PARAMEDIC ' �f Hx., DISPATCHER: + 47 NA�i CHIEF COMPLAINT: DRY RUN:,YES ONO REASON FOR DRY RUN LIZ XODQ7G_ e AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X - :`:+ MEDICAL COVERAGE:_- _ INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: } S.S.N i PRIVATE INS.CO.: BASE RATE: KAISER N: ` I MULTIPLE PTS. BASE RATE BLUE CROSS N: L TOTAL MILES: X _ .�, MEDICARE E.O.B. ATT. ROUND TRIP: O YES 13 NO O YES -❑ NO NIGHT: (19:00-07:00) CCHP/PPHPN: EMERGENCY RUN: MEDI-CAL N: r '1 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: z' CITY: STATE: ZIP: COMMENTS: TOTAL: _ � 0 0 r'y 0 9 PATIENT RECEIVED BY: X. _ .......:... .. ... .... . ISIONA i lliri CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N r 3 / 1 6.'7 y I . ; I j ,,r; -I .. EL I 1 CHECK OR/ILL IN APPROPRIATE SPACES DATE: 5( I'1 - y 1 PAYIENTS NAME � ❑ M' ❑ F COMPANY N � ••• ADDRESS,-,--- .Iit AGE ' V AJ '..CITY STATE ZIP DOB ❑ Sn OM OT ❑W 13Th 13F . �— `:: DRIVER'S LICENSE N; PHONE - NATURE OF DISPATCH I:e,)c 1'I^-I in wv(=(J r . !_ TYPE OFTRANSPORT:� AMBULANCE-0 OTHER _ -- STATION 1(A)_218)_31C1_4(D)_51E1� f INCIDENTPI,OCATION 1 5::' RESPONSE CODE: ROIJESTED BY: TIME— (24 HOUR CLOCK) �- - - - TO SCENE S.O. CALL RECEIVED _ '3 1 ::J !y .• f W O P.D. TIME 10-8 .AT NT DESTINATION-. ; FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 . '� I M f 1 MILEAGE: 1 ❑ OTHER/PVT TIME 10-7 . .• a �' END TIME 10.98 r � OC10R 1'"""� �' PMD%AA' START ' ' I TIME 1D-22 �{; _- °,::HOW CHOSEN: _ v TOTAL STANDBY TIME i . ,❑ NEAREST-p, D FAMILY ❑ TRANSFER ' WAIT TIME _— ❑ PATIENT D DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: �f PT. AMBULATORY? ' PATIENT TAKEN TO AMBULANCE: CG' V RESPONSE ZONE ❑ YES. ❑ NO D WALKED ❑ GUERNEY ❑ OTHER.,' - ` PATIENT CONDITION: - .1 DRIVER (�LI� C'K �j� �? _EMT-1A aV+ gA, TECHNICIAN PARAMEDIC Hx: -- DISPATCHER: - �i„ ;CHIEF COMPLAINT: I _ DRY RUN: YES ❑ NO REASON FOR DRY RUN 10-2 �.O t AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 91--9.o,.lL_ 1j..'PATIENT REFUSED SERVICES: (SIGNATURE) X� I MEDICAL COVERAGE-__. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: 5.?.�S.S. - r •: PRIVATE INS.CO.: BASE RATE,—; KAISER 0: MULTIPLE PTS. BASE RATE BLUE CROSS N: r " 1 `` ' TOTAL MILES: ° - 'X + MEDICARE N I E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO , O YES 13 40 KNIGHT: (19:00.07:00) ; CCHe/PPRP C. ; EMERGENCY RUN: MEDI-CAL N: ! ' ' ' "j'•1 CODE 2 , ;...t�.< OTHER:" OXYGENS (PER TANK) ;1 P.O.E. STICKER D YES O NO `' NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) " E.K.G.: (PER EPISODE) t'L!'"'NEAREST-RELATIVE/RESPONSIBLE PARTY:-- I.V.! LPER ADMIN.) X -� DRUGS: (PER ADMIN.) X NAMEr- RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) STATE_- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE- DRY RUN: (AUTHORIZED) +^+ -EMPLOYER: - ••- -OCCUPATION: OTHER:. ... 4 L , ;ADDRESS: "'.CITY: - STATE: ZIP: —COMMENTS:- i - TOTAL: PATIENT RECEIVED BY: X (SIGNATUREI r ►M5-1 CONTRA COSTA COUNTY '' AMBULANCE PRE-HOSPITAL CARE FORM I 1 UNIT �.� AUTHORIZATION N •'^+ CNECR OR FILL IN APPROPRIATE SPACES DATE: I ATIENTS'NAME ' ' r ❑'M ❑ F COMPANY# l n i ADDRESS (� �� fC G4 j< 1- AGE — ' CITY STATE ZIP DOB - 0 Sn 0 M O T 0 W O Th. O F f - DRIVER-9 LICENSE N f PHONE NATURE OF DISPATCH 72! TYPE�O((//FF�TRANSPORT: AMBULANCE 0 OTHER rr❑ — STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ lNCIDh OC�ON l `) W ,{/ RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) � '` ' ' L .. f TO SCENE- _ S.O. CALL RECEIVED �L Z 26 1 J l0 P.U. TIME 10-8 17 PATIENT•DE TINAT N: --� FROM SCENE 0 FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: 0 OTHER/PVT TIME 10.7 END TIME 10-98 frDOCTOR A T: PMD/ER ' STAR _2 -7 T TIME 10-22 LL G `l r HOW CHOSEN: L ... TOTAL STANDBY TIME 13 NEAREST 0 FAMILY ❑ TRANSFER WAIT TIME ` ❑ PATIENT r 0 DIRECT ❑ OTHER CALL BACK#: AMBULANC COMP NY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE `1 0 YES ❑ NO 0 WALKED 0 GUERNEY O OTHER PATIENT CONDITION:,- _. DRIVERMT-1A 7 �vT 1 f)l; , I a ! :•.' TECHNICIAN '13 1) PARAMEDIC , Hx: DISPATCHER: 8S Q 60 qo J_ CHIEF COMPLAINT: DRY RUN: YES 0 NO REASON FOR DRY RUN Z-z- O l'J AUTHORIZATION FOR DRY RUN(EMS USE ONLY) tY�—[as (0—� yyy q,l (ij ),PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: I (� S.S.# I t PRIVATE INS. CO.: BASE RATE: KAISER MULTIPLE PTS.BASE RATE BLUE CROSS#: t TOTAL MILES: X MEDICARE N ) I E.O.B.ATT. ROUND TRIP:- O YES 0 NO 0 YES O NO NIGHT: (19:00-07:00) CCHP/PPRP#: ! _ EMERGENCY RUN: MEDT-CAL#: J ' CODE 2 13 OTHER: OXYGEN:,(PER TANK) C-�l P.O.E. STICKER ❑ Y O 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: STATEZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WOR PHONE: DRY RUN: '(AUTHORIZED) ..EMPLOYER: OC UPATION: OTHER: ADDRESS: _CITY: STATE- ZIP. COMMENTS: TOTAL: 1 I PATIENT RECEIVED BY: X • —. Provider retaf. Whit. .rd hf,L ,•.. hatum rv•I„ , (SIGNATURE) r,r �, .,L: � �,. •.•tip., �;r ,,,, [hs-I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION# 22— 6-45 . __. CHECK OR FILL INrtAP`PAOPRIAIE SPACES „�. DATE: PATIENT'S NAME_. LL�.1l C.L.t (P I ��. M ❑ F COMPANY# ADDRESS -tt -�-- 5.__'.. ��,� ►�� AGED_' ' CITY_ L'i, _ STATE ' ( r ZIP _ DOBE ❑ Sn O M OT W O Th O F S` DRIVER'S LICENSE# —� PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEQ OTHER❑ __ — STATION 1(A)_2(8)_3(C)_4(D)-5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) .]] DD I TO SCENE V S.O. CALL RECEIVED J I ` O P.D. TIME 10-8 . PATIENT DESTINATION: FROM SCENE- ❑ FIRE _ TIME 10-97 y�t �`, ��.� Z ❑ PSAP -TIME 10-49 • '. - _ �. MILEAGE: ( ❑ OTHER/PVT TIME 10.7 a�L c END_J_f -) TIME 10-98 "- ) DOCTOR PMq EF START- 3 TIME 10-22 HOW CHOSEN: l/ TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER 1 I WAIT TIME �. PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: _ RESPONSE ZON YES �❑ NO 11WALKED *GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER c`p EMT-1A t - -- v1 ` TECHNICIANiUm ARAMEDIC Hx: n DISPATCHER: j CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (�� ( PATIENT REFUSED SERVICES: (SIGNATURE) X 7It / MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. # .. 1 PRIVATE INS. CO.: BASE RATE: MO KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: �1 X SP�� •:�S¢i.s�-• r l MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO , • Q� 1 ❑ YES .❑ NO NIGHT: (19:00-07:00) 30 CCHP/PPRP#: EMERGENCY RUN: I rMEDI-CAL#__;� CODF( 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.: (PEA ADMIN.) X (� _ 1 -,tN{� ';`, DRUGS: (PER ADMIN.) X NAME: , `h 1 p t�P.\1 ` RELATIONSHIP. E.O.A.: (IF NOT REPLACED) - -- ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN:. (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: i CITY: STATE: ZIP! - COMMENTS:— AS TOTAL: l( G•GU - �• . PATIENT RECEIVED BY:X C �T L Provider reta:r Vhite ,J.� T�'r. cJrf 5etur+ Ye':"•� May f• jW..F when hi I,ing (SIGNATURE) DIS-T CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0 4 3 CHECK OR fill INAPPROPRIATE SPACES DATE: :a- -:62 t t PATIENT'S NAME"' 6 It-4n,w►� ' O M ❑ F COMPANY N ADDRESS 1 ! AGE CITY .STATE ZIP -___ DOB - ISSn OMOTOW O Th OF OS DRIVER'S LICENSE N ' I PHONE —_ NATURE OF DISPATCH 1 '-7 9 - TYPE OF TRANSPORT:, AMBULANCE D OTHER❑ — -- STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:, ; RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR OCK) j TO SCENE- `8 S.O. CALL RECEIVED ��Ys��- a-��i "ti - ❑ P.D. PTIME 10-8❑ FIRE TIME 10-97 1 PATIENT DESTINATION: FROM SCENE.._) ❑ PSAP TIME 10-49 �'�� -' G'I'= MILEAGE: ❑ OTHER/PVT TIME 104 t END TIME 10-98 f?.DOCTOR"' --a^ I PMD/ER START t TIME 10-22 L� HOW CHOSEN: - TOTAL STANDBY TIME ❑ NEARESV ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT O DIRECT O OTHER CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY9 PATIENT TAKEN TO BU LANCE: (� RESPONSE ZONE ❑ YES NO O WALKED ❑ G RNEY ❑ OTHER �'V• 93:' PATIENT CONDITION: -, DRIVER /t G,d,-' /� L EMT-1A TECHNICIAN c-0 PARAMEDIC � j DISPATCHER: k 5aYDSQ( CHIEF COMPLAINT: DRY RUN:,tQ YES ❑ REASON FOR DRY RUN /t-"4.,!!-- ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) qq a .< ",;,;,PATIENT REFUSED SERVICES: (SIGNATURE) X I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.M / . r 1 PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS/ADMIN.) x BASE RATE BLUE CROSS N: ' TOTAL MIX MEDICARE R� E.O.B. ATT. ROUND TRO YES ❑ NO O YES "O NO NIGHT: (1907.00) CCHP/PPRP K: 1 EMERGENUN: MEDI-CAL M: ( (" COD3 OTHER: OXYGEN: TANK) P.O.E.STICKER 13 YES ❑ NO NEONATACUBATOR) DATES BILLED: STANDBY: ER 15 MIN.) E.K.G.: (PISODE) NEAREST RELATIVE/RESP NSIBLE PARTY: - I.V.: (.PER IN.) XDRUGS: ( DM .) XNAME: RELATIONSHIP: E.O.A.: (IF PLACED)ADDRESS: ORAL AIR (IF NOT REPLACED)CITY: STATE_ ZIP: C-COLLARNOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) •EMPLOYE OCCUPATION: OTHER: ADDRESS: ' - CITY: STATE" ZIP: COMMENTS: - TOTAL: PATIENT RECEIVED BY:X _ Pnmider rvta(. ��:lr„ I •... ,... ,. .(SIGNATURE) CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I '� UNIT lEtjAUTHORIZATION 3 CHECK OR FILL IN APPROPRIATE SPACES DATE: � (� I PATIENT'S NAME OM OF COMPANY N / JQ ADDRESS AGE1 / CITY STATE______..r._.ZIP DOBSn OM OT ❑ W ❑ Th ❑ F ❑S s DRIVER'S`LICENSt N t-- PHONE _ NAT RE OF DISPATCH I S k� HED TYPE OF TRANSPORT:, AMBULANCE O OTHER O _ STATION 1(A)-2(B)_3(C)_4(D)_5(E)_ INCIDENT:J.00ATION: RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) C`n O I n GA- , ` C-' -- L� I TO SCENE- -S.O. CALL RECEIVED I 33 " V." M Ic/'1 W`(� o r ',Q(� y T_ O P.D. TIME 10-8 PATIENT DESTIN TION: -- - - c��l� 1 FROM SCENE - ❑ FIRE TIME 10-97 - T� [� n ❑ PSAP TIME 10.49 L MILEAGE: ❑ OTHER/PVT TIME 10-7 I END-, : TIME 10.98 F.DOCTOAi .11V_ ! _ ` PMDIER START TIME 10-22 Z� HOW CHOSEN: �__� TOTAL. STANDBY TIME 2-x,.,10 NEAREST 0 FAMILY ❑ TRANSFER WAIT TIME —_ O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES, 0 NO 0 WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: '- DRIVER EMT-1A NIT aJ I I TECHNICIAN iC)Cl PARAMEDIC qqqHx: _ DISPATCHER: on I CHIEF COMPLAINT: DRY RUN: ES` NO REASON FOR DRY RUN QlqAUTHORIZATION FOR DRY RUN(EMS USE ONLY) SC PATIENT REFUSED SERVICES: (SIGNATURE) X r , MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. C rI BASE RATE: KAISER K'. MULTIPLE PTS. BASE RATE BLUE CROSS C. ' ` TOTAL MILES: X MEDICARE N:' If:.O:B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES �0.NO NIGHT: (19:00-07:00) CCHP/PPRP N:'' EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: L I OXYGEN: (PER TANK) P.O.E. STICKER 0 YES 0 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 ��7 TOTAL: =5� 1`1 ~ __ PATIENT RECEIVED BY: X i3110 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Zv AUTHORIZATION v l,I CHECK OR FILL IN APPROPRIA7E SPACES DATE: ..�jl ly_'3 PATIENT'S NAME—A'klyP_J..' j.�/_._.. __ 7 F COMPANY a _.�..... ADDRESS ._6 5 1 .... -- ST ----- --- - AGE CITY-s2,%CHM 0,0 STATE- __ ZIP 540I ___ __ DOB9-kjj�/& IS Sn ❑ M O T ❑ W O Th ❑ F ❑ S DRIVER'S LICENSE K ..(V..IA.. PHONE 23:600 NATURE OF DISPATCH _._ S t-)U Vr cam__. TYPE OF TRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION. RESPONSE CODE. REOUF.SFED BY TIME - (24 HOUR CLOCK) TO SCENE - Z ❑ S O. .___.._ ._ CALL RECEIVED ❑ P U. - --- TIME 10-8 PATIENT DESTINATION FROM SCENE - •� ❑ FIRE __.___. TIME 10-97 ❑ PSAP TIME 10-49 _ MILEAGE. fg-OTHER P(2) TIME 10-7 T_ /, END �U 'v C_ .rai��..— TIME 10-98 DOCTOR _.--. ___ PMDI START— TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER _— -- WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER ) CALL BACK a: AMBULANCE COMPANY: ea5 PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE 2- YES YES ❑ NO ❑ WAL';ED GUERNEY ❑ OTHER 1 PATIENT CONDITION. _ DRIVER___-��� 41 5=/�—/_—�._-- EMT-IA�,� N `SEC F,-/),i TECHNICIAN __ � `�'`- —___ PARAMEDIC �. Nx: ?rrV 1111AS_1 5- -- - _ _. - -- L DISPATCHER: - k CHIEF COMPLAINT: T�ht'_ T.(t.1/.L-z�_1a.��1-�= DRY RUN. ❑ YES Q NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLYI ' lL� PATIENT REFUSED SERVICES (SIGNATURE) X MEDICAL COVERAGE NDUSTRIAL ❑ YES I$NO NO. OF PATIENTS: h PRIVATE INS. CO.:— S`�2 -z BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE / BLUE CROSS a: ,_ TOTAL MILES:. +l X % -y' 7`' -J MEDICARE a: E.0 B. ATT. ROUND TRIP: 11 YES NO 40�r ❑ YES ❑ NO NIGHT: (1900- 07:00) CCHP/PPRP a: EMERGENCY RUN: MEDI-CAL a: CODE.5'3 .�OTHERf__ _ 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: _1 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: AODRES$:� - CITY �— STATE: ZIP:— 1f� C —�MMES -�-�Q-��" Yl A�,TV -Q '-IQ '� , I K11LNT HL( EIVF t) !SV X ' / 0ej 7� 5 ...—_ - --- F'r.m .!r�rrt�r•: w9;••, .• 1 I •. t I. 1.. ISI InE Lr. 1 CONTRA COSTA COUNTY AMBULANCE 5 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 3 A•' CHECK OR FILL INAPPROPRIATE IA��TTEE SPACES DATE: PATIENTS N1AAME��� _3H tt`IJ� �. �t� ❑ M F COMPANY ADDRESS AGE.(lt1__ CITY/.',CA,- STATE L44 ZIP - DOB—__ Sn ❑ M ❑ T ,❑/W ❑ Th OF Os DRIVER'S LICENSE N _ _ PHONE t .'??1� NATURE OF DISPATCH �V c TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ _- _..___ STAT10 1(A) 0_31C14(D)-5(E)- INCIDENT LOCATION: �? c f RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ,I TO SCENE- " S.O. CALL RECEIVED / / /I �•!®oP.U. TIME 10-8 L— v PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �L O PSAP TIME 10.49 MIL GE: O OTHER/PVT TIME 10-7 1 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 i ✓ HOW CHOSEN: TOTAL STANDBY TIME !: O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _- O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCCECQMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: >' RESPONSE ZONE O YES ONO ❑ WALKED ❑ GUERNEY ❑ OTHER .,r1 PATIENT CONDITION: DRIVER.-M.`' I_ ( EMT-IA t ` TECHNICIAN_ �J�, A r�I-,C-,C �' L PARAME I ( Hx: 1LV (h-cx(Oh5 Co/I/1(!.��I DISPATCHE �c ( C.( •ilIC't ., - -- - CHIEF COMPLAINT: D �`� DRY RUN: YE ❑ NO REASON FOR DRY RUN 9, AUTHORIZ N FOR DRY RUN(EMS USE N}Y) PATIENT REFUSED SERVICES: (SIGNATURE) X •/( c o I. , MEDICAL COVERAGE:�^ n ,Y/INDUSTRIAL ❑ YES 13 NO NO. OF PATIENTS: S.S.N ��`4 -J O -_I 0_3 A / PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X 1 MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO •r O YES O NO NIGHT: (19:00-07:00) Iv D CCHP/PPRP N: EMERGENCY RUN: (+�(� MEDI-CAL x: 0-76 �S 3�6-Z7 CODE 2/3 1 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ 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) r, �r�• PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: .�.�--- -.______.._... _._ TOTAL:.. _. ►.VLJ. PATIENT RECEIVED UY X I;IrfiA T IpF) - - - 1 V' I CONTRA COSTA COUNTY O AMBULANCE , PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION N8,32393" l CNECK OR F?LL IN APPROPRIATE SPACES DATE: 'PATIENTS NAM ' ,.'. _,1• - O1 M' OF COMPANY# ADDRESS; U i ! AGE i lN CITY STATE ZIP DOB �$n OM O T OW OTA OF O-S " �%'• / f .1 DRIVER'S LICENSE#; - - PHONE NATURE OF DISPATCH (- q TYPE OF TRANSPORT:'AMBULANCE 0 OTHER - I STATION 1(A)._2(B)_3(C)_4(0)_5(EI_. t , INCIDENT LOCATION- :i RESPONSE CODE: R UESTED BY: TIME—(24 HOUR CLO K) ' TO SCENE- O. CALL RECEIVED cc WCS7 ��rJ� L� OR-t>a(� ; � O P.D. TIME 10-8 ,Q :J _ PATIENT DESTINATION: . FROM SCE ❑ FIRE TIME 10-97 i nn ❑ PSAP TIME 10-49 v L i ,TIL G ❑ OTHER/PVT TIME 10-7 END TIME 10-98 ,1 DOCTOR! ` ' ' I . - ., PMD/ER START - " ) TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME -,+.. O NEAREST O FAMILY r O TRANSFER WAIT TIME 1 O PATIENT " ❑ DIRECT O OTHER CALL BLACK#: AMBV,1ANC E COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: --- S, L7�. [RESPONSE ZONE ❑ YES O NO O WAL KED O GUERNEY O OTHER PATIENT CONDITION." DRIVER r�A RAIN�D� C�" EMT-IA R .qI3k��(rlcl-� ' I rr TECHNICIAN c��r PARAMEDIC F fix: O�ZL LH �o.J� N u -V�C�ye.,�1DISPATC R A W CHIEF COMPLAINT: DRY RUN: \YES O NO REASON FOR DRY RUN AUTHOR ION FOR DRY RUN (EMS USE ONLY) I I q� i:: PATIENT REFUSED SERVICES: (SIGNATURE)'xi 5� MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO' NO. OF PATIENTS: S.S. # PRIVATE INS.CO.: - BASE RATE: KAISER#: MULTIPLE PTS. B SE RATE BLUE CROSS#: TOTAL MILES: X MEDICARE#: ' E"O"B.ATT. ROUND TRIP. ' YES O NO _ O YES .O NO NIGHT: (19:00 07:00) CCHP/PPRP#:' VKE C RUN: MEOI-CAL#: ID 2/3 I OTHER: (PER TANK) P.O.E. STICKER O YES ONO `" L: (INCUBATOR) ( DATES BILLED: : (OVER 15 MIN.) ER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: ADMIN.) X (PER ADMIN.) X -"-NAME:- - RELATIONSHIP: . . . NOT REPLACED) i ADDRESS: RAL AIRWAY: (IF NOT REPLACED) j '--CITY: - STATE_ ZIP: C- LLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY R (AUTHORIZED) " EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: - " COMMENTS: _ TOTAL:53 PATIENT RECEIVED BY:X ' (SIGNATURE) n r,, onru+• v.' t !%f' utiin Fii"ina ENS-1 IJ _ CONTRA COSTA COUNTY � AMBULANCE c� PRE-HOSPITAL CARE FORM I UNIT F(�^") ] AU(HORIIZZATIONN#..L?_� CHECK OR FILL IN APPROPRIATE SPACES U DATE NUG. . ') ENo� i PATIENT'S NAME __.Y ��� v11.°.� - R __..... ❑ M f COMPANY 2 ADDRESS 0 CfAGE ClTY1=I ��- STATE .. `^.. —__.._ ZIP DOB ❑ M OT ❑ W ❑ Th ❑ F 13 S Q, / DRIVER'S LICENSE+1'_._ .._. __.... - PHONE 372-92-74-__ NATURE OF DISPATCH TYPE OF TRANSPORT APABULANCE OTHER❑ INCIDENT LOCATION: n n RESPONSE CODE: RE UESTED BY. TIME- (24 HOUR CLOCK) " C�l'C7 _ RP�Nco TO SCENE - 2 S.O. .___. .._.._. CALL RECEIVED �� ----- - --- ❑ P.D. --- —.. TIME 10-8 PATIENT DESTINATION. FROM SCENE-� ❑ FIRE __.____... TIME 10-97 ,r /^� '' ii _ ___ ___ ❑ PSAP TIME 10-49 L MILEAGE ❑ OTHER/PVT TIME 10-7 Z-2 ���� END--.__ __ .4 .-^ TIME 10-98 DOCTOR PMD/ER START_Z_7_-,(_'_-_ TIME 10-22 HOW CHOSEN: TOTAL _�-..� —� -- STANDBY TIME ❑ NEAREST V'FAMILY ❑ TRANSFER WAIT TIME �— ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE�O��P NY: PT AMBULATORY? PATIENT TAKE TO AMBULANCE: j . RESPONSE ZONE ❑ YES l�NO ❑ WAL::E_ GUERNEY ❑ OTHER —_�- -. PATIENT CONDITION: DRIVER. /'TLaARAMED r TECHNICIAN_._. U`�r_i:►LL___,.._. r t - M--- - ---- DISPATCHER: . L�11 Hx: CHIEF COMPLAINT: DRY RUN ❑ YES Ol NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN/EMS USE ONLY1 PATIENT REFUSED SERVICES: (SIGNATURE) X.__—__________.____ MEDICAL COVERAGE. INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS: .. __. ..,..____ ___-- ____. i /C PRIVATE INS. CO.:___ BASE RATE: KAISER a' _^. _ MULTIPLE PTS. BASE RATE _. BLUE CROSS#:`. _ l—_ TOTAL MILES: X wO MEDICARE #:_ —_ E.O.B. ATT. ROUND TRIP ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07.00) CCHPiPPHP#: 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: JQ1WAQQ_�RELATIONSHIP:I�5.1R. E O.A.. (IF NOT REPLACED) ADDRESS:_—�AM� ORAL AIRWAY (IF NOT REPLACED) STAfE.-.__-_ ZIP:..___-.— C-COLLAR: (IF NOT REPLACED) /S•C7) � PHONE: -- ___-- WORK PHONE:.___-____.___.__— DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:.--.-______ OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: 101 At _------.._------_--... _ .----- VA 1 If IJ 1 111 i f tiff 11 10 X t • Ln•:•l ' ' . ---- ` /J | �, CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0. PATIENTS NAME OM OF COMPANY N c?, X0-2 ADDRESS, AGE- D RIVER'S LICENSE# PHONE NATUR?DF DISPATCH 11 TYPE OF TRANSPORT: AM13ULANCE OTHER INCIDENT LOC TO RESPONSE CODE: REOUESTED BY� TIME- (24 HOUR2fLR,CK) P TO SCENE- t3 S.O.- CALL RECEIVED PATIENT DESTINAON: FROM SCENE - 0 FIRE TIME 10-97 MILEAN, 0 OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 | 13 NEAREST 11 FAMILY uTRANSFER WAIT TIME � . "^..=". ^~ "."=~. ^~ "="" . � PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE- I Y ' PATIENT CONDITION: DRIVER PIA'11--Fy- U15 EMT-lA TECHNICIAN IPARAMEDIC VA . *^: DIS PATCH sn::::::: � / � �/1 ~l ,/» CHIEF COMPLAINT: onv vso 0N REASON FOR DRY RUN //U� AoTwOn/z�nowFOR DRY RUN/EmyussowL ' ~/�7 PATIENT REFUSED SERVICES: (a/GmATuns) n ' c���� \ MEDICAL COVERAGE: INDUSTRIAL— 0 Y-- 0 NO NO. _ PATIENTS: auw PRIVATE INS.CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS If: ` TOTAL MILES: x MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES O NO � 0 YES ONO NIGHT: (19:00-0/m0 CC*p/pp*pw` EMERGENCY RUN: wco/-oALw. u]os u/o OTHER: oxvocw: (pen TANK) P.O.E. anovEn O vso ONO ' NEONATAL: (/mougAToP) DATES BILLED: arxwoBY: (ovsn 15 m/m) exm.: (psn sp/000s) mEAnsmTns��r/ve�nsapowa/a�sp�nr�� /x: (PER ADMIN.) x onuGa: (psm Aow/w) x _ NAME: RsLAnnwe*|p: __-__' e0,x.: (Ip NOT REPLACED) Aoonse$� �R�� mRwwv� UFwDrnEp��C�o) � � . CITY: ' STATE____%/p:__-__ C'COLL*n: (IF NOT REPLACED) � p*oms wDnnp*owE onvnuw �u7 ' � � � (AUTHORIZED) __ ^��_~_. _ ) EMPLOYER: OCcupATmw:-__-_____- oT*sn: Aoonsgs: onT: STxTe:____ZIP: __�_' . COMMENTS: - 19 | . TOTAL: -'_ �^ . | . ' pAnemrRECEIVED nvx Provider retain white pd K"k copy *,,,^ y� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHOR17-ATICW 0 CHECK OR FILL IN APP OPRIATE SPACES DATE: / ~` PATIENT'S NAME_. f _�_ _�� Gf I(,ql O M (J F COMPANY M , CITY` f �_�_ STATE ZIP D0 ❑ Sn OM ❑ T ❑ VN ❑Th ❑ F PS DRIVER'S LICENSE N _.. __.__.... _ __. .. PHON - NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEP-OTHER❑ _____ _._______,__ STATION 1(A)._.2(8)_3(C)_4(D)_5(E)_-_-_� INCIDENT LOCATIO RESPONSE CODE: REgPJESTED BY: TIME- (24 HOUR C4QCK) J _� �J A TO SCENE WS.O. CALL RECEIVED ck r �— ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCEN O FIRE TIME 10-97 ❑ PSAP TIME 10.49 c MILER ❑ OTHER/PVT TIME 10-7 ,' : END_ _ TIME 10-981-57 DOCTOR PM /ER START TIME 10-22 �^ I HOW CHOSEN: TOTAL 5 STANDBY TIME 1NAREST O FAMILY O TRANSFER ` WAIT TIME r PATIENT O DIRECT ❑ OTHER I CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: �l RESPONSE ZONE_ ❑ YES O NO ❑ WAL"ED ❑ GUERNEY 11OTHER PATIENT CONDITION. DRIVER _ E,IKk;IA TECHNICIAN PARAMEDIC Hx: �— DISPATCHER CHI F OMPLAINT: y 1 fl-1 DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN i _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ -" 11 MEDICAL COVERAGE: INDUSTRIAL Cl YES ❑ NO NO. OF PATIENTS: S.S. 0, PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE LUt CRO TOTAL MILES: X (r" �I 1 MEDICARE#: E.O.B. ATT, ROUND TRIP: ❑ YES ONO l r ❑ YES ❑ NO NIGHT: (19:00•07:00) �U 11� 1 j, CCHP/PPRP a: EMERGENCY RUN:.MEDT-CALM: CODE 2 3 I i OTHER: OXYGEN: (PE�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 ' C� DRUGS: (PER ADMIN.) X NAME: _� .`..Y.� .C� RELATIONSHIP:�_LA.,G_ E O A. (IF NOT REPLACED) 1 ADDRESS: :!u —___� 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:��� 5 PATIENT RECEIVED BY:X ' n_-..: �•t.... •..c c,...... nr^ c•A�a t_:T :h,T (SIGNATURE) Of5-i 1r 11 (I . CONTRA COSTA COUNTY 1 AMBULANCE ULAN CE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# — 7-71 r 1 c y�) CHECK OR FILL IN APPROPRIATE SPACES DATE PATIENT'S NAME s11� �``U E%['(4.) CL111�' ��5 ❑-M VF COMPANY ADDRESS AGE=I.�.- !CG 1-S CITY STATE--_.-- ZIP---- __ ._ DOB'.a--lb.7'�1 )� Sn ❑ M OT OW O Th OF OS a3 " � IG DRIVER'S LICENSE # __...__. _ _._. _ PHONE j i 1 NATURE OF DISPATCH...'./.J L - TYPE OF TRANSPORT AMBULANCE OTHER❑ INCIDENT LOCATION: RESPONSE CODE: E UESTED BY: TIME- (24 HOUR COCK).-/ (r TO SCENE- r� .O. _.___.._.__ CALL RECEIVED �� TIME 10-8 v7-f i C L ATIENT DESTINATION: FROM SCENE ❑ FIRE ___ TIME 10-97 ❑ PSAP TIME 10-49 "� - 11 — �1�V� MILEAGE: ❑ OTHER/PVT TIME 10-7 / r END---_,_Ir 1TIME 10-98 DOCTOR �1N_e� — PMD/ R) START__l!77,.�._ TIME 10-22 HOW CHOSEN: TOTALSTANDBY TIME ❑ NEAREST O FAMILY ❑ T ANSFER WAIT TIME _- ❑ PATIENT ❑ DIRECTOTHER �� `J J CALL BACK#: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANC c RESPONSE ZONE)ONE YYES O NO WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER TECHNICIAN �N)I f(�- PARAMEDIC i-Ix: - DISPATCHER: CHIEF COMP A 'I I T: ( __tet_ .�K _. C�S�' DRY RUN: ❑ YES �NO REASON FOR DRY RUN 2 -_l a�li ._ _i'�t� ��t1 AUTHORIZATION FOR DRY RUN (EMS USE ONLY) S� yy PATIENT REFUSED SERVICES: (SIGNATURE) X-_-__-_._-__.__- MEDICAL COVERAGE: INDUSTRIAL ❑ YES L(NO NO. OF PATIENTS: S.S. # IS—�2 --- \PRIVATE INS. CO.: BASE RATE: ccs fSER It: _ MULTIPLE PTS. BASE RATE r B UE CROSS#: TOTAL MILES: i 1 X MEP3ICARE#: / 'Ln �� E.O.B. ATT. ROUND TRIP: 13 YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) ' C�• HP/PPRP#: -- EMERGENCY RUN: ' M DI-CAL#: b Q 1 e' (_r _ COD 2.13 T ER: __ OXYGEN: (PER TANK) P. E. STICKER ❑ YES ONO NEONATAL (INCUBATOR) 1 DATES BILLED: - STANDBY: (OVER 15 MIN.) E K G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V: (PER ADMIN.)_— X DRUGS: (PER ADMIN.)_--_ X NAME: RELATIONSHIP: -_ E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE-_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: --_--- ---_ ----.___-- --- CITY: - STATE:--.ZIP:------- ---- - --- - ---- - COMMENTS: Ni r - -_- TOTAL PAIII NI III (:I IVI 1) IIY X 1 (J r•..,.ri.lrr r•,•r.r. G•;. . .. � (':I(:NA'lllll') CI �1 N COSTA COUNTY AMBULANCE7 P PRE HOSPITAL CARE FORM i UNIT AUTHORIZATION N 1�= ls. CMECK OR O'ILL IN ACCROPRIATE SIACEf DATE: PATiENT•S NAME L ❑ M ❑ F COMPANY 0�` L 1 / ADDRESS:t'- - -1 AGE- r c V�V CITY STATE-----,ZIP DOB ❑ Sn PCM OT OW O Th ❑ F DS DRIVER'S LICENSE N s I PHONE NATURE OF DISPATCH (IIIIs(c A _ TYPE OF TRANSPORT:, AMBULANCr TH£R❑ STATION 1(A)l,,24)._3(C)_4(D)_51E)_ INCIDENT LOCATION) - 1 �- IC RESPONSE CODE: EQUESTED BY: TIME—(24 HOUR CLOCK) !� c L � TO SCENE- S.O. CALL RECEIVED Cr2� v ` ��` ! ❑ P.D. TIME 10-8 PATIENT DESTINATIO :- FROM SCENE- ❑ FIRE TIME 1D-97 1 O PSAP TIME 10-49 �'�.1 ► `t.i f i ! MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 "DOCTOR I' r j PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME L> •. • ❑ NEAREST,,,.; ❑ FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK 0: AMBULANCE CO�P�A�Y: T. AMBULATORY? PATIENT TAKEN TO AMBULANCE: � 1 RESPONSE ZONE_Z ❑ YES ❑ NO ❑ WALKED O GUERNEY O OTHER PATIENT CONDITION: DRIVER . AI I 3 EMT-1A TECHNICIAN Q R-1 2 S PARAMEDIC Hx: DISPATCHER: �Q/17( P qqqCHIEF COMPLAINT: ' DRY RUN: JVYES ❑ NO REASON FOR DRY RUN 10%72L AFD AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �� I PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: y �/ S.S.M - - PRIVATE INS. CO.: BASE RATE: KAISER R; MULTIPLE PTS.BASE RATE BLUE CROSS 0: ` TOTAL MILES: X N MEDICARE#, ( E.O.B. ATT. ROUND TRIP: ❑ YES ONO I i O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 0:'` ' I EMERGENCY RUN: MEDI-CAL 0: CODE 2/3 OTHER: 7 OXYGEN: (PER TANK) P.O.E. STICKER DYES 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) FA PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) '—EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE• ZIP: COMMENTS: TOTALS5 011 •• PATIENT RECEIVED BY:X 00"22 Provider retair• Ai t• card Pink ropy . Retum Yr.'L,, ••nty t• Ev L,hnn bii'i,,o r"`-' CONTRA COSTA COUNTY AMBULANCE - /1 PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION B ) ( CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME—p r,9a�e_& O M jkP COMPANY 0 ADDRESS AGE/� V ,,t CITY STATE ZIP DOB"—�2 ❑ Sn M O T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE z-_�l_� NATURE OF DISPATCH �1Y1 �T^� M PHONE_ TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ S,J INCIDENT LOCATION: I RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 1�9_ 2- _�f TO SCENE- -2- TIME 0-8 9� CALL RECEIVED ( � PATIENT DESTINATION: FROM SCENE- Q O FIRE TIME 10-97 O PSAP TIME 10-49 r,2 2 MILEAG ❑ OTHER/PVT TIME 10-7 ^�' `�T!,•�v C� END TIME 10-98 II � DOCTOR PMD/ER START TIME 10-22 C� - OW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O YES ❑ NO, ❑ WALKED ❑ GUERNEY ❑ OTHER �p y PATIENT CONDITION: DRIVER /' ������-5-1 y` T-1_ TECHNICIAN PARAMEDIC Hx: DISPATCHER: �J/IT � Q:;� Jn o CHIEF COMPLAINT: DRY RUN: KION YES ❑ NO REASON FOR DRY RUN 7 ,.J•pvT�f uT ((l1 AUT R FOFqDRY RUN(EYS USf ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X_ �� ��1577 77a� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO .NO.OF PATIENTS. S.S. R PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE fi\UE CROSS#: TOTAL MILES: X M ICARE U: E.O.B. ATT. ROUND TRIP: O YES O NO DYES ONO NIGHT: (19:00-07:00) t C IPPHP M:I EMERGENCY RUN: MEDI-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 NAME6L' // La h/.c, 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) n cy EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL. r I _-. PATIENT RECEIVED BY: .X_ 0072-3 — F7"v .frr r•rt.:ic L'F{.r +:/ !,:,.I (SIGNATURE) .•.•Fi. r/,i^ r.. :.•4..: t:I ia: [MS-I ACNTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N �� �!2�. �••(' CHECK OR FUL IN APPROPRIATE SPACES DATE:. PATIENTS NAME OM OF COMPANY N " V / ADDRESS AGE Doc V N CITY STATE ZIP DOB ❑ Sn �M ❑ T//��❑��--W//��//❑Tj77Thh ❑ FF 0 S/ �/ DRIVER'S LICENSE N _ PHONE -- NATURE OF DISPATCH ��!��-/� TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME - (24 HOUR CL CK) TO SCENE- KS.O. CALL RECEIVED O P.U. TIME 10-8 3 r 1.G-AAOCTOR ATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ![ ❑ PSAP TIME 10.49 MILEAGE: 11 OTHER/PVT TIME 10-7 - L _ END TIME 10-98 17- s, PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULAN�E,� PANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES O NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EfAT- TECHNICIAN 2 Z� - AMED qoo Hx: UNK u n^ DISPATCHER: ti // CHIEF COMPLAINT: K pp'(m DRY RUN:% YES ❑ NO REASON FOR DRY RUN NE 1/0 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) � 2 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: rl 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) vw EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: /� STATE: ZIP: COMME TS: PC IBCA - coG TOTAL);I -- 00724' PATIENT RECEIVED BY:X 11+�iidnr tvh7J. tM1i t. r J J'i•:1 .•,qr. 4,t;.r... •( _ 'vi:.. (SIGN<.TURE) i' r 1'7"i�;� EMS-) 11 \� CONTRA COSTA COUNTY AMBULANCE 25 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL.W APPq OPRIA IE SPACES DATE: I .. PATIENT'S NAME. __.A Ae5 cddie N1 U. W- F COMPANYq L/ _ ��,_-_. C L ADDRESS 1 _l. -�_---v-1� ((�n AGE /c /p�7-I�7� o6) CITY_ ------- STATE%- ZIP��Q�Y' DOB J SC J _`C+03 Sn O T ❑ W ❑Th FO f� ` $ DRIVER'S LICENSE ------ PHONE._.__. �J.r1.� taIATURE OF DISPATCHc���e �. 1 �1. TYPE OF TRANSPORT: AMBULANCE OTHER❑ �- INCIDET�OCAT ON: RESPONSE CODE: REQr?ESTED BY: TIME- (24 HOUR O K) - ��� > TO SCENE- S.O. CALL RECEIVED 6 _� tiErJ�+1�.-1. -_ �•�� _ v ►❑,�P TIME 10-8 PATIENT D INATION: FROM SCENE- AFIRE- TIME 10-97 p'Z� t(� f �:� ❑ PSAP TIME 10-49 )'1 MILEAG . Cl OTHER/PVT TIME 10-7 1 _ END 1� TIME 10-98 DOCTOR � PM`D�CFr START d TIME 10-22 HOW C�EN: TOTAL — STANDBY TIME 'NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME Cl PATIENT ❑ DIRECT ❑ OTHER �_ CALL BACK k: AMBULANCE COMPANY: cy PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5/0 RESPONSE ZONE ❑ YES ❑ NO ❑ WAL'CED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVZO %-Arl Z3Z L I(7) EMT-1A _ ��' TECHNICIAN PARAMEDIC Hx: _L L- -_ \__ _ DISPATCHER: CHIEF COMPLAINT: DRY DRY RUN: 13YES O 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 RIVATIt INS, AQ_ - BASE RATE: MULTIPLE PTS. BASE RATE LUE CROSS 4: TOTAL MILES: X 'J Zrs• .. MhUICARE 4: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19.00-07:00) CCHP,'PPHP#: EMERGENCY RUN: �� �✓ �� MEDI-CAL t+:: _____--- CODE 2/3 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 11j. ' /. DATES BILLED:- STANDBY: (OVER 15 MIN.) ,�; E.K.G.: (PER EPISODE). NEAREST RELATIVE!RESPONSIBLEZTY:� I.V.: (PER ADMIN.) X I {�7� DRUGS (PER ADMIN.) � X ,((�� K 1 1 ��_ E.O.A.: (IF NOT REPLACED) NAME: T�Q�nn 11 A_ =.�E_TIONSH^ ADDRESS: l b vQ. j lJ�-1 ORAL AIRWAY: (IF NOT REPLACED) CITY: .jo_ _PbtL_. __ STATE-b-_*ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 3 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: — - CITY: ___—ESTATE: ZIP: COp ENTS:\2X f*m TOTAL:`. -_ ,-- PATIENT RECEIVED BY: X 00725. ►y•wi'rr rrta:c writ, ,�:,i %•i.::: rnpp 6rturn Yr'lcl,- -pp f. fV" "$,n 6i1'�ng (SIGNATURE) Q15-1 CONTRA COSTA COUNTY ). AMBULANCE ,y / PRE-HOSPITAL CARE FORM 1 UNIT r�, AUTHORIZATION M�1 - I. CHECK OR FILL IN APPROPRIA rE SPAM DATE: �� •� ) ,•� PATIENT'S NAME _._:'___- �- - l 1 C ll_l - J ❑.M jY F COMPANY N / 6f ADDRESS x'`-_(•l '7 ,I •f I I ` I.��t-,1 r— AGE 5 t� OO!f'�],- [ �'`�T_• - � _ $TATE ( 1P .� ^ �ISn M T O y ❑ 0 FCITY te5133 DRIVER'S LICENSE a PHONE_[-1'1..1`'�`� NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE,q OTHER❑ __ y:,;;6... ' INCIDENT LOCATION: RESPONSE CODE:. REQUESTED BY: TIME- (24 HOUR qq .(i ,f TO SCENE- /n q S.O. CALL RECEIVED - .L � — G_ _- ❑ P.U. TIME 10-8 �: .. PATIENT DEST16T'iON:1 FROM SCENE-n ❑ FIRE TIME 10-97 : /--1- ❑ PSAP TIME 10-49 � MILEAGE: ❑ OTHER/PVT TIME 10-7 -A3_� 09 I 1 (� r�JL5 END Z TIME 18 DOCTOR O11_t PMD/pR,' START TIME 10-22 {; ' •' %'+- - HOW CHOSEN: TOTAL " STANDBY TIME''i.` ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME IIT COTHER PATIENT ❑ DIRET � CALL BACK M: AMBULANCE COMPANY:'• -c t PT AMBULATORY? PATIENT TAKE TO AMBULANCE: RESPONSE ZONE YES 11 NO ❑ WAL`<ED gGUERNEY ❑ OTHER PATIENT CONDITION: DRIVERS' MX p'� TECHNICIAN / PARAMEDIC .: Hy-' 'j it ')_, �1 DISPATCHER: C EFF MPLAINT: DRY RUN: ❑ YES d NO REASON FOR DRY RUN 1 _ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) J. n PATIENT REFUSED SERVICES: (SIGNATURE) X__. MEDICAL COVERAGE: INDUSTRIl�J_ ❑ YES NO NO.OF PATIENTS: s�t�l S.S. 0 PRIVATE INS. CO.: _____ _ BASE RATE: KAISER#: HAUL TIPkE PTS BASE RAT&- � BLUE ROSS p; _ i - ---� / t - ,^ • ; �I'�1t"MttES: _- `"r X G •.�J :. /y.�;'•. MED ARE N^ /- i I _E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO n.o w-c cu ❑ YES ❑ NO NIGHT: (19:00-07:00) 'W U GCHP/PPRP EMERGENCY RUN: MEDI CAL A� /�/:'o // _I/_-L CODE 2/3 OTHER:— / OXYGEN: (PER TANK) z''! �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 s:- ' DRUGS: (PER ADMIN.) X NAMES '...'.. �-}i,..r�'`I __ RELATIONSHI `' E O.A.: (IF NOT REPLACED) ADDRESS:✓ ,I/ ___ ORAL AIRWAY: (IF NOT REPLACED) CITY: _._._ _.. STATE—_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) i EMPLOYER: ___ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: -- 9 -7t77""�;• '� Vj TOTAL . _ — PATIENT RECEIVED BY:X White (SIGNATURE) r Pros ider rrtn:., r.d I'tr,; .•nrp return Yn',: • :rrY t M.- when F:I'inp } ;• ftiy� 2 Olf-� O CONTRA COSTA COUNTY AMBULANCE c) r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL IM APPROPRIATE SPACES DATE: PATIENTS NAME 'OS O u iKm ❑ COMPANY a ADDRES /�u 1 Q __ AGE /- CITY STATE-S_�cf�- 21P_C�.4D.O. DOBQ��`�71CJ ❑ Sn ®M ❑ T ❑ W ❑ Th 0 ❑ $ DRIVER'S LICENSE a _________._-._.__-. PHONE_232 7(p NATURE OF DISPATCH_`_ -— TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ __..___-___..___ .___-. _ INCIDENT LOCATION: I RESPONSE CODE. REO ESTED BY TIME - (24 HOUR CLOCK)? -- ,,,, QPD TO SCENE - 2 . ___ .__. _ CALL RECEIVED K� �/L fy( Q - ��l ' -------.J-- ❑ P.D. ------ TIME 10-8 � PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 y — MILEAGE.`,-7 ❑ OTHER/PVT TIME 10-7 END_ ,S� TIME 10-98 DOCTOR PMD/ER STARTA45 I.�]_ _ TIME 10-22 HOW CHOSEN: TOTAL _ _1 — STANDBY TIME _ ❑ KAREST ❑ FAMILY ❑ TRANSFER WAIT TIME PATIENT ❑ DIRECT ❑ OTHER c CALL BACK#: AMBULAt�,CKQMPANY: PT BULATORY? PATIENT TAKEVO AMBULANCE. 51 RESPONSE ZONE YES -❑ NO ❑ WAL'<ED WGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER C>�_SJO �. EMT-1A �— TECHNICIAN ` P RAMEDI Hx: ' v L (LUie-E DISPATCHER: —LLCM'%7 _I'a `•7 II •� CHIEF COMPLAINT: S — DRY RUN: ❑ YES O'NO REASON FOR DRY RUN J 3� AUTHORIZATION FOR DRY RUN (EMS USE ONLY) 7 PATIENT REFUSED SERVICES: (SIGNATURE) X J MEDICAL COVERAGE- DUSTRIAL ❑ YES 11 NO NO. OF PATIENTS: s.s. 56 2-9 2g (:)32Z PRIVATE INS. CO.: BASE RATE: I ISER MULTIPLE PTS. BASE RATE BLS' E CROSS#: � �f L � TOTAL MILES:_.— —_ " ✓ X � l� DICARE R: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) �'JJ ,I�CCHP/PPRP k: EMERGENCY RUN: .� >• ) �6 C MEDI-CAL a: CODE 2 3 OTHER: OXYGEN: (PER TANK) -'• ' U7 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:u'S•C:.!# L St!_; CCUPATION -.r'ti- ti. OTHER: _ ADDRESS:NH U n L (.�•L" rJ ':J ', •� •`�� ,'.'`' � .' CITY: C STATE' ZIP.—_ —— ----- ---._ COMMENTS: — --------- --- - ' TC)TAl CONTRA COSTA COUNTY AMBULANCE _ PRE-HOSPITAL CARE FORM I I UNIT AUTHORIZATION x iVL . CHECK OR FILL IN APPROPRIATE SPACES DATE: / & I h3 PATIENT'S NAME—� ��/�1�T `� C/lM ❑ F COMPANY# ADDRESS 3 :2.� LQI�-L c��__f4 SS_( Z AGE 0 CITY ("QWQ STATE_i CLE ZIP 9�r s Z-CJ DOB �7_ ❑ Sn OM�T OW O Th OF p$ 1 i ' DRIVER'S LICENSE a ___ PHONE_LLL=/3��_ NATURE OF DISPATCH �LA� TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ --_ STATION 1(A),2(8)_3(C)_4(D)_5(E)_( INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK TO SCENE- S.O. CALL RECEIVED E(-( 11�5 r�LR(- L`_SSq /t'1 I Z ❑ P.D. TIME 10-8 PATIENT DE TINATION: FROM SCENE- ❑ FIRE TIME 10-97 �Z 0 C ( 13PSAP TIME 10-49 _ \ _ MILEAGE: ❑ OTHER/PVT TIME 10-7 n END. ` q` � TIME 10-98 DOCTOR 1 �Z-- PMD/®R START Cf�• c7 TIME 10-22 } HOW CHOSEN: TOTAL �� STANDBY TIME •❑ NEAREST ❑ FAMILY O TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT Fl, OTHER 51. -710 CALL BACK K: AMBULANCE COMPAN,)':A S --- PT. AMBULATORY? -PATIENT TAKEN TO AMBULANCE: , RESPONSE ZONE ES ❑ NO O WAL KED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER ? EMT-1A TECHNICIAN S�(2f/ PARAMEDIC � - Hx: �sqco - DISPATCHER: CFjIEF PLAINT: �� DRY RUN: ❑ YES 8-MO REASON FOR DRY RUN " /�Z)t�+11 fit!I C�+• AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— I MEDICAL COVERAGE: INDUSTRIAL ❑ YES I NO NO. OF PATIENTS: S.S. a 5y 3'' 13 "39y PRIVATE INS. CO.: /JJ►`( BASE RATE: l�•l�.-+ KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: X SD la.SO- \I AAEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO `I` ❑ YES O NO NIGHT: (19:00-07:00) ? �l . CCHP/PPRP a: EMERGENCY RUN: 30.C�a. �` MEDI-CAL a: CODE 2(3 ` 1 OTHER: OXYGEN: (PER TANK) -i P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ,NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ,.��rr DRUGS: (PER ADMIN.) X NAME(-/�(S { /]0S C O T A RELATIONSHIP: E.O.A.: (IF NOT REPLACED) - ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: ____ STATE–C,6-1 ZIP: C-COLLAR: (1F NOT REPLACED) PHONE: WORK PHONE: DRY RUN:"(AUTHORIZED) EMPLOYER: LV.Iit.NPluq SIA OCCUPATION: OTHER: ADDRESS: CITY: Q- STATE: ZIP:— COMMENTS: IP:COMMENTS:) CO u LO�,►- �f-M£;dliSS c�kltr LA b/(1�_AAJ C;%]1 F TOTAL: SO PATIENT RECEIVED BY:X I.- :• : ISIGNATU as t CONTRA COSTA COUNTY `� AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION K ✓ CHECK OR PILL IN APPROPRIATE SPACES DATE: / , PATIENTS NAME Zv!n Q rz NF z y j 0 u N P4M ❑ F COMPANY M ' ADDRESS CAL( (-- D� ,f AGE ' CITY!' 'AR I Ot /� STATE iL / zip_1 y �S DOB ` _LY O Sn OM T OW O Th OF 6S DRIVER'S LICENSE M - PHONE Y0`L.y_ _ NATURE OF DISPATCH_/L TYPE OF TRANSPORT: AMBULANCE OTHER❑ — _ STATION i(A)_2(B)_3(C)_4(D)_5(E)_ �. INCIDENT LOCATI N: RESPONSE CODE: RIE0ESTED BY: TIME– (24 HOUR CLOCK) ,f TO SCENE- a S.O. CALL RECEIVED L 1 L r S Q 1 N C T. Y"�% O P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 / Z— O PSAP TIME 10-49 1 MILEAGEq () �/ ❑ OTHER/PVT TIME 10-7 ENp—�-- TIME 10-98 DOCTOR A PMD®R� STARTS TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT THER r(ANtU_ A2kt STCALL BACK 0: AMBULANCE COMPANN� PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE Z� ❑ YES IlYNO O WALKED YGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER —Ltn�l r��e EMT-1A t r � LeTECHNICIAN Owu PARAMEDIC x: � C1 �'�` DISPATCHER: it! ` CH F COMPLAINT: m i h f�G�l M GG DRY RUN: O YES NO REASON FOR DRY RUN q5, rc-V 16 kJ s / Q(_ AUTHORIZATION FOR DRY RUN (EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL CO E AG� _- �`QUS�RIAL O YES O NO NO. OF PATIENTS: S.S.N `�— P BASE RATE:KAISER R�Nsfo.: Q '>~ MULTIPLE PTS. BASE RATE SL OSS M: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: O YES O NO �y�`�✓ vJ O YES ❑ NO NIGHT: (19:00-07:00) COHP/PPHP M: _ EMERGENCY RUN: MIDI-CAL M: 0 0 C �L�4 CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER Q YES �1D 2384288 Q NEONATAL: (INCUBATOR) DATES BILLED: J 33 7( STANDBY: (OVER 15 MIN.) ' E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X �'.NAME' RELATIONSHIP:—RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 1ORAL AIRWAY: (IF NOT REPLACED) 4 - CITY: STATE— ZIP: C-COLLAR:.(IF NOT REPLACED) _ PHONE: A a ff WfRK PHONE: ` 1) DRY RUN: (AUTHORIZED) EMPLOYER- OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: ujL - ,,,5 0079 ---.. _ TOTAL' — - -- l L� ?LL Com' L 4-1, PATIENT Rf:rE1VEn OY X ��_t�� �a�( L-.�L P,• , I,,, ,�, ISIGNATIIRF 1 1 I V •l_ �r PATIENT'S NA-ME: Joe Wallace ADDRESS: 22 Ruby ` ' Richmond,Ca. ; DATE OF SERVICE: Q�1��� l .•.: yj�i`, AUTHORIZATION NUMBER:83-13847 AMOUNT DUE: $202.50 ' 41 INCIDENT LOCATION: 22 w_ Ruby Richmond �:• PATIENT DESTINATION: Brookside Hospital j .. ' 1{ 408,0 = � . r t 61 kp 16 2 26 Auc 16 2 29 AH 83 AuG 16 2 31 AN •'83 �f�JUU l AN 3 , 1 ; Sp NUMBERi CAII RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 r CALLED BY- PATIENT INFORMATION �' ± i •`+ D NAME: - _ _ _ _ _ _ _ _ _ _ _ C_Q +� C 7 AGENCY: _ -- ._-_.. ___._-_ _ __ __ CUSTOMER # (PT. 1): DOB SUS s v DEPT;FLOOR;ROOM 9: NAME: _: t I (1 , �Oe m N - -_ - -_----------- v CALLBACK a: INS. TYPE: PVT MCAR MCAL KHP PHP VA IND CHAMPUS v INCIDENT LOC: ----- ._� fl—'!� POLICY/MCAL N: NCNC: m =y .= - a -- ----- -- - - -- ---- MCAR p: m VERBAL PRIOR: Q CROSS STREET: 4� t JURIS: - I- Civ /�/_.. /,C N-- -- ---- DOCTOR: 173L7 1 --- - DESTINATION: 4� -_ - _-_____ PT. #2 NAME: DOB: NATURE: _ VX m/4x 15L-e eA COST. a 3D PT. #3 NAME: DOB: C o p s TYPE OFC ��y/J,R�ANp S TIME UNIT -_-�? CUST. it n lL w CREW: _. -_L/ _ WAIT TIME: YES NO REASON: OUNIT TYPE: ALS 6B WC RESPONSE CODE: 0 1 0 7) 3 4 REASON FOR 10-22: = O C" a INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 0 3 4 CANCELLED BY: u `_--___--- COMMENTS: i' Li C �L; �/t C2. O N BY: END MILEAGE: -.�01�'�-- r'"`V d`�.0 ¢J TIME: - _ __ BEG MILEAGE: D DISPAT ER: r m TOTAL MILES: a XL-Ol NOIIVIS 1V 3DNvin9Wv 6l'Ol ONIN 8 3DNV1F19WV 86-01 319VIlVAV 3DNV1f19WV L-Ol IV14 H11AD4vingwy po �, Hd 90 91 9nd Ego ss Z � ., r gf,ifjlit►' c e; ' - Pin ar - „� -- j z�`+1t.'►'` �! -�y�.�-__:`- i- #vim I . .Ilk •a y�+� '� � � 3 • i f.'RLQ ♦..^�J���/ �. �"}L�_',�• •.1� .. ,t �� = •-� �i .4LJ izv J7�R3r t'La.yb'SS'5��+ls ' pill 1111 Vp '•, .` •.,' t�f.� � ;T SKr �' ��� � �������^-�••.y��rr-�R i .. _. 1_ ��a #.�`�'ii.tZ 4'U tr SM;�•;,th4 :` �. �^• .�. Lt's� .�a.- •''j�Y.rJ' •kati.V�W. 'i.'. CONTRA COSTA COUNTY \ LA5ANCE113�`��PRE-HOSPITAL CARE FORM I � ® AUTHORIZATION N 7 CHECK OR f/Ll INAPPROPRIATE SPACES DATE: 116 .1 PATIENT'S NAME M ❑ F COMPANY N La(,2 ADDRESS ` 3 13 -t)Ll- I Rc-(. �,D /AGE I �� `� I J CITY "/�. fa STATE C'p ZIP DOB �1 9Z- ❑ Sn ❑ M T ❑W 13 Th E3 F DRIVER'S LICENSE p _� PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:. AMBULANCE 0 OTHER❑ _` r STATION 1(A) 2(B)_3(C)_4(D)_5(E)_,•- -1 INCIDENT LOCATION. RESPONSE CODE: VOUESTED BY: TIME— (24 HOUR LOCKSTO SCENE- O. CALL RECEIVED --LQ�3(-1` (�� If U�NIACp D. TIME 1Q8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 �1 ❑ PSAP TIME 10-49, - I^�- �; -/Kr MILEAGE: ❑ OTHERIPVT TIME 10-7 •�2 END TIME 10-98 t✓ c " DOCTOR - v L PMDD START 50.U TIME 10.22" - +-� H HOSEN: l� TOTAL 5 't' STANDBY TIME . :'NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 4J ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK K: AMBULANCE COMPANY: --� /P AMBULATORY? PATIENT T KE TO AMBULANCE: RESPONSE,-ZONE YES Cl NO Cl WAL'(ED UERNEY ❑ OTHER 1 1 PATIENT CONDITION: DRIVER 1N EMT-1A 1 TECHNICIAN_ ' PARAMEDIC J Hx: � _ __ DISPATCHER: • j ( CHIEF COMPLAIN[: e, ��LND DRY RUN: ❑ YES O REASON FOR DRY RUN _.l 1 AUTHORIZATION OR DRY RUN(EMS USE ONLY) 1 1 UL C PATIENT REFUSED SERVICES (SIGNATURE) X 1 '�OMEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. K PRIVATE INS. CO.: BASE RATE: L KAISER x: MULTIPLE PTS. BASE RATE �• "I BLUE CROSS M" _ tom 1C_ TOTAL MILES: X =3 0 MEDICARE C E.O.B. ATT, ROUND TRIP: ❑ YES ❑ NO '1 ❑ YES ❑ NO NIGHT: (19:00-07:00) • 1 •30" f r CCHP/PPHP#: EMERGENCY RUN: : i •`) MEDI-CAL K: CODE 2�3 I �C''�, — I� �1 o-� 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 CDRUGS: (PER ADMIN.) X NAME: QUI!_I-` RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE__ZIP: - C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: /- ADDRESS: 3e _6Ja zlL CITY: STATE: ZIP: /�><<• a,�. •(JjJ L� 5(0 COMMENTS: -r{ vhJ � c tV TOTAL:,:�'S r`f PATIENT RECEIVED BY:X Provider retair Whitt r-f r,:*,,.. ,•.•pp . getkm Yr•,(L• -,,Py t, ENS when hit-ink (SIGNATURE) MFL CONTRA COSTA COUNTY AMBULANCE �t 4 PRE-HOSPITAL CARE FORM 1 UNIT AUT'HORIZATt0 �M CHECK OR FILL IM APPFOPRIATf SPACES DATE: `PATIENT'S NAME ' i ❑ #,,o F COMPANY# ' ADDRESS„ * ( L AGE— CITY GE CITY STATE ZIP DOB _ ❑ Sn ❑ M ❑ Th ❑ F O S DRIVER'S LICENSE U ' ' PHONE _ NATURE OF DISPATCH a !A TYPE.OF TRANSPORT:,AMBULAN OTHER T STATION 1(A)-2(8)-3(C).._..4(D)-5(E).,� INCIDENT LOCATION; SI : RESPONSE CODE). REO ESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- S.O. CALL RECEIVED Q 2— .-JL- -„..�+v ;;r): ❑ P.D. TIME 1t1-8 . PATIENT DESTINATION:,'—.t"11$r j IttC 2. FROM SCENE- O FIRE TIME 10-97 , ❑ PSAP TIME 10-49 END MILEAGE: � O OTHER/PVT TIME 10-7 .i ` TIME 10-98 TaR a ti'y (` •f1 'r2�. - PMDCER START' TIME 10-22 t�G "- � HOW CHOSEN: TOT STANDBY TIME �t-yy❑ NEAREST,-.%❑ FAM ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBUI ge4 `)MPA � _ PT. AMBULATORY? � PATIENT TAKEN TO AMBULANCE: I. .�} RESPONSE ZONE _ ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' I PATIENT CONDITION:----'- DRIVER j' EMT-1A I TECHNICIAN 77 PARAMEDIC Hx: 2 - N - i • DISPATCHER: CHIEF COMPLAINT: ” DRY RUN: , YES ❑ NO REASON FOR DRY RUN Hwya AUTHORIZATION FOR DRY RUN(EMS USE ONLY) -. ; 'RAd I)DWATIENT REFUSEDrSERVICES:(SIGNATURE)X MEDICAL COVERAGE-.. INDUSTRIAL ❑ 4ES'❑ NO NO,OF PATIENTS: S.S.# PRI A I BASE RATE: ,KAISER� MULTIPLE PTS. BASE RATE GLUE CROSS#: "" TOTAL MILES: X '"s'`• MEDICARE# + E.O.B.ATT. ROUND TRIP:' ❑ YES ❑ NO i:' '• ❑ YES 'O NO 'NIGHT: (19:00-07:00) i CCHP/PPHP r EMERGENCY RUN: ► -N,:.. MEDI-CAL#; -... �,. t a:. CODE 2/3 OTHER:_ I� OXYGEN; (PER TANK) P.O.E. STICKER YES ❑ NO "" NEONATAL: (INCUBATOR) j DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST-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) i -" EMPLOYER: N. OCCUPATION: OTHER: -ADDRESS: I CITY: STATE- ZIP- A0733 `7 COMMENTS:- TOTAL: ` CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNIT 1 1 AUTHORIZATION M b 3 '71,), 2 CHECK OR Flll IN APPROPRIATE.SPAC£S DATE:._ _ t • '^ PATIENT'S NAMEC_L1 I1 ;�f M ❑ F COMPANY M ( r I / ADDRESS �' C L 7 f H c—i_t f l l it-, -)� AGE r./�, CITY_� ' * �STATE ( 0 ZIP Z ' / - l DOB.iLL1La 13 S, O M dT 0 W O Th O F Q$"1 i •I -- / 1f "� I DRIVER'S LICENSE N PHONE NATURE OF DISPATCH (S L� i TYPE OF TRANSPORT: AMBULANCE. OTHER❑ __ _ _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)�._ -- INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CL CK) TO SCENE- O'S.0. CALL RECEIVED /0 .. _ �j )) �1►1 ))(C c C la Ic phC�� Z— ❑ P.D. TIME 10-8 I PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 q_ :1 ❑ PSAP TIME 10-49 - �' c'< <` 11 _ MILEAGE: ❑ OTHER/PVT TIME 10-7 fte � M _ END ,U' TIME 10-98 :b2,3 DOCTOR N 1 14'C tL PM •ER STARTTIME 10-22 ) HOW CHOSEN: TOTAL JAl An STANDBY TIME ❑ NEAREST ❑ FAMILY .❑ TRANSFER _ WAIT TIME 1 ❑ PATIENT [(DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: C PT AMBULATORY? PATIENT TAKEN TO AMBULANJ ) RESPONSE ZONE _ YES ❑ NO Z WAL'<ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER_1, A 1 (/c-/< MT-1A' 2 TECHNICIAN PARAMEDIC { HxT1• .2 r l lc'J lY' L._t11)4C\� IG kl l( I11i11.X(jIEPATCHER: CHIEF COMPLAINT: D''all< DRY RUN: ❑ YES t O REASON FOR DRY RUN 'U AUTHORIZATION FOR DRY RUN(EMS USE ONLY) (`L PATIENT REFUSED SERVICES: (SIGNATURE) X_ I EDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: �Q (,KA IS ER'w: I C [ �>' '17_ MULTIPLE PTS. BASE RATE � �•�, ""T J BLUE CROSS#: TOTAL MILES: X MEDICARE tl: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO �- I� ❑ YES ❑ NO NIGHT:(19:00-07:00) —� �II,I CCHP/PPRP#: EMERGENCY RUN: 3 ©� MEDT-CAL M: CODE'2/3 L OTHER: OXYGEN: (PER TANK) -� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X NAME: I Fir,r'I Al• RELATIONSHIP:'31 Ir 111211 O.A.: (IF NOT REPLACED) ADDRESS: ,� 2 7 f i c•ll' I, lx• (VICIIN RAL AIRWAY: (IF NOT REPLACED) CITY: ( 11 II'f 0110 STATE ('14 ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: le L' WORK PHONE:•'' DRY RUN: •(AUTHORIZED) EMPLOYER: T OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: - COMMENTS: F TOTAL. . (� _ PATIENT RECEIVED BY:X ` Provider retaic VAite --d •'e.' r7p� haturn Yf*lc-a• ^ p, I• PEW chin hil:inp (SI ATURE) OSS-1 I � CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUT ORIZATI N» 2341 RS6 �1....••, , . r i I 6 1O3 CHECK OR FILL IN APPROPRIATE SPACES DATE- PATIENTS NAME ❑ M ❑ F COMPANY N ADDRESS-, K VO AG*E1__ c I/ t w CITY STATE_ ZIP DOB ❑ Sn Om OW O Th OF OS 17 VRIVER'S LICENSE IV , - PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:,AMBULANCE C) OTHER D _ -- STATION 1(A)_2(B)_3(C)_4(D)_5(E),_ INCIDENT LOCATION: J_ %;-� RESPONSE CODE': REQUESTED BY: TIME— (24 HOUR CL99K) TO SCENE- 2' 36-' S.O. CALL RECEIVED ( , D P.D. TIME 10-8 PATIENT DESTINATION: __.._.i FROM SCENE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 - `/" -_ ENDS— TIME 10-98, PMD/ER START TIME 10-22 C 1 rt43 HOW CHOSEN:. TOTAL STANDBY TIME 2"3 1 D NEAREST ' FAMILY O TRANSFER WAIT TIME ❑ PATI ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE CMANY: r PT. AMBULATO PATIENT EN TO AMBULANCE: RESPONSE ZON ❑ YES. ❑ D W KED ❑ GUERNEY O OTHER . PATIENT CONDITION: DRIVER A•'Fa T 1AAT-1A i NII Ft( TECHNICIAN , ( 04 _3�-� PARAMEDIC Hx: DISPATCHER: Lt^ CHIEF COMPLAINT: DRY RUN: )R',YES ❑ O REASON FOR DRY RUN 4.7 '2 Z Y AUTHORIZATION FOR DRY RUN(EMS USE ONLY)_!, F 7 yy • PATIENT REFUSED SERVICES:(SIGNATURE) X 4 MEDICAL COVERAGE: ..__- INDUSTRIAL O YES ❑ NO NO.OF PATIENTS: S.S.N PRIVATE INS.CO,: BASE RATE: e• KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: I TOTAL MILES: X MEDICARE K; E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP.M:r' EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: '(PER TANK) - P.O.E. STICKER ❑ YES O N NEONATAL: (INCUBATOR) C_�_' DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ---NEAREST-RELATIVE/RESPO IBLE 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: e ' ,COMMENTS: TOTAL: PATIENT RECEIVED BY: X__ CONTRA COSTA COUNTY AMBULANCE J3-t3 e6 2 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION., CHECK OR Flll IN APPROPRIATE SPACES DATE: _ PATIENT'S N�AgME FalgA.CU__�.._�L d Pk >��: � M ❑ F COMPANY# ADDRESS I / -1 �C�LE4--vIleL, AGE CITY_�. STATELZIP ` ly DOB)'�� SS ❑ Sn ❑ M 16.❑ W 11Th ❑ F O S�-fc DRIVER'S LICENSE a __-_____ _. __�_ PHONE -w�r_ 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) � r L J(� TO SCENE- KS.O. CALL RECEIVED 3 l ��y!se P.rc� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE-3 ❑ FIRE TIME 10-97 ^ ❑ PSAP TIME 10-49 .:A O.- �I dMILEAGE: 13OTHER/PVT TIME 10-7 \ 'J ENnD �• TIME 10-98 DOCTOR __ /ly PMD/o START- - TIME 10-22 HOW CHOSEN: TOTALV1 STANDBY TIME t P,NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY_ I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON ❑ YES RNO ❑ WAL"ED uq GUERNEY O OTHER PATIENT CONDITION: DRIVER " 0 ` ) T-1A f t � TECHNICIAN PARAMEDIC Hx: �� DISPATCHER: HT) _/� ❑ YES NO REASONFORDRYRUNCHIEF COMPLAIN DRY RUN �i AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. a o:5:9 - PRIVATE INS.CO.: BASE RATE: -S�r�-f I KAISER a: MULTIPLE PTS. BASE RATE 7 " BLUE CROSS#: TOTAL MILES: J X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 r ❑ YES ❑ NO NIGHT: (19:00-07:00) y i CCHP/PPRP#: EMERGENCY RQN-, MEDT-CAL a: CODE 2/3 1 I'� OTHER: OXYGEN: (PER TANK) lr� P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) J DATES BILLED: STANDBY: (OVER 15 MIN.) 71 !/ E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE.PART,,_� I.V.: (PER ADMIN.) X - DRUGS: (PER ADMIN.) X �j NAME: RELATIONSHIP; E.O.A.: (IF NOT REPLACED) ADDRESS: ���' ORAL AIRWAY: (IF NOT REPLACED) �M�II CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) - c PHONE: j WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYERV. _QL %2.St('QCCUPATION:4 OTHER: -- �I C(Q� ADDRESS: N LI 10 /.% ' ?. 1 /?�•2 f� .�O•Uh L -43CITY: STATE: ZIP: CO,MYENTS: TQTAL:a• �rJ ) ' JUOM PATIENT RECEIVED BY:X ➢r i•idr- rv• �ti.•,. � n:.:. .. c,. (SIG AT R ) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ' ; UNIT AUTHORIZATION N •' CHECK OR FILL IN APPROPRIATE SPACESQ L 1 DATE: PATIENT'S NAMEVYJILC__ ADCL L A I_❑('F COMPANYM I '` 1� -'- ADDRESSS, •�)Y JTA �.1< AGE - A(20 CITY )L' _ STATE C ZIP DOBl__oJ_�J 1j CI Sn D M.� W O Th O F O S DRIVER'S LICENSE a _____-___-._ _ PHONE_`=J `L1E_�� NATURE OF-DISPATCH5 "l - TYPE OF TRANSPORT: AMBULANCE OTHER❑ _- STATION 1(A 42(B)_3(C)_4(D)_5(EL�. INCIDENT LOCATION: RESPONSE CODE: RFAUESTED BY: TIME— (24 HOURCLOCK) TO SCENE- 0. CALL RECEIVED , ❑ P.D. TIME 10-6 � PATIENT DESTINATION: 3. I I ( c1 lu FROM SCENE- ❑ FIRE TIME 10-97 ^/ oZG/= _. •�I� ,,tt O PSAP TIME 10-49 ^�•;- ��-.I.. 5 P MILEAGE: O OTHER/PVT TIME 10-7 �. END- TIME 10-96 DOCTOR _ vS �� ���1'j PMD(o START - rJ ' 1 TIME 10-22 HOW CHOSEN: TOTAL (' STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER (�J WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBUL� NCE COMPANY: J PT AM U ATORY? PATIENT TA EN�.TO AMBULANCE: RESPONSE ZONE ❑ YES�I NO ❑ WAL°:ED�UERNEY ❑ OTHER PATIENT CONDITION: DRIVER L.�?WC ` �7 EMT-1A TECHNICIAN- P _ t- lT1PARAMEDIC • Hx: O_N � �'i itJ DISPATCHER: �>gR- CHIEF COMPLAINT: -.,1_____4_0 G "znE 2t DRY RUN: ❑ YES O ASON FOR DRY RUN V f �,^�P AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO, OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE3. B #. TOTAL MILES: X MEDICAR tl '� - j� �— E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: 09:00-07:00) CCHP/PPRP M: EMERGENCY RUN: i MEDT-CAL k: CODE 2/3 ����� OTHER: OXYGEN: (PER TANK) �4-p P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: IN.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: _ )l�•5 �5 (�_4� RELATIONSHIPS ) E O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY:_ _.`_ STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION:- OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL 0 -0737 07 PATIENT RECEIVED BY' X (` Provider rvcr! Vhi r,i P:,:; •.p ..-. �. . .... (SIGNATURE) ��- CONTRA COSTA COUNTY ^AMBULANCE �I v PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 r�►• CNECK OR FILL IN APPROPRIATE SPACES DATE: ��/•~ 'PATIENTS NAME O M­O F COMPANY 0 ADDRESS AGE c' CITY - --STATEZIP ..DOB - 1 ' O Sn OM OT OW O Th OF O S DRIVER'S LICENSE N _ - PHONE NATURE OF DISPATCH f TYPE OF TRANSPORT:,AMBULANCE 0.OTHER 13 = STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ 1NFDENT LOCATIONJr/7 RESPONSE CODE:- REOt1ESTED BY: TIME— (24 HOUR CLOCK) yv ( TO SCENE- S.O. CALL RECEIVED \1QQi 2ysL CLQ/ r ��O- r ❑ P.D. TIME 10-8 PATIEI T DEST ATION:.••--- FROM SCENE- O FIRE TIME 10-97 O PSAP TIME 10-49-- } MILEAGE: O OTHER/PVT TIME 10-7 r� END TIME 10-98 DO&OR PMD/ER START TIME 10-22 HOW CHOSEN: t TOTAL STANDBY TIME M-O:NEAREST�' O FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: RESPONSE ZONE PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: O YES .O NO, ,. O WALKED O GUERNEY O OTHER " PATIENT CONDITION:. - DRIVER L ` ', EMT-tA 1 TECHNICIAN ) PARAMEDIC I Hx: "`" DISPATCHER: qq CHIEF COMPLAINT: DRY RUN: EYYES O NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) :1 h PATIENT REFUSED SERVICES:(SIGNATURE) X �J a' MEDICAL COVERAGE: .-. _i INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. M ' •� - `> PRIVATE INS.CO.: BASE RATE: KAISER it: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES O NO O YES O NO NIGHT: (19:00 07:00) CCHP/PPHP#:r' ' ) I EMERGENCY RUN: MEDI-CAL K: r 1 CODE 2/3 OTHER: ' '' ! OXYGEN:. (PER TANK) P.O.E.STICKER O YES O NO J NEONATAL. (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) —NEAREST RELATIVEIRESPONSIBLE PARTY: ' - I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X `NAME: "' RELATIONSHIP:—, E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) `CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) t�tldJ EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: `COMMENTS: �. TOTAL: '.fir 6 a.38 PATIENT QrrrlVrn RY X _ `---.---.-__—.-- CONTRA COSTA COUNTY AMBO.AN.CEE. PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION#kz7-,3> CHECK OR FILL IN APPROPRIATE SPACES DATE:�,J.( PATIENT'S NAMEJ�..._. -1 ❑ M RF COMPA_N,JIY# Mq � 9 33 ADDR . S �y �1 �I -- --- r---._. AG I�/ CITY STATE ZIP�y DOB ,� o s� O M I��p W O Th O F O S DRIVER'S LICENSE a _._...___ _ _ PHONETC(C-1 NATURE OF DISPATCLd TYPE OF TRANSPORT: AMBULANCE OTHER❑ C INCIDENT LOCATION: RESPONSE CODE: REOU O BY: TIME- (24 HOUR LOCK TO SCENE IT� CALL RECEIVED P.U. TIME 10-8 PATIENT DESTI TION: FROM SCENE ❑ FIRE I 1 1 '-1 TIME U-97 ?_�Z- �� �7L' ❑ pSAP TIME 10-49 Js2, --,n -- — -- MILEAGE: ❑ OTHER/PVT TIME 10-7 S-L- �( END- / q TIME 10-98 7 QS . DOCTOR _. _ PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL _ STANDBY TIME 2 NEST ❑ FAMILY ❑ TRANSFER WAIT TIME _- ATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMS LAN COMPANY: PT AA ULATORY? PATIENT TAKEN TO MBULANCE: RESPONSE ZONE L �S 13N0 ❑ WAL',ED ERNEY ❑ OTHER 7. PATIENT CONDITION: DRIVER )`��^� L� � MT-tA TECHNICIAN �"L PARAMEDIC I t' H. _�'-I _ _ \. DISPATCHER4 CHIEF COMPLAINT:`� \L_ RY RUN: ❑ YES O REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) %.___^-_. -- MEDICAL CO ERAGE: INDUSTRIAL ❑ YES O NO. OF PATIENTS: S.S. it / PRIVATE INS. CO.: _ - BASE RATE: �LL� KAISER a: __ MULTIPLE PTS. BASE RATE �j `• BLUE CROSS a: TOTAL MILES: �3 X 50 �'►• SQ MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO I� ❑ YES ❑ NO NIGHT: (19:00-07:00) �ED HP#:_ -_ - EMERGENCY RUN:L a: • ` ' �.ti 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.) % 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 ADDRESS /Uty - CITY: STATE: ZIP: COMMENTS: - — TOTAL: ,z y% r' - - - - 00-739 ' ' ! 39 PATIENT RECEIVED BY:X \` I�nui,frr rr.ui-. G�ir• v i Iti:. .,rp �rc�r. Yr'i..r -nF. " R1. L,h,n tif'ing (SIGNATURE) OIs-1 CONTRA COSTA COUNTY AMBULANCE lk PRE-HOSPITAL CARE FORM 1 UNIT �O AUTHORIZATION F 3 CHECK OR FILL INAPPROPRIATE SPACES I L DATE: PATIFNT'S NAME--4-(- + _',L cJ_�1r^I � M ❑ F COMPANY M ADDR`1 SS Ceut'i � f.s__--- - - AGE CITY__ �'�c' STATE._._ ZIP___ DOB ❑ Sn ❑ M ❑W ❑ ❑ F 0 S DRIVER'S LICENSE p __ ..__. ..._ .. _.._._.__._.__._ PHONE----.,------ NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE OTHER❑ .._____—_-�__. INCIDENT LOCATION: r RESPONSE CODE: REOUESTED BY: TIME— 124 HOUR CLOCK) LL, TO SCENE )PI-S.O. CALL RECEIVED —clg9 S. 9 5-, ❑ P.D. TIME 10-8 ; PATIENT DESTINATION: FROM SCENE �- — ❑ FIRE TIME 10-97 :w. ❑ PSAP TIME 10-49 ~ MILEAGE: OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR - _. _ PMD/ER START TIME 10-22 :/Z HOW CHOSEN: TOTAL _ STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 11: AMBULANCE COMPANY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE. ✓7 RESPONSE ZONE ❑ YES ❑ NO ❑ WAL' ED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER__.. r"' TECHNICIAN 3 Q PARAMEDIC Hx: __LS �_�_I_ )-,�_____.�_�t_��--L: DISPATCHER: e CHIEF COMPLAINT __._—___._____ DRY RUN: YES ❑ NO REASON FOR DRY RUN A'�//77 ORI ATION FO DRY �RUN �(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X-v -t�/�L�� CA.L COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: Css Ic PRIVATE INS. CO.:_.______.-.--__._ BASE RATE: KAISER K: __ _^___� MULTIPLE PTS. BASE RATE BLUE CROSS a __ TOTAL MILES: X MEDICARE K: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP s:___ -- EMERGENCY RUN: I MEDI-CAL N:_ CODE 2/3 } OTHER: OXYGEN: (PER TANK) , P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 11111 -DATES BELLED: STANDBY: (OVER 15 MIN.) r E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V. (PER ADMIN.) X / A` DRUGS: (PER ADMIN.) X NAME:Luw.i►�-GIraQ.r3-.—_— RELATIONSHIP:,LO--,— 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) U EMPLOYER: -- OCCUPATION: OTHER: ADDRESS: CITY _—_ STATE: ZIP:— COMMENTS: IP:COMMENTS: — TOTAL 00'7 .0 .....•.;,•.. - ,�•_ F.. (SIGNnrUPE1 as-I CONTRA COSTA COUNTY AMBULANCE +I� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION a Z 95 7 'NECK OR FILL IN APPROPRIATE SPACES DATE: `3 -t•b "~� PATIENT'S NAME JJV M ❑ F COMPANY M� ADDRESS _L '- ir: �,,n S'=%• AGE .2 3 ��•l; I I Q I t ~ CITY STATE �'r ZIP DOB-3_ ❑ Sn ❑ M JQ T ❑W ❑ Th OF OS -- DRIVER'S LICENSE u ___ _ _ PHONE _L�—L_.J 5�{ _5 NATURE OF DISPATCH (I-_7 -' TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ _ _-y_.._. STATION 1(A)_•2(B)_3(C),X4(D)_5(E)�. INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME– (24 HOUR CLOCK) TO SCENE- 3 ja S.O. CALL RECEIVED Z_::�_ L J=� C ❑ P.D. TIME 10-8 - sp PATIENT DESTINATION: FROM SCENE - 11 FIRE TIME 10-97 _PL ❑ PSAP . TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 \ END__ 1 S TIME 10-98 DOCTOR _lu.�: PMC START ms`s 7 TIME 10-22 HOW CHOSEN: TOTAL % rS STANDBY TIME --^-� -$R NEAREST ❑ FAMILY ❑ TRANSFER - WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER <�� CALL BACK M: AMBULANCE COMPANY: _ PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE --� S ❑ YESNO 11Wf.l':ED�GUERNEY 13OTHER PATIENT CONDITION: DRIVER FC— It 1�7 EMT-tA TECHNICIAN - PARAMEDIC Hx: �e, 1('• VI Vf DISPATCHER: �� E-Q C 4e-, 2- � - CHIEF COMPLAINT: _LL=+.I< IA'A DRY RUN: ❑ YES�'NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X - J MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S.a PRIVATE INS. CO.: BASE RATE: 150�- KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS q. TOTAL MILES: +� X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ - _ - I ❑ YES ❑ NO NIGHT: (19:00-07:00) : CCHP/PPRP k: EMERGENCY RUN: .YS/Y I� {/� MEDI-CAL M: CODE 2(3 ) V OTHER: OXYGEN: (PER TANK) J P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) _ DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ----• nn � DRUGS: (PER ADMIN.) X NAME:_1/�r' Ifs RELATIONSHIP:�41•11-1 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: cz)-� l4L5 COMMENTS: - TOTAL: �� -• •- PATIENT RECEIVED BY:X 974 Provider reta:: Chi tr (SIGNATURE) vis-1 ,•?p� 5et�r+. 7r'.,t• ^r�. !M' utivn bil:inp CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION*En^ Jb1�( CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME ,I J�r ' I,1, E `' ( t , = ; M 13 F COMPANY M I _ ADDRESS �:�- - --_-- AGE l i - _ + STATE-- ZIP_ DOB_L �_� ❑ Sn 13M ❑ T KW O Th O F 0.3 - "{t �� , DRIVER'S LICENSE K __-__._-___.. __.____ PHONE J_-� {��ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ -- - ----- STATION 1(A)_2(B)_31C1_4(D)_5(E) - INCIDENT LOCATION: RESPONSE CODE: R QUESTED BY: TIME— (24 HOUR CLOCK) I l t ,<INp TO SCENE- Z O. CALL RECEIVED ❑ P.D. TIME 10-8 t 1, PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 QG� MILEAGE: ❑ OTHER/PVT TIME 10-7 �`��'?�' / END f TIME 10-98 -t_2_ ? r DOCTOR `` L�1' PMD/ER START 1�_1_L_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER p WAIT TIME ❑ PATIENT O DIRECT I OTHER ML ;I ���� ` <<) CALL BACK b: AMBULANCE COMPANY: , J PT 'AMBULATORY? PATIENT TAKEN TO AMBULANCE: J O RESPONSE ZONE YES ❑ NO 110 WAL'<ED ❑ GUERNEY O OTHER r� PATIENT CONDITION: DRIVER Q) EMT-11A TECHNICIAN 3 PARAMEDIC L I I , Hx: J L Z I T L.1`'l DISPATCHER: - 1 _ CHIEF COMPLAINT: I`.C - j �- 4L `-� DRY RUN: 13 YES Z NO REASON FOR DRY RUN `I AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 'i —� PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YESKNO NO. OF PATIENTS: S.S. q PRIVATE INS. CO.: BASE RATE: - KAISER.#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: / X - MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES ❑ NO 1 / ❑ YES ❑ NO NIGHT: (19:00-07:00) CC�(PPH�,bn :. � I �4��1 1 EMERGENCY RUN: vU• � �� ( I MEDI-CAL b: CODE 2/3 Ii l OTHER: _ OXYGEN: (PER TANK) �f() 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:— COMMENT IP:COMMENT ) CL6lc. - Tt7TAl n n PATIENT RECEIVED BY:X I ...:,•._ ;�.:., (SIGNATURE) EMS-I CONTRA COSTA COUNTY AMBULANCE �f�/�(��� _. PRE-HOSPITAL CARE FORM I UNIT 7 AUTHORIZATION N s}} 7 CNE CX OR flLl IN APPROPRIATE SPACES DATE: PATIENT'S NAME_I��� 1-x,11'\r\D (�(c".r\fL /) — L Q M �❑--��F COMPANY A ADDRESS _ '� f)I/ /� /)L� �� 1 AGE s 2 c 7 CITY I- C( 't?_�. STATEZIP DOB ❑ Sn ❑ M ❑T. jrW btTh: OF �7g "; PHONE—_. L ���� DRIVER'S LICENSE tI�]L.�S CL:J-�_:_ _ -_�39t_ CO NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE'yj OTHER❑ _— STATION I(A)_2(B)_3(C)_4(D)_51E ....._. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- ) S.O. CALL RECEIVED -0-1 : �� la _ _-- .0 <_.� P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 V Ef, 2' ❑ PSAP TIME 10-49. MILEAGE: ❑ OTHER/PVT TIME 10-7 ��>�� -� \ END 1�'' TIME 10.98.,. DOCTOR �-1 PMD/tj START z_U TIME 10-22 HOW CHOSEN: TOTAL I_ STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER L WAIT TIME ~ ❑ PATIENT O DIRECT BOTHER�7E.0 j_Zq%CL )U CALL BACK N: AMBULANCE COMPANY; PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: p RESPONSE ZONE 2 YES ❑ NO WAL',ED ❑ GUERNEY ❑ OTHER f PATIENT CONDITION: DRIVER /' C4 rq 1 V EMT-1A 1 �.,-y- TECHNICIAN�os G5 PARAMEDIC Hx: DISPATCHER: V ? ' CHIEF COMPLAINT: 1�_�SSS'._� DRY RUN: 13 YES IR NO REASON FOR DRY RUN �] (Alli L �'� 1' �4'L> AUTHORIZATION FOR DRY RUN(EMS USE ONLY) y / I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES X NO NO. OF PATIENTS: 12 PRIVATE INS. CO.: BASE RATE: I. KAISER a: MULTIPLE PTS. BASE RATE � \' BLUE CROSS k: TOTAL MILES: X J2_ 6 MEDICARE#: E.O.B. ATT. ROUND TRIP: O YES Ji•NO ❑ YES ❑ NO NIGHT: (19:00-07:00) EMERGENCY RUN:CCHP/PPRP a: �r-.T._ MED(-CAL><: CODEC) L_—�' OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES C0•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 Lf Y L RELATIONSHIP:W) E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE—_ZIP: C-COLLAR: (IF NOT REPLACEDI - - PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: l� OCCUPATION: OTHER: - -- ADDRESS: CITY: STATE: ZIP: COMMENTS: VP- —�- ��> TOTAL: - 1nre, L 11 Irl*2k IN i•Ltov C PATIENT RECEIVED BY: Xr, `S� CONTRA COSTA COUNTY AMBULANCE /J �Z 1 PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION N CHECK OR ML IN APPROPRIATE SPACES DATE: • h I YPATIENT'S NAME O.M ti F COMPANY N ESS. ( AGE ADDR .a.. L4 I g xf / I CITY = vy STAT `oS/r� �� 4G S7 ui76'Oe " O Sn OM ❑T. O W O Th ❑ F 13S ^'• DRIVER'S LICENSE N t PHONE �__ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE D OTHER Cl STATION I(A)_2(8)_3(C)-_4(D)_5(E)_ INCIDENT LOCATIONT N.: RESPONSE CODE: RESTED BY: TIME— (24 HOUR CLOCK) I - TO SCENE;,� PS.O. CALL RECEIVED q :L� m%.NA • 13 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 TIME 10-98 i' EDOCTOR 1 PMD/ERr START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME :. ? �,❑ NEAREST;'? ❑ FAMIL4 O TRANSFER WAIT TIME O PATIENT O DIRECT O OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE OYES ONO . O WALKED O GUERNEY O OTHER PATIENT CONDITIONr - - ) DRIVER - - J C) EMT-tA I TECHNICIAN PARAMEDIC Hx: - DISPATCHER: ZRic 16".6 I o '^ CHIEF COMPLAINT: DRY RUN: O YES O NO REASON FOR DRY R AUTHORIZAT N FO DRY RUN(EMS USE ONLY Y\)� ,• •- - _rte_ P`.,j i�.r.. PATIENT REFUSED SERVICES:(SIGNATURE) X•�_ �7 �I MEDICAL COVERAGE: . . INDUSTRIAL O YES O NO NO. OF PATIENTS: S.S. k 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 .O NO NIGHT: (19:00-07:00) CCHP/PPRP N:n 1 ( EMERGENCY RUN: , MEDI-CAL N: CODE 2/3 `. OTHER; 1 OXYGEN: (PER TANK) a . P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) ti E.K.G.: (PER EPISODE) "—NEAREST RELATIVE/RESPONSIBLE RTY: I.V.: (PER ADMIN.) X i 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) —EMPLOYERS OCCUPATION: OTHER: ADDRESS: '—CITY:----- STATE: ZIP: CV 71 `: lCOMMENTS: - ul TOTALK lcrlj l �I PATIENT'S NA''11:: Aileen Lamson ADDRESS: 2547 Rarra-tt live. Richmond, Ca. r DATE OF SERVICE: 08-17-83 t• .{ ; : AUTHORL7.AT.UN NUMBER:8313931 MOUNT DUE: sQi nn INCIDENT LOCATION: 2547 Barrett Ave. Richmond 1 PATIENT DESTINATION: Brookside Hospital 's r. i -!%T 1 3 .w J t �_♦ 7 1,..i ��, J ,meq f{�` ,t.' ,t , AUG t S 17 AM '83 AUG 17 518 AH '83 AuG 17 5 1.1)(11 ;9 19 AM '83 r SO NUMBER P;'�I�, CAII RECEIVED AMBULANCE DISPATCHED AMBULANCE ENROUTE 10.8 N CALLED BY- PATIENT INFORMATION O NAME: -------- --__.__._. ...--_.. _- ---__.-------- --- � '�� C AGENCY ..- ._ ....- ---- " ------ - CUSTOMER #( DOB. DI- ZDE PI'FLOOR/ROOh1 a; __. ... ._.. -__� NAME: )' UnQg� - __ m v CALLBACK Of PV �_-._-__ _ INS. TYPE: T MCAR <ETZb KHP PHP VA IND CHAMPUS ->i N i I INCIDENT LOC: �.. .. -� ��fl_r L� �'-' POLICY/MCAT#: D7 cl ]N9 30,7 qi(t m = Q - -- ----- .... _.__�..._-_ MCAR #: A D CROSS STREE?: VERBAL PRIG o •� £ 1� -... -- 0 41 a JURIs _-__. C.{Y 1'i,Ll i_1:T1 u-n a.----------- DOCTOR: ----- DESTINATION: -___LJ ff_. `.'(�___._____ PT. #2 NAME: DOB: D NATURE: .. 01G i t^1 _._-.�fc_K.� CUST. a PT, 03 NAME: DOB: c o TYPE OF CALL ItJ�GDTRANS TIME UNIT a jo CUST. p n c� m w CREW: —tab�Y_�J4�]C�V+.i�t�ctI&A CL� WAIT TIME: YES NO REASON: Z y f /� O UNIT TYPE:(lv) BLS WC RESPONSE CODE: 0 1 2 ��4 REASON FOR 10-22: p c rw F INCREASE/DECREASE CODE:2 3 10-49 CODE: 0 1 O2 3 4 CANCELLED BY: ,''„ cn a p J, 1 COMMENTS: _ L u BY: END MILEAGE: p O ; Z (A a TIME: -- BEG MILEAGE: � 8 : _a D PA CHER: TOTAL MILES: - --- Z --- - -- — 00748 P XL- 1 OI1V1S IV 3:)NVlfIBWv 61.01 ONIN21 3DNv1f18Wv 86-01 319VIIVAV 3:)NV1f19WV L-01 1V11dSOH 1V nNV1f18WV ony [1# Nd th 9 ti and Fee Htl Zo 9 tlI IL Tit ir t y' t•1 j, L r .,.4'r�µ,,�. •-.:tip*�..f%rt�- f • lir ' :. �Y t +fie-rsVJ �:•j{d� 1 �.j fr,6��,ta= t�`�TyYI��.v}f'�.M � C w . � t �I ��t•L t, CONTRA COSTA COUNTY AMBULANCE Y` PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M CHECK OR flit IN APPROPRIATESPACES DATE:. ��' PATIENT'S NAME Om ❑ F COMPANY M n ) ADDRESS AGES ` r CITY STATE ZIP DOB ❑ Sn OM ❑ T OW O Th OF O S DRIVER'S LICENSE# - PHONE _ _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ _ - STATION I(A)_2(8)_3(C)-4(D)._5(E)_ INCIDENT LOCATION:. RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- © S.O. CALL RECEIVED %• 3 '_3 ❑ P.D. _-- TIME 10-8 1 -- ` PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _T ❑ PSAP TIME 10-49 �- �,� MILEAGE: ❑ OTHER/PVT TIME 10-7 'T END TIME 10-98 j DOCTOR'-• I PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ?i';.•, ❑ NEAREST O FAMILY ❑TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: C RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER iJ -f 7L PATIENT CONDITION: DRIVER( Gr �« _ EMT-1A TECHNICIANbu PARAMEDIC Hx: DISPATCHER: Lfqq CHIEF COMPLAINT: DRY RUN: fl YES 13 NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1 r' MEDICAL COVERAGE: INDUSTRIAL 13 YES ❑ NO NO.OF PATIENTS: S.S. M PRIVATE INS.CO.: BASE RATE: KAISER M: 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#:'I ( 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: TOTAL:,-ham•1�'✓ 0 0 Ta1 _. PATIENT RECEIVED BY: X. _ !'nii.!nr r. .r • N.r., ..! e... t... „ (SMNAlURE) CONIRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT . AUTHORIZATION N Y CHECK OR FILL IN APPROPRIATE SPACES DATE: / Sr PATIENT'S NAME ���+�.1�Z�� �.1_ _-� � K.,M ❑ F COMPANY M / 2� (/"`��U � AD �ESS --- -- �- -- 1 `==1��l� AGE/�CIT ( �N tt� STATEOI� ZIP DOB_tD(LA50 O Sn OM OT OW O Th ❑ F OS DRIVER'S LICENSE K _.__..—._ _ ._—. PHONtfjg�CJ� _j:? NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ __ STATION I(A)_.2(8)._3(C 4(D)_5(E)� INCIDENT LOCATION: RESPONSE CODE REOUESTED BY: TIME— (24 HOUR CLOCK) ` r l TO� SCENE- XS,0. CALL RECEIVED P"D. TIME 10-8 •L3 l: _ j PATIENT DESTINATION. FROM SCENE11FIRE TIME 10-97 / -7-1 ❑ PSAP TIME 10-49. t nW, MILEAGE: ❑ OTHER/PVT TIME 10.7 END J TIME 10-98 DOCTOR _ PMD® START_ TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST . ❑ FAMILY ❑ TRANSFER _ WAIT TIME - �J PATIENT O DIRECT ❑ OTHER <I CALL BACK M: AMBULANCE COMPANY/�q 5 P�} AMBULATORY? PATIENT TAKEN TO AMBULANCE: Q ' RESPONSE ZONE ( ' �C3�YES ❑ NO ❑ WAL':ED XGUERNEY ❑ OTHER PATIENT CONDITION: DRIVERM (nuc SgU EMT-lA TECHNICIA r 9 b() PARAMEDIC S Hx: tti( �� CL�-�\}( � / DISPATCHER: CHIEF COMPLAINT:�1�ti/1/` Z�MA DRY RUN: OYES ❑ NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 'f I PATIENT REFUSED SERVICES: (SIGNATURE) X-_._._ - 1 I MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �`S- /' S.S. a Z Z;el PRIVATE INS. CO.: BASE RATE: KAISER a: MULTIPLE PTS. BASE RATE _ BLUE CROSS 4: TOTAL MILES: X MEDICARE M: E.O.B. ATT. ROUND TRIP: O YES O NO ~ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP,'PPHP#: EMERGENCY RUN: - i MEDI-CAL a: 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) 1 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 EN IP:COjIENJ7 ' Uao-i A � TOTAL: __. _ SL PATIENT RECEIVED BY:X _ Provider recoi�. Vhi•, .•r? 1 ..: •,�i4 SCCLT .•n • . _vNr whin DiVing (SIGNATURE) Dlf-1 &INTRA COSTA COUNTY AMBULANCE � BUL � Z P E-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION O 3/ �s CHECK OR FILL INAPPROPRIATE SPACES " DATE: PATIENTS NAME G�1 Nl7 E 1 A/u//v I OM *F COMPANY It ADDRESS �`7 ��, PLO-O- & AGE CITY_ i`�. STATE ZIP ` L, D/O/B���- ❑ Sn O M O T 1P O Th O F O $ DRIVER'S LICENSE R — _ PHONE NATURE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ — __ STATION 1(A) 2(8)_3(C)-4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: EQUESTED BY: TIME- (24 HOUR COCK)_ TO SCENE 4S.O. CALL RECEIVED it Res f ❑ P.U. - TIME 10-8 y 01 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 i :c,�_" ❑ PSAP TIME 10-49 " U No3' MILEAGE: ❑ OTHER/PVT TIME 10-7 a a- ENDTIME 10-98 DOCTOR K► J C'S PM /ER STAR TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST O FAMILY 13TRANSFER WAIT TIME � a PATIENT ❑ DIRECT ❑ OTHER go CALL BACK M: AMBUL C COMPANY: PT. AM PATIENT TA EN AMBULANCE: `��, RESPONSE ZONE / ❑ YESrNO D WAL'<ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER//'- / 1 r C'•1F-' j �; EMT-1A TECHNICIANO, "�<:k �'.'1[: •i1��`'L PARAMEDIC }' I Hx: `IZ .n.�p DISPATCHER: �G4�C�-1�� L•.� E 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. R _53 a_ _n V Z110 -7 IVATE CO.. C(`-Kf'c('l �o(,A L•�)-- BASE RATE: KAISER N: - 1ry�4�'J f1r1� MULTIPLE PTS. BASE RATE BLUE CROSS M: %�O^l^1 /_ 4 TOTAL MILES: MEDICARE C ' E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: � J MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: P �^ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: I]L5�1 ~ ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE--ZIP: C-COLLAR: (IF NOT REPLACED) PHONE- WORK WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: 1 �_ OCCUPATION: OTHER: lII ADDRESS: 5 CITY: STATE: ZIP: COMMENTS: o 74 � --- 1 t7 I TOTAL 0 0'7 49 PA 111 NI IILI;I IVI 1)BY X --- r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT P.7 AUTHORIZATION 0 53- 1 7 CHECK OR flLl IN APPROPRIATE SPACES DATE:-- J J PATIENrsS NAME ❑ M ❑ F COMPANY 10 ADDRESS. •'�'" � AGE~ CITY STATE ZIP DOB O Sn ❑ M OT W O Th O F OS DRIVER'S LICENSE 0 �- ) - PHONE �_ NATURE OF DISPATCH ' 179 TYPE OF TRANSPORT: AMB ULANCEIX OTHER 0 STATION 1(A)_2(B)_3(C)_4(0)-_5(E)E i INCIDENT-LOCATION.' RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) ?�/�'� ---� TO SCENE-.Qp RL S.O._ CALL RECEIVED 1� : 37 _ 2�-/t,A / �t�lV `• _ ❑ P.D. TIME 10 8j� 7 PATIENT DESTINATION: FROM SCENE- D FIRE TIME 10-97 �Q`� (j ❑ PSAP TIME 10-49 Dl`n yGr11x Q MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10.98 rDOCfOA ' t PMD/ER L START TIME 10.22 ` / : HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST, D FAMILY ❑ TRANSFER WAIT TIME D PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: CJ�� RESPONSE ZONE D YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: ( DRIVER L_G C'vEMT-1A TECHNICIAN � , - PARAMED jjt Hx: DISP O(oATCHER' r • ` CHIEF COMPLAINT: .DRY RUN: YES ❑ NO REASON FOR DRY RUN ti�l�'r/SJ Jy2� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 't. PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. 0 PRIVATE INS. CO.: BASE RATE: KAISER R: ` . MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE 1t: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO O YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N:^ ' , I EMERGENCY RUN: MEDT-CAL N: - ` i ' t 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) z. PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER-- - OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: TOTAL: 0 PATIENT RECEIVED BY: X 0 •. ...�r.... .... .. .. (SIONA itlnt'1 I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT [1-3-] AUTHORIZATION CHECK OR FILL IN APPq OPp1A7E SPACES DATE: PATIENT'S NAME MXF COMPANY#� A-7008 ADDRESS _ L� I �►-- C I �Q-,S4 N AG 19 I /� CITY �C,I�c1rW�c? STATE Q �— ZIP! DO ___` _L�❑ Sn O M O T O Th O F O:S ' DRIVER'S LICENSE PHONE Q1 VATURE OF DISPATCH 1 TYPE OF TRANSPORT: AMBUL-ANCt❑ dTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) ����U ^1 TO SCENE CALL RECEIVED I� :3 C + ' 1V ❑ P.D. TIME 10-8 PATIENT DESTINATION: ��,( '� I✓) FROM SCENE- ❑ FIRE TIME 10-97 O PSAP TIME 10-49 - MILEA 0_0THER/PVT TIME 10-7 .•� ' '�' END TIME 10-98 J l DOCTOR _ .-_ _ PMD/ER START- TIME 10-22 `" HOW CHOSEN: TOTAL -_ STANDBY TIME 0 NEAREST "_�,ILY ❑ TRANSFER WAIT TIME -TIENT O DIRECT ❑ OTHER 5 CALL BACK#: AMBULANCE COMPANY: PT. AMBULATORY') PATIENT TAKEN AMBULANCE. tJ RESPONSE ZONE S ONO 13WAL',ED UERNEY O OTHER PATIENT CONDITIOPJ: DRIVER-_-]/" 31 J rw n'Lc m TECHNICIAN_r PARAMEDIC Hx: ._._ _�.__- __-_`__ DISPATCHER: lam/IL I,C)F J CHI OMPLAIN ._��Z V'�v� DRY RUN: ❑ YES f, NO REASON FOR DRY RUN --- AUTHORIZATION FOR DRY RUN.(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL CO DU T IAL ❑ YES ❑ NO NO. OF PATIENTS: PRIVATE INS. CO.: _—_ BASE RATE: KAISER tr: _ _. MULTIPLE PTS. BASE RATE r BLUE CROSS# TOTAL MILES: X MEDICARE #: E.O.B. ATT. ROUND TRIP: O YES ❑ NO o vJ d S OYES ❑ NO NIGHT: (19:00-07:00) 1 CCHP,'PPHP#: EMERGENCY RUN: �� a i U� 1 MEDI-CAL a: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL (INCUBATOR) DATES BILLED: - STANDBY: (OVER 15 MIN.) E.K.G-: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN) X Vun (�{,, S DRUGS: (PER ADMIN.) X NAME:_ �r`__ 1"r R1ELATIONSHIP 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: -J~J PATIENT RECEIVED BY: f� ufJrr ry tai: ��itr .xd p:r.: .•'gyp Arts} Y,' _ .^f. f.7/5 ;.,hr-, t•i1_ RE) OIS-1 ,��.. t�-8-$3 a-ty,rpz.- y` CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT P7 AUTHORIZATION# 5 CNECU 014 FILL IN APPROPRIATE SPACES r •„ ,., DATE: �• PATIENTS NAMES_TL40jLll i9 + 'A ��T J^f�l.F I II � 1/M �-❑,�F COMPANY# r - ADDRESS. 1(24 7I ,��1N 016LOAVC.Q 23 1 AGE�_�_�Z CITY Avt_ J-ASTATTE�',-`IC ZIP 490 -DOB I I42- 1 0 Sn ❑ M O T. O W O F -9f"VE" LICENSE# —!CZ�15cL1 L PHONE _U A) NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE a OTHER _--I STATION I(A)_2(8)_3(C)'f'A(Dl_"50E INCIDENT LOCATION: RESPONSE CODE: RE�UESTED BY: TIME—(24 HOUR } / r CI^ /y n� TO SCENE- 19.S.O. CALL RECEIVED [CO ( � c7 !'1i 1/�• i ❑ P.D. TIME 10-8 ;'I' PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP -TIME 10-49j.A011 _ MILEAGE —� O OTHER/PVT TIME 10.7 E1 N END 5 3�3 TIME 10-98:� DOCTOR PMD/ER START - TIME 1022 j HOW HOSEN: TOTAL — STANDBY TIME G4 NEAREST ❑ FAMILY ❑ TRANSFERWAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER / CALL.BACK#: AMBULANCE C MPANY:1), - -_ .1 !Z'' a .1 {.�,T •4. PT. AMBU TORY? PATIENT TAKEN TO AMBULANCE: ,--• •---�U RESPONSE ZON rep ❑ YES lNO ❑ WAL'<ED O�GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER L-wp_ pl o. EMT-IA I �--/�7, n TECHNICIAN P AMEDI 7 8 Hx: D14 • CADISPATCHER: � C ;1 CHIEF COMPLAINT: L A-IC, Tb NCxts DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLO. • s; 9 I PATIENT REFUSED SERVICES:(SIGNATURE)X tom; // r• 111 ° i•. MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S. # °55b- 8(343 --- PRIVATE INS. CO.: r BASE RATE: - 31 s KAISER w MULTIPLE PTS.BASE RATE BLUE CROSS#: 17 TOTAL MILES: 7 v' X MEDICARE#: E.O.B. ATT. ROUND TRIP:"'❑ YES O NO ❑ YES '•L) NO NIGHT: (19:00.07:00) CCHP/PPHP#: EMERGENCY R `MEDI-CAL#: No CODE 2 3 7:;I•.Iaa�' X `\\OTHER OXYGEN: (P TANK) rt (1!1Yj F. E ICKER ❑ YES ❑ NO V"� NEONATAL: (INCUBATOR)rN�'I3W 3�'.c.e: _)X DATES BILLED: STANDBY: (OVER 1S MIN.) ; L I" E.K.O.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: - I.V.: (PER ADMIN.)* ' - X^"" s C� � 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) .fir•_, EMPLOYER: OCCUPATION: OTHER:-- ----- -- --- - ADDRESS: ✓J./ /�f�b �s•CJD 6� CITY: STATE' -ZIP: - - COMMENTS: IrVf- — F6106 199 4764 O - --,r ----- TOTAL: "`! - - tk • • i;. rZ� --- - - PATIENT RECEIVED BY• Provider rrrn'- �f:ry ,,a n:.: ,.,r� s ..,.— .. ,. ...•• ..�... .:• ISIGNA URE) ENt_I'. CONTRA COSTA COUNTY' AMBULANCEe )v ,� /,/) D PRE-HOSPITAL CARE FORM 1 UNIT ^� AUTHORIZATION N S �• 1 •, CNECK OR FILL IN APPROPRIATE SPACES - DATE: /'•�� 1�•'�' PATIENT'S NAME ❑ M ❑ F COMPANY N ADDRESS AGE CITY STATE__ ZIP T_ DOB " ❑ Sn O M ❑ T O W 13Th 13F 13S I . DRIVER'S LICENSE N — PHONE NATURE OF DISPATCH n•'� A�t_CC TYPE OF TRANSPORT:. AMBULANCE❑ OTHER O _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)A INCIDENT LOCATION:' '•�/L� RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- III S.O. CALL RECEIVED • 1e - l/!.1nD� f L� C. �r O P.D. TIME 10-8 u"., PATIENT DESTINATION: FROM SCENE -/, 13FIRE TIME 1x97 U ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 j'DOCTOR PMD/ER START--- TIME 10- 22 L C HOW CHOSEN: TOTAL STANDBY TIME '�� -':• .❑ NEAREST ❑ FAMILY ❑ TRANSFER I WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY O OTHER :ter. PATIENT CONDITION: DRIVER "J �L )�C.t..0-�_1 (off (_) EMT-tA TECHNICIAN PARAMEDIC Hx: DISPATCHER: N le yQ/ CHIEF COMPLAINT: DRY RUN: t3 YES 11 NO REASON FOR DRY RUN-' I 'r AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 95y MEDICAL COVERAGE: INDUSTRIAL O YES ❑ NO NO. OF PATIENTS: L/ S.S. N �. PZISER TE INS. CO.. BASE RATE: K $C MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE 0: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:' EMERGENCY RUN: MEDT-CAL 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/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) 4. EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY:- TATE' ZIP: COMMENTS: - TOTAL: �,� �� Cy 00175 c ' PATIENT RECEIVED BY: X n.....,i._ ,r.. „.. ISIGNA tURF) " CONTRA COSTA COUNTY AMBULANCE / L� PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N J2/17 a CHECK OR FILL IN APrROPgUTE SPACES DATE: PATIENT'S NAME S�il� ��'`_L!_'_i 1_LL 12-M ❑ F COMPANY N t ADDRESS 1 L)�1 -1 / `Y�� AGE f f �' fj ��%'J > STATE_C'/ ZIP�__ DOB ❑ Sn ❑ M ❑ T O W ATh O F S- - t DRIVER'S LICENSE b ___ PHONE ________ NATURE OF DISPATCH SI �- e .�. TYPE OF TRANSPORT: AMBULANCE-OTHER Cl STATION 1(A)_21B)_3(C)_4(D)_5(E) .--•--' INCIDENT LOCATION: RESPONSE CODE: REOUESTEO BY: TIME- (24 HOUR CLOCK) A / TO SCENE- � CALL RECEIVED 3'� o� 1' U L 1`1 /����/c�[/! ) 4- ❑ P.D. TIME 10-8 T•sv t PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97rs c� l\( y- ❑ PSAP TIME 10-49 dll ( 1 l� MILEAGE: 13OTHER/PVT TIME 10-7 END TIME 10-98. -- DOCTOR PMO/ER START TIME 10-22 ZI: 7 - HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: , PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: r RESPONSE ZONE ❑ YES ❑ NO ❑ WAUIED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER '-zoc) EMTT1 TECHNICIAN L 3 5 PARAMEDIC t'ATA Nx: MG DISPATCHER: -1 c : CHIEF COMPLAINT: �Nt DRY RUN: ,AYES ❑ NO REASON FOR DRY RUN I A THORIZA ION FOR RY RU EMS E ONLY)- PATIENT NLY)PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES 7KN0 'NO.OF PATIENT : .. Cs-s.1 .5& -7 3�i -S� fS(Q ... `" PRIVATE INS. CO.: BASE RATE: , - KAISER a: MULTIPLE PTS. BASE RATE BLUE CROSS it: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO T ❑ 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 Cl 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: C STATE: ZIP: COMMENTy�; � T (JO! - S L_Gb i E T: I 1 CONTRA COSTA COUNTY AMBULANCE ',7Q3_ PRE-HOSPITAL CARE FORM I UNIT [� AUTHORIZATION CNECK OR FILL IN APPROPRIATE SPACES - DATE: 'PATIENTS NAME OM ❑ F COMPANY M ADDRESS • ' AGE_' CITY STATE ZIP__�_T__ __ DOB O Sn ❑ M OT OW / Th OF EfS EA -CL LICENSE N ' PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:. AMBULANCE 0 OTHER 0 _ STATION 1(A)_2(B)_3(C)_4(D)_5(E)._ <C INCIDENT LOCATION } r�r' RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR C K) TO SCENE- 2 S.O. CALL RECEIVED L� J Ac-g (AJ -114t ad)( PL►s a� 1yY�: � . '0 J ❑ P.b. TIME 10-8 PATIENT DESTINATION: .. I FRO CENE ❑ FIRE TIME 10-97 �L� I ❑ PSAP TIME 1049 /j CMILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 i.bbCTOFI t I I PMD/ER START TIME 10-22 s_ HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT O DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' PATIENT CONDITION: i DRIVER T � LL L� U[) EMT-1A jeA C Ej! TECHNICIAN L4, C' ! 7 PARAMEDIC Hx: DISPATCHER: —T �^ cQ Ll GHIEF COMPLAINT: DRY RUN: y� YES ❑ NO REASON FOR DRY RUN 10-11 L��L"� q qq l AUTHORI TION FOR DRY RUN(EMS USE ONLY) ;'. PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. k 1 1 ' PRIVATE INS.CO.: BASE RATE: KAISER R) MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE C. E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDI-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) 'y NEAREST RELATIVE/RESPONSISLE 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:rZIP:(�rr COMMENTS:�� �L�(� lij ac '1� % P Eh TOTAL I ' _-. ------ ----- -. _ _.... PATIFNT PFrFIVFn Ry X .� CONTRA COSTA COUNTY AMBULANCE �� ., PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M t3 - <-. CNECK OR Fit IN APPROPRIAT(SPACES DATE: .y PATIENT'S NAM[---_ '.�--(_ /,_-- > M ❑ F COMPANYM ADDRESS �'1_/S—� f?%/c�/C /� UC/���A AGE �' / _ CITY `� r �:' STATE �� ZIP��✓. _/ 1Z _ - — DOB ❑ Sn ❑ M ❑ T ❑W WU OF .3 S' DRIVER'S LICENSE a _._______ _ �_—_ PHONE _%�� _ NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEP.OTHER❑ __ _ STATION 1(A)._2(9)_3(Cl_4(D)_5(E)_�_W---_. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- ikS.O. CALL RECEIVED LLF Y O P.U. TIME 1D-8 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 .3 ' U TIME 10-22 HOW CHOSEN: TOTAL I STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER ( - WAIT TIME O PATIENT EIRECT 11 OTHER 1 CALL BACK N: AMBULANCE COMPANY: I PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: j C7 RESPONSE ZONE 2 ❑ YES O ❑ WAL'CED NZUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �u0l�L� ' 1 C� FluT-IA / r 1 �� ,l TECHNICIAN ,)X ke. I D PARAMEDIC 1 Hx: f j�/ /DISPATCHER: I CHIEF COMPLAINT. l c�?� `'Z >'/� G�� DRY RUN: ❑ YES NO REASON FOR DRY RUN --' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) { PATIENT REFUSED SERVICES: (SIGNATURE) X_ - ' MEDICAL COVERAGE: INDUSTRIAL ❑ YES Vt_40 NO. OF PATIENTS: PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUECROSS M: TOTAL MILES: �� , X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) \ CCHP/PPRP k: EMERGENCY RUN: S� ` MEDI-CALM: CODE•2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ggA 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) 1 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 00756 ` Provider retain. Yhi rr +d n:" .� � ..,- � . . � - �.. (SIGNATURE) [TIC-I r CONTRA COSTA COUNTY AMBULANCE I 3 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M 2 I I. CHECK OR FILL INAPPROPRIATE SPA�C7ES DATE: IX ' ;. PATIENTS NAME I ` ❑ M ❑ F COMPANY t�� D ADDRESSoe AGE ALU CITY STATE ZIP DOB_ ❑ Sn OM ❑ T O W ❑ Th ❑CSF ❑S DRIVER'S LICENSE N _ PHONE -- NATURE OF DISPATCH — TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: �'�� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR C O"K) t -� OLVb , O TO SCENE- 3 S.O. _ CALL RECEIVED Ci� ❑ P.D. TIME 10-8 iPATIENT DESTINATION: fJ 0 0 FROM SCE N - ❑ FIRE TIME 10-97 I _ ❑ PSAP TIME 10-49 P2 1,`: `^ -� n� t d MILEAGE:^ ❑ OTHER/PVT TIME IU 7 END TIME 10-98 t DOCTOR PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE CO PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER _ .(?U PATIENT CONDITION: DRIVER rn�I I I Q_� �` EMT-1A II '; j I:•' TECHNICIAN PARAMEDIC L� Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN/ATION YES ❑ NO REASON FOR DRY RUN 4' qr' AUTHORI FOR DRY RUN(EMS USE ONLY) t l PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. # PRIVATE INS. CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP 4: 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/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: 1 �SyT,ATE: ZIP: COMMENTS: _G3'1�1 P t 1J T TOTAL. P°i PATIENT RECEIVED BY: X F?•+ . '.r �. �;: ...i (SIGNATURE) .. .. r., .i., EMS-1 c ��1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT /� AUT ORIZATIONN CHECK OR PILL IN APPROPRU TE SPACES DATE: ATIENS NAEP ' O M 13 F COMPANY O ADDRESS AGE f,.4 r4 CITY STATE ZIP DOB ❑ Sn OM ❑ T ❑ W ❑ Th ❑ F OS i DRIVER'S LICENSE S _ PHONE _ NATURE OF DISPATCH I TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ STATION-1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: S� �> RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- , � O"S.O. CALL RECEIVED /� ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE - ❑ FIRE , TIME 10-97. ❑ PSAP TIME 10-49 J�� =•j"_.L "'I 0 �f MILEAGE: ❑ OTHER/PVT .TIME 10-7 � I END TIME 10-98 DOCTOR' PMD/ER START 1 TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK w: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ) RESPONSE ZONE fT ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER t /�/�°/s1-�,/i' 11.l�% PATIENT CONDITION: DRIVER EMT-1A TECHNICIANS/ .' ' �f% 1� PARAMEDIC Hx: DISPATCHER: ( n I j CHIEF COMPLAINT: DRY RUN: 0 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: IA 1 S.S. # PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE R: N ��'1 - C` " —'TZ�' E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL R: 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 i 00758` PATIENT RECEIVED BY:X I (SIGNATI'AF) CONTRA COSTA COUNTY . AMBULANCE f ) �- PRE-HOSPITAL CARE FORM I UNIT �! AUTHORIZATION / LL CHECK OR FILL IN APPROPRIATE SPACES DATE: tl y PATIENT'S NAME17Q L r C:r'_ -S J Rte. O M [ F COMPANY M_ ADDRESS 1-7 t� u� AGE CITY. r STATE_ ZIP U I DOB9---/- G -OSn OM O T OW O Th C 0S_ DRIVER'S LICENSE a PHONE,;7 3 -�.�-� NATURE OF DISPATCH��!"U-`��t�_�Q TYPE OF TRANSPORT: AMBULANCE L) CTHER❑ __ _ _— .- STATION 1(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME - 24 HOUR CLOCK r7 v '� /� TO SCENE- ❑ S.0. < CALL RECEIVED __---- �' Q P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE FIRE TIME 10-97 O PSAP TIME ID-49 -�- MILEAGE: ❑ OTHER/PVT TIME 10-7 — 1� END TIME 10-98 I�• � :�i, �- �• DOCTOR ._ So T PM /ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 0: AMBULANCE COMPANY: -. CIT PT AMBULATORY? PATIENT T 1311E 13O AMBULANCE: �, RESPONSE ZONE YES NO WAL';ED GUERNEY OTHER K PATIENT CONDITION: DRIVER m/ ll�I1Yds/ ,r r7 '0EMT-1A_ TECHNICIAN �_�-��l T14ti't/�� PARAMEDIC 1 Hx: � 2_ ,�, ��� DISPATCHER: �lN ''' 00 j CHIEF COMPLAINT: _���� Q� DRY RUN: O YES IIVO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— ''ff MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: 'SlCJ S.S. #---T--��,T{ ^ PRIVATE INS. CO.:� -� 1 %lJ �- 11) BASE RATE: KAISER P: MULTIPLE PTS. BASE RATE _ BLUE CROSS#: TOTAL MILES: X 1 MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP;PPRP a: EMERGENCY RUN: C) MEDI-CAL a: CODE 2/3 OTHER OXYGEN: (PER TANK) JJdi' 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 rti.,r"��^ rr•.: L'6j ...1 c:.: .rp - Grl:. v-•,..,,. ro- ..4r t.. r� IGNAT E) U�S-1 CONTRA COSTA COUNTY AMBULANCE ] PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENTS NAME- ulV ��A V t' i ! /� il'v"` T � M ❑ FR COMPANY N ADDRESS AGE A lvolfAl CITY STATE ZIP DOB O Sn OM ❑ T OW O Th &F O S DRIVER'S LICENSE N ) PHONE NATURE OF DISPATCH -1td1eV•4Al TYPE OF TRANSPORT: AMBULANCE 0 OTHER O _ STATION 1(A),X2(8)_3(C)_4(D)_5(E).._ 4 INCIDENT LOCATION: '\L� RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) A (� TO SCENE- Q S.O. CALL RECEIVED ✓ 2 ❑ P.O. TIME 10-8 �p PATTEN DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 p �; } I O TIME 10-49 �U -ZZ OTHER/PVT L MILEAG O OTHER/PVT TIME 10.7 END TIME 10.98 ` DOCTOh.i ;f_' ) PMD/ER START TIME 10-22 ` > HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER WAIT TIME -- ❑ PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 510 RESPONSE ZONE � ❑ YES ❑ NO D WALKED ❑ GUERNEY O OTHER ) PATIENT CONDITION: DRIVER NO T-1 TECHNICIAN PARAMEDIC Htt: DISPATCHER: 'j nni CHIEF COMPLAINT: DRY RUN: AYES ❑ NO REASON FOR DRY RUNT7T���u (�[y AUT RIZ N F RY UN(EMS USE ONLY) ( T ! PATIENT REFUSED SERVICES: (SIGNATURE)1Q"S ` ta` 5 MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S.N PRIVATE INS.CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO D YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) I P.O.E. STICKER O YES O NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) -" NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X 'NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) " CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) V V PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: * STATE: ZIP: -' COMMENTS: n (� n11 d)0 1 TOTAL: �.. _ FIAT IF lIT nrrri,,!•n r, v CONTRA COSTA COUNTY AMBULANCE `}�•� j'�`) PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M.f_� CHECK OR FILL IN APPROPRIATE SPACES DATE: 2-w� ❑I M O F COMPANY N "PATIENTS NAME ADDRESS AGE1 C 1101 1C' 1 CITY STATE— ZIP DOB ' ❑ Sn ❑ M O T O W O Th F Q $ DRIVER'S LICENSE N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:I AMBULANCE D OTHER❑ _ -- STATION 1(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:: , RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) a� . TO SCENE- S.O. CALL RECEIVED C l l �J F Y O P.D. TIME 10-8 `. PATIENT DESTINATION: FROM SCENE - 0 FIRE TIME 10-97 w i1 11 PSAP TIME 10-49 ��Yc:::r�.,.c- !'• ._.'i r: I MILEAGE: 0 OTHER/PVT TIME 10-7 END TIME 10-98 ILDOCTOA i).. ' + PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST. 2 ❑ FAMILY O TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY: c�tS' PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5/0 RESPONSE ZONE . .937 O YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ( Q i PATIENT CONDITION: DRIVER ` 8 EMT-tA TECHNIC IA PARAMEDIC E>K, Q Hx: DISPATCHER: 1- LA` ICiI;I (� CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN (f (f AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 4 / PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: i S.S. 0 ! PRIVATE INS.CO.: BASE RATE: KAISER R: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE K: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO Cl YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL 0: 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) C EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: '- COMMENTS: TOTAL: 761. PATIENT RECEIVED BY:X CONTRA COSTA COUNTY AMBULANCE Q L� PRE-HOSPITAL CARE FORM I UNIT � AUTHORIZATION I CHECK OR FILL IN APPROPRIATE SPACES DATE: / —7 'PATIENTS NAMEnE N K (�`�`; T��II l,,K J �� � ❑ F COMPANY I ADDRESS N� 6161 kr.n�)�a[�1� AGE qU CITY l STATE ZIP DOB! ❑ Sn OM OT OW ❑ Th F"Us DRIVER'S LICENSE I tA- PHONE NATURE OF DISPATCH S TYPEOFOF TRANSPORT: AMBULANCE GYOTHER _..__ .._ .. STATION I(A)_2(8)_3(C)_4(D)_5(E1. INCIDENT LOCATION: RESPONSE CODE: REO�IESTED 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 L Q ❑ PSAP TIME 10 49 `4 e -N - '`" MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR 1 f l7 PMD R START TIME 10-22 HOW OSEN: TOTAL STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER I ) 1 CALL BACK I: AMBULANCE ffWA�IY: PT. AMBU�LARY? PATIENT TAK�EN�O AMBULANCE: j+r RESPONSE ZONE//T�SS ❑ YES C20 ❑ WALKED "IF ❑ OTHER I PATIENT CONDITION: DRIVER rtf°�ySCfJ ir' .AT-tA TECHNICIAN PARAMEDIC Hx: 11// DISPATCHER: CHIEF COMPLAINT: W --'_ VVvleSS. 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: L" s.S. I 3a4 4- (o PRIVATE INS. CO.: BASE RATE: / 7) ii KAISER I: MULTIPLE PTS. BASE RATE TOTAL MILES: X J ��'✓'' 1' MEDICARE I: �7—(1(-- E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES U NO NIGHT: (19:00- 07:00) CCHP/PPRP I: EMERGENCY RUN: J r J� MEDI-CAL C CODE 2/3 / I 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: ENKINS tCiCiaRELATIONS MT-'"L4 E.O.A.: (IF NOT REPLACED) ADDRESS' e S ORAL AIRWAY: ,(IF NOT REPLACED) CITY: STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: 034 -S-)yy WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: MMTTS:►� { - a vlg6If' 4o -Si,!I Ct u e -4o rs5 — TOTAL:-L� - �- - PATIENT RECEIVED By' X - • Pmwilar rttair, White ..r.d f'i.:: ,•,,rF SatLni r', r •,.L, • . ��.. i.h:'• FiI i•i,I LMS-1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION 0 2 1 I Y Q Y-7— 7t 1 I CHECK OR FILL IN APPROPRIATE SPACES DATE: /if J PATIENT'S NAME—�!LC C_i;uLl�_ O M PrF COMPANY 0 r ADDRESS -j-_7!l- Ll AGE �y � CITY -'C STATE ZIP L_'Lh ?� DOB_ah,,&O_ ❑ Sn OM OT OW O Th �F O S'1 DRIVER'S LICENSER __.t _____S__.:t:'—_ _ PHONES11 NATURE OF DISPATCH Y1l N L'I.r r1 l 1 TR"05. TYPE OF TRANSPORT: AMBULANCE p OTHER❑ STATION 1(A)_2(8)_3(C)_4(D)_5(EI_ •-�-I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) C C TO SCENE- S.O. CALL RECEIVED ('r ,tet• CSQ�_ z ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 :O ! r( - - 2--- O PSAP TIME 10-49 a6 I � __�Lr^__rr d'l• > j .i. ' MILEAGE: ❑ OTHER/PVT TIME 10-7 — - END 67•& TIME 10-98 47. DOCTOR �L Lrr �� !3 PMD'!ER START 0 *,)• 3 TIME 10-22 --� HOW CHOSEN: TOTAL `)- 3 STANDBY TIME ❑ NEARESTFAMILY 13TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: CR 1 27 PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5/0 RESPONSE ZONE b ❑ YES NO ❑ WAL'<ED GUERNEY ❑ OTHER d 1 PATIENT CONDITION: DRIVER_ ��►a (k VA 3BO EMT-tA 77 TECHNICIAN R L h et 4 _-�, 130 PARAMEDIC u Hxt'i A�-� 4a1�—ALL fI i n _[t.r-t,rn it DISPATCHER: H01=1 f_ CIA1.0 100 (f 1 CHIEF COMPLAINT: / DRY RUN: ❑ YES E1,440 REASON FOR DRY RUN AUTHORIZATION F R DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X— MEDICAL COVERAGE: INDUSTRIAL ❑ YES 19"NO NO.OF PATIENTS: C PRIVATE INS. CO.: BASE RATE: KAISER R: MULTIPLE PTS.BASE RATE BLUE CROSS a: �� TOTAL MILES: s X —� - c�, (MEDICARE A; �� �f Q % C' J E.O.B. ATT. ROUND TRIP: ❑ YES O NO ~ O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: ' MEDT-CAL#: CODE 2/3 ! t� 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:r 1 n•+_./�1I_'!/ RELATIONSHIP: �r�a:1 P ,E.O.A.: (IF NOT REPLACED) 7qADDRESS:( f 70c-r,�r rt:i. Il: Ll I?C-4 / ORAL AIRWAY: (IF NOT REPLACED) CITY:_J�N STATE_c+o. ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: f 1 y 2 `I 7 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: - - ADDRESS: CITU: STATE: ZIP: COMMENTS: 2 Ic Pt I .S'3 1'i .1 r I? TOTAL: Pp.,- ; F, c P C'Y. 7Y0 '/c/. P4�i( ./( ./ cllr(_Jaci. Imir _ PATIENT RECEIVED BY: t+�•,ii!r- �.�:. yi..., .•� . •-r� GrtLr Yr.. n,_ (SIGNATURE). rhea hil'iaa OIS-1 CONTRA COSTA COUNTY AMBULANCE Q� PRE-HOSPITAL CARE FORM I UNIT 1 AUT, ORIZATION#60 141 �1 CHECK OR FILL IN APPROPRIATE SPACES DATE:' (, I l� 73 - } j ' 'FATIENT5 NAME OM OF COMPANY 0 ADDRESS; ^' a AGE, I�) , CITYr' I i, STATE��.ZIP S DOB 13S O M O T 0 W O Th F O S i DRIVER'S LICENSE M N PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:i AMBULANCE❑ 'OTHER❑ _ STATION 1(A)_2iB)_31C)_4(D)_5(E)_ 1 INCIDENT LOCATION: ' RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLOCK) J � TO SCENE- X S.O. CALL RECEIVED `� 11 ❑ P.D. TIME 10-8 �� I PATIENT DESTINATION: FROM SCENE-d ❑ FIRE TIME 10-97 D�Y ❑ PSAP TIME 10-49 1n I' ` ~' `1 T ' MILEAGE: 11OTHER/PVT TIME 10-7 T '�- 1 END TIME 10-98 :-DOCTOR' ► - 1 PMD/ER START TIME 10-22 s HOW CHOSEN: ___.._.. TOTAL STANDBY TIME O NEAREST •? Cl FAMILY O TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK 8: AMBULANCE COMPANY � PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: to RESPONSE ZONE ' ❑ YES ❑ NO _., O WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �' ( EMT-1A TECHNICIANShe-"-L4Le:3 B5 PARAMEDIC Hx: �Q(Z� QS ' DISPATCHER: HAFT LEY OOH CHIEF COMPLAINT: -set Z-.'' a DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 853. HORJZATVR TY RUN­(E4LS USE ONLY) ct A.t J;' PATIENT REFUSED SERVICES: (SIGNATURE) X9 yuq MEDICAL COVERAGE:. - . . .l INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: S.S.A ' t PRIVATE INS.CO.: BASE RATE: - KAISER K: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N:• E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP M:" ' f t EMERGENCY RUN: MEDI-CAL C 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) G�^ – EMPLOYER: OCCUPATION: OTHER: !' ADDRESS: - CITY: STATE: ZIP: -_COMMENTS: i -- TOTAL: '�Z • ` � CONTRA COSTA COUNTY AMBULANCE `/�/�l/ LJ PRE-HOSPITAL CARE FORM I UNIT - AUTHORIZATION N 0 ! CHECK OR FILL IN APPROPRIATE SPACES , / DATE: PATIENT'S NAME C�f�_Lr:_��J � T�-{� 64bG- k yM ❑ F COMPANYN�� ADDRESS (�_Xc��� / �l/1�` /AGE/-7 � CITY�L '� S1gTE�/,+_� ZIP / DOI�/�J� O Sn ❑ M OT ❑W O Th $F O$- DRIVER'S LICENSE a _Iu.'� � /1.4?. _---_. PHONE_d32_) _*,_, NATURE OF DISPATCH ��- TYPE OF TRANSPORT: AMBULANCE OTHER❑ _- - STATIO 1(A) 2(8)_3(C)_41D)_5(E)_ INCIDENT LOCATION: (,! RESPONSE CODE: ED BY: TIME- (24 HOUR CIL K) TO SCENE- S.O CALL RECEIVED CJ C , _ TIME 10-8 PATIENT DESTINATION: FROM SCENE FIRE TIME 10-97 / /J / C , O PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10.7 1 _ END TIME 10.98 DOCTOR __ I_�� PMD/ER START 1_(�_ TIME 10-22 HOW CHOSEN: TOTAL 97 STANDBY TIME ❑ AREST ❑ FAMILY ❑ TRANSFER / WAIT TIME ! PATIENT O DIRECT ❑ OTHER l CALL BACK N: AMBULANCE CPM _RANY: -.'_.. 1 PT. AM TORY? PATIENT TAK N/0 AMBULANC _c)lo RESPONSE ZONE 13 YES NO O WAL <EDUERNEY OTHER Q _1 PATIENT CONDITION: DRIVER. �OmMT-tA 1/ � TECHNICIAN I �j�`L PARAMEDIC 1 HX:�ry•/0'(c`6 "�� �c/C/—I C/PiI � DISPATCHER: �� Z-C ^1 CHIEF COMPLAINT: DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION F DRY RUN(EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X— - MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. N -, PRIVATE INS. CO.: BASE RATE: KAIS R#: MULTIPLE PTS. BASE RATE J' BLUE CROSS N: TOTAL MILES: 5, X MEDI�ARE a: 1 E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 1 ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: sL�=...0 MEDT-CAIS CODE 2/3 / c_ OTHER: OXYGEN: (PER TANK) O� 111 P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ��• d DATES B!LLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ��, DRUGS: (PER ADMIN.) X NAME: J�—L.J�^ ri ('l RELATIONSHIP: E.O.A.: (IF NOT REPLACED) —- ADDRESS: � �' ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ ZIP: . C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE. DRY RUN: (AUTHORIZED) EMPLOYER: , OCCUPATION: OTHER: ADDRESS: �L-4 ? s . , -•. i'. /O. ✓U /I CITY: r STATE: ZIP: -- COMMENTS:—A )rZIJA e r'vYl /412f_� s!� ���_ TOTAL:' PATIENT RECEIVED BY:X 00765 Pr+nidrr rr•.r' t✓<;• ^m ��•., y,,. .. r.. .•►.•. t....�� (SIGNATURE) OSS-1 y� CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M I` CNECK OR FILL INAPPROPRIATE SPACES l� i DATE: `� 4 u PATIENTS NAME -- /�L JWM Sp / ❑ FFC OMPANY�M ADDRESS ( 3U AGE-AL Ol v�- /❑ Sn ❑ M� O TCITY STATE ZIP 7rySD — ❑ W ❑ Th GKF O S 7 ' fi J� /L DRIVER'S LICENSE M ___ --._--__ PHONE�� 3' S_Z5_.3 r! NATURE OF DISPATCH G#- h TYPE OF TRANSPORT: AMBULANCE THER❑ _-._ _-______.._.. STATION 1(A)_2(8)_3(C)-4(D)-5lE)__�_ INCIDENT LOCATION: - - RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE - O. CALL RECEIVED S. ❑ P.U. TIME 10-8 PATIENT DESTINATION: � 1 FROM SCENE- ❑ FIRE _ TIME 10.97�I 2• ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END �( �L ��� TIME 10-98 " DOCTOR 60 ►v I <' (2") N PMD(F) START_1µ TIME 10-22 HOW CHOSEN: TOTAL 1 STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER - WAIT TIME O PATIENT DIRECT ❑ OTHER `, ' CALL BACK#: AMBULANCE COMPANY: PT,4AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE '~ YES 13 NOW ALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER � i' LAS- TECHNICIAN T��t �17� •^ PARAMEDIC 7- HX: DISPATCHER: / CHIEF COMPLAINT: de a 4�AJ it V A D.S DRY RUN: ❑ YES �NO REASON FOR DRY RUN r:) E v A It c uJ AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED S VICES: (SIGNATURE)X- MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S. M PRIVATE INS. CO.: BASE RATE: KAISER C MULTIPLE PTS. BASE RATE ,�y � BLUE CROSS M: TOTAL MILES: X ]2� � v ' MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO / ❑ YES O NO NIGHT: (19:00-07:00) �:.�✓�� EMERGENCY RUN: 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) NEARESTnRELATIVE/RESPO/NSIBLE PARTY: I.V.: (PER ADMIN) X /` G Q F 27" /C IC k(PLA s 1_4 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: - riA 110rt /, C 'COMMENTS: � ��=- -�-�=- '"•' � tf c - c.,, _ TOTAL: _ PATIENT RECFIVED BY: X _. � _ (SIGNI TUBE) �� f /� CONTRA COSTA COUNTY AMB RNgEk- S5 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION �� CHECK OR FILL IN APPROPRIATE SPACES t DATE: PATIENTS NAME n. ❑ M F COMPANY N ADDRESS AGE CITY `v TATE c— ZIP _ DOB3 1 'Z' el3 ❑ Sn ❑ M ❑ T ❑ W ❑ Th O F O S DRIVER'S LICENSE N _ ____.__..__— PHONEg33-1-3 ./---- NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANC OTHER .. STATION I(A)_2(B)_3(C) 4(D)_5(E)_ INCIDENT LOCATION: RESPONSE CODE: REOU D BY: TIME- (24 HOUR CLOCK) r r TO SCENE O. - CALL RECEIVED ❑ P.D. TIME 10-8 1 PATIENT DESTINATION: FROM SCENE ❑ FIRE _ TIME 10-97 ` ❑ PSAP TIME 10.49 MILEAGE: ❑ OTHER/PVT TIME 10-7 7 END �• TIME 10-98 i DOCTOR 1APMD START TIME 10-22 HOW CHOSEN: TOTAL A STANDBY TIME ❑ NEAREST - FAMILY ❑ TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: ^ , PT. AMBUL ORY? PATIENT TAKEN T AMBULANCE: RESPONSE ZONE ❑ YES NO ❑ WALKED r'" GURNEY ❑ OTHER r PATIENT CONDITION: DRIVER I' EMT-tA r TECHNICIAN Y PARAMEDIC Hx: DISPATCHER: L r CHIEF MP AINT: n,-rf, DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN (�1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r' 51 PATIENT REFUSED SER ICES: (SIGNATURE) X_ l�v MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N PRIVATE INS. CO.: BASE RATE: I SG.La KAISER N: MULTIPLE PTS. BASE RATE � r BLUE CROSS N: TOTAL MILES: X ICA E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES O NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: , MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X .�r SIJ33 M DRUGS: (PER ADMIN.) X NAME:O Q- ��L!LJ RELATIONSHIP E.O.A.: (IF NOT REPLACED) ADDRESS:_SC-n0.k ORAL AIRWAY: (IF NOT REPLACED) C CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) 5' PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: e cmENTS: G h c� (� TOTAL: g_�I7 67 ,C 2 1 i� E$ �� .. PATIENT RECEIVED BY. X (SIGNOTURE) !'rrrridor Mfair: whit, •.1 r' .pp4afr.r. ,. .. sr .,, !.1 r,rr LMS-I CONTRA COSTA COUNTY V AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N -/C/��S CHECK ON FILL/N APPROPRIATE SPACES DATE: gal , 7/s 'PATIENTS�NAME`' - 0'M ❑ F COMPANY N ADDRESS 5 fqAGE - CITY -..,--...STATE ZIP DOB O Sn OM OT Ow 13Th O F b(S- " DRIVER'S LICENSE N i PHONE - NATURE OF DISPATCH 449,:�o + TYPE OF TRANSPORT:. AMBULANCE OTHER _ STATION 11A)--.2(B)_31C1._41D)._61E)_ INCIDENT LOCATION; 1 ;K RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) 1 TO SCENE- AS.D. CALL RECEIVED❑ P.O. TIME 10-8 , r PATIENT DESTINATION: d FROM SCENE- ❑ FIRE TIME 10-97 �' A ) �l ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 �; I- ,,• END TIME 10-98 i P:bbCTOR U- Y PMD/ER START ' TIME 10-22 r t'y HOW CHOSEN: TOTAL, STANDBY TIME 11 NEARESTO FAMILY O TRANSFER ' WAIT TIME O PATIENT ❑ DIRECT 13OTHER CALL BACK N: AMBULANCE COMPANY: _ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: J L> RESPONSE ZONE ❑ YES O NO ❑ WALKED ❑ GUERNEY O OTHER �T PATIENT CONDITION: -' DRIVER1T=T7L� TECHNICIAN �i�r ` R PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN 'Cu AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 f 7 Q,,•!' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: i INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: _ tv S.S.N 4 ` - PRIVATE INS.CO.: BASE RATE: KAISER C 1 MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: X MEDICARE N; E.O.B.ATT. ROUND TRIP: OYES ❑ NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N:'I ) ' EMERGENCY RUN: MEDI-CAL N: 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 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) J EMPLOYER: - OCCUPATION: OTHER: ADDRESS: - --CITY: STATE- ZIP: COMMENTS: ~ TOTAL: ✓ ���c2� ?) ( �'O PATIENT RECEIVED BY:X C pr.wid�r tvt1lr oft. l 1; . .7, O.,r,, . . ... ISIONAtURE) •� i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM 1 UNIT © AUTHORIZATION N CHECK OR fill IN APPROPRIATE SPACES DATE: IJ,, PATIENT'S NnAMEy 1 ❑ M ❑F COMPANY N ADDRESS „ e L4 S Q,� S e2 J ) C AGE---r— U CITY STATE_ _.T ZIP DOB ❑ Sn ❑ M ❑ T ❑ W ❑Th ❑ F O S DRIVER'S LICENSE N (- PHONE NATURE OF DISPATCH ���• TYPE OF TRANSPORT:t AMBULANCE OTHER❑ ' STATION t(A)_2(B)_3(C)_4(D)_5(E)_ INCIDENT ,IOCATION'- S. RESPONSE CODE: REQUESTED BY: TIME— (21 HOUR CLOCK) 7 I A TO SCENE- z S.O. CALL RECEIVED LL�L_: 1-3 ) Yom► �; i_LEr ( P.D. TIME 10-8 PATIENT DESTINATION: ... ` FROM SCENE- ❑ FIRE TIME 10-97 QD ❑ PSAP TIME 10-49 V^, 77+ .,k�:� 7 �'%= ' 0 1+ MILEAGE: ❑ OTHER/PVT TIME 10-7 � K i END TIME 10.98 PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ^i t 13 NEAREST;.�,y ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT O OTHER CALL BACK N: AMBULANCCOMPANY: PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: 1` ' RESPONSE ZONE ❑ YES,,❑ NO r ❑ WALKED ❑ GUERNEY ❑ OTHER I PATIENT CONDfTION: "' DRIVER �Gul/C'1C n V AT- �`11`(� ` __ .I TECHNICIAN ���/l ZI I? PARAMEDIC Hx: DISPATCHER: /-, l v �2-g CHIEF COMPLAINT: S �� A /�G DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN UTHORIZATIOF R DRY UN( USE ONLY) (/yy ; CONTRA COSTA COUNTY AMBULANCE ` PRE-HOSPITAL CARE FORM 1 UNIT ,.7 AUTHORIZATION N CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME. l ❑ M F COMPANY N _-' '• ADDRESS - l ( �^ s.'} AGE /,3 ,a 9 0 CITY l bI`J�) STATE c/ ZIP DOB_51(9� ❑ Sn O M ❑.T ❑ W Cl Th. O F DRIVER'S LICENSE# ___ _ _ PHONE_��'�_�_— NATURE OF DISPATCH_�a�+� TYPE OF TRANSPORT: AMBULANCE 0 OTHER❑ __ - STATION 1(A)_2(8).._3(C)_4(0)_5(E) INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) �^ �1 TO SCE E- S.O. CALL RECEIVED-AJA 1� ❑ P.D. TIME 10-8 (', PATIENT DESATION: FROM S ENE- ❑ FIRE TIME 10-97 /� :.y r`�; vv t ❑ PSAP TIME 10-49 �L�:� MILEAGE:� , 413OTHERIPVT TIME 10-7 ; ENDS TIME 10-98 .,:..x_.3' DOCTOR Vo_" PMD/ER START 20 TIME 10-22 HOW CHOSEN: TOTAL k STANDBY TIME ❑ NEAREST O FAMILY ❑ TRANSFER WAIT TIME _ ❑ PATIENT O DIRECT O OTHER CALL BACK N: AMBULA l�PANY: PT. AMBULATORY? PATIENT TAEN TO AMBULANCE: �'jJ RESPONSE ZONE - YES ❑ NO O WALKED UERNEY O OTHER 1 PATIENT CONDITION: DRIVER EMT-IA TECHNICIAN LAPARAMEDIC f Hx: �� k i� ' DISPATCHER: 1 1" 1 C l CHIEF O LAINT: DRY RUN: OYES ❑ NO 1 REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) II /� PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. N n� c PRIVATE INS. CO.: BASE RATE: � 1�1L_ 51-0/ KAISER R: MULTIPLE PTS. BASE RATE c 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: C Clj4 CODE 2/3 (' OTHER: _ OXYGEN: (PER TANK) _ P.O.E. STICKER ❑ YES ❑ NO BILLED CO. NEONATAL: (INCUBATOR) DATES BILLED: STANDBY. (OVER 15 MIN.) APR 0 .5 1 E.K.G.: (PER EPISODE) NEAREST ELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: W, RVATIONSHIPQLZIIC - 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: C � 4 TOTAL: PATIENT RECEIVED BY:X 14 Provider reta:: Vhi rr _rd !K-% Copp .Srfurn Ye:Iuw +npy r Ekc when bit i-,p (SIGNATURE) S r CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ) r h ) AUTHORIZATION N of 3` CHECK OR FILL INAPPROPRIATE SPACES - DATE: Q :sr} �PATIENT-S NAME" Dor o rJ OIM O F COMPANY M ADDRESS • " AGE CITY STATE—,ZIPS_ DOBE_ O Sn OM ❑ T O/}WO]Th OF O S I , ►L 4 GT�� - DRIVER'S LICENSE M 1 PHONE NATURE OF DISPATCH , TYPE OF TRANSPORT: AMBULANCE THER 0 STATION 1(A)_2(B)_3(C)_4(D)_-5(F,l--,---'— ( I INCIDENT LOCATION:'—— RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- �S.O. — CALL RECEIVED C1-P.D. TIME 10-8 • PATIENT DESTINATION: - FROM SCE E- O FIRE TIME 10-97 - ----- 0 O PSAP TIME 10-49 .� MILEAGE: ❑ OTHER/PVT TIME 10-7 T1 _ END TIME 10-98 DOCTOR' �'`�' I PMO/ER START TIME 10-22 �5 HOW CHOSEN: TOTAL STANDBY TIME "'"r '❑ NEAREST,'nl ❑ FAMILY ❑ TRANSFER WAIT TIME y O PATIENT ❑ DIRECT O OTHER CALL BACK q: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE- -q3T ❑ YES ❑ NO,r ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVERL' EMT-1A ��1$(� _i TECHNICIAN <'1 '� PARAMEDIC Hx: �. _ - DISPATCHER: yqq CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN n 77 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 'PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL O YES 0 NO NO. OF PATIENTS: S.S.« - cl ' PRIVATE INS.CO.: BASE RATE:- KAISER•: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X MEDICARE K: E.O.B.ATT. ROUND TRIP: O YES ❑ NO _ O YES •O NO NIGHT: (19:00-07:00) CCHP/PPRP N:" r EMERGENCY RUN: MEDI-CAL M: `' CODE 2/3 OTHER: OXYGEN: (PER TANK) C P.O.E. STICKER O YES O 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: T T q 007 0 1 (-.. PATIENT RECEIVED BY:X ISIGNA-1URE) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION k t� CHECK OR fILL IN APPA OPR1AfE SPACES - DATE:. \') �.� �� �'A 3 PATIENTS NAME? „G'7n �- ✓�r� Ude ❑ M t(F COMPANY ADDRESS / iZ� ` % �i���N--.C//Yff)�^ �o 'J� AGE CITY STATES ZIP DOB 11 11Sn OM ❑ T ❑ W O Th O F ,5 DRIVER'S LICENSE k PHONE ;?))iW /NATURE OF DISPATCH. ' TYPE OF TRANSPORT: AMBULANCE OTHER C STATION 1(A)_2(8)._3(C),4(D)._5(E)._ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 11 I� TO SCENE - lJ D S.O. CALL RECEIVED ❑ P.D. TIME 10-8 " PATIENT DESTINATION: FROM SCENE- O FIRE — TIME 10-97 . : , K� _ , s C�� —� yO� OTH TIME 10-49 ,c��'1 CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N A.1•• •„ ' CHECK OR FILL INAPPROPRIATE SPACES DATE:. 1 PATIENT S NAME " f 01k#\0 F COMPANY M A 7 /f ADDRESS ' AGE— CITY GE CITY- - '-STATE ZIP DOB 0 Sn, 0 M 0 T 0 W 0 Th 0 F ¢ DRIVER'S LICENSE N � � ' PHONE NATURE OF DISPATCH / ZR-- _i TYPE OF TRANSPORT:I AMBULANCE 0 OTHER❑ _ STATION 1(A)_2(B)-31C)._4(D)_5(E)_ INCIDENT LOCATION-. � S. RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) i t TO ENE- S.O. CALL RECEIVED ` :LD a -��TL2 , ., ❑ i ,- P.D. TIME 10 8 PA IE�T DESTINATION: . .__) FROM NE- , ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 t ff END TIME 10-98 - U 1 DOCTOR " ? 4' PMD/ER START TIME 10-22 �- HOW CHOSEN: _ --1 TOTAL STANDBY TIME 2Tj.. 0 NEAREST-,-,-' 0 FAMILY 0 TRANSFER WAIT TIME ❑ PATIENT DIRECT ❑ OTHER CALL BACK N: AMBULANCE CO ANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: ��(lI RESPONSE ZONE ❑ YES, 0 NO ❑ WALKED 0 GUERNEY Cl OTHER PATIENT CONDITION.- DRIVER EMT-1A TECHNICIAN �� PARAMEDIC Hx: DISPATCHER: qx CHIEF COMPLAINT: DRY RUN: 11 YES 0 NO REASON FOR DRY RUN rS- ��� - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) .-`. J PATIENT REFUS SERVICES: (SIGNATURE) X 9Sa- MEDICAL COVERAGE: . INDUSTRIAL ❑ YES ❑ NO No.OF PATIENTS: S.S. N J 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: 0 YES ❑ NO 0 YES -0 NO NIGHT: (19:00-07:00) CCHP/PPRP N:Z' EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: " I OXYGEN: (PER TANK) P.O.E.STICKER 0 YES 0 0 _ NEONAT�L: (INCUBATOR) C DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) �—NEAREST RELATIVE/RESPON PBLE 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:,_� �' �i CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FO I UNIT AUTHOR17-ATION It CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME OM OF COMPANY# ADDRESS AGE o gy1 CITY STATE ZIP DOB ❑ Sn ❑ M ❑ T O W ❑ Th ❑ F e S DRIVER'S LICENSE# _ PHONE NATURE OF DISPATCH 7g TYPE OF TRANSPORT: AMBULANCE IP OTHER❑ INCIDENT LOCATION: E lC RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CL CK)�, l s TO SCENE- ANS.O. CALL RECEIV � ED ALL " ��' -ry -I c&:Films ❑ P.U. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 .� ❑ PSAP TIME 10-49 j 6/ c. MILEAG ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 t� HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME _ O PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE CO P�Y: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: U RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER N PATIENT CONDITION: DRIVER 1 1! .2")0 EMT-tA t TECHNICIAN_ PA MEDIC Hx: DISPATCHER: _ b 0 CHIEF COMPLAINT:2IA G- _ _ DRY RUN:4e' ❑ 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: 9l� 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 O YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: CODE 2/3 C OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEJRESPONSIBLE 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_ 007714 . (SIGNA PURE) ..-. . ICONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT Z AUTHORIZATION 09/ ��I '• CHECK OR FILL INAPPROPRIATE SPACES DATE: •• •" :? 'ATIEN7'S ,,,NA���ME�_ '1_____ ��_�--tC- R5M ❑ F COMPANY# ADD9ESS.�'�-> —___.__j1AGE CITY- _ STATE-C�C&,- ZIP_- DOB(/1_ ,7 ❑ Sn ❑ M ❑ T ❑W ❑ TTS ❑ F .f g DRIVER'S'LICENSE d -- - PHONE /�` .`�v- NATURE OF DISPATCH I TYPE OF TRANSPORT: AMBULANCE'OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOURCLRCK) //1 1 77) r r TO SCENE- S.O. _ CALL RECEIVED / U qC ❑ P.U. TIME 10-8 { PATIENT DESTINAT N: FROM SCENE- ❑ FIRE _ TIME 10-97 ' _ ❑ PSAP TIME 10-49 MILEAG ❑ OTHER/PVT TIME 10-7 ' r 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#: AMBULANC�jJc NY: ) c PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WAL`QED ❑ GUERNEY ❑ OTHER _ i.. � � PATIENT CONDITION: DRIVE G EMT-tA TECHNICIAN 4- 0 PARAMEDIC Hx: __.___--__-______.______ DISPATCHER: L CHIEF COMPLAINT. _____ ___ __-� _ DR4RU : r�--YES NO REASON FOR DRY RUN PrF1'NaAUZiff-AT F DRYN(EMS �IS€ O VJ 407c 1�•' PATIENT REFUSED SERVICES (SIGNATURE) ), MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S. it PRIVATE INS. CO.:--- BASE RATE: _..J KAISER#: MULTIPLE PTS. BASE RATE T BLUE CROSS#__. ____ TOTAL MILES: X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO --- t ❑ YES ❑ NO NIGHT: (19:00-07:00) j CCHP/PPRP#: _ EMERGENCY RUN: MEDT-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 RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �, RUGS: (PER ADMIN.) X y NAME _S� .IL e __-_ __ ATIONSHIP: __ A.: (IF NOT REPLACED) ADDRESS: ________ - ORAL AIRWAY: (IF NOT REPLACED) CITY- STATE_ZIP: - C-COLLAR: (IF NOT REPLACED) - T a PHONE: WORK PHONE.. DRY RUN: (AUTHORIZED) EMPLOYER: _-_- __. OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:— COMMENTS: IP:COMMENTS: 4", TOTAL: -• 77 PATIENT RECEIVED BY:X Frnv(drr rrta'- :lit. „ri Pi:•. ,••7p Frtur� (SIGNATII QEr' -_ tJIS-1 rp CONTRA COSTA COUNTY AMBULANCE ' 1 :� PRE-HOSPITAL CARE FORM 1 UNIT .L AUTHORIZATION N 1 CHECK OR PILL INAPPROPRIATE SPACES DATE: 'VATIENrs NAME ❑"M ❑ F COMPANY N ADDRESS,-., , AGE CITY—- f- - - STATE_� _ ZIP DOB D Sn PM ❑ T{ ❑W O Th ❑ S DRIVER'S LICENSE N PHONE _ NATURE OF DISPATCH TYPE OF TRANSPORT:t AMBULANCE OTHER 0 _ STATION I(A)_218)_3(C)._4(D)_51E)_ INCIDENT LOCATION:) RESPONSE CODE: R�EOO STEO BY: TIME– (24-HOUR CLOCK) TO SCENE- �'S.O. CALL RECEIVED : ) Y7 � L^ A 12 LI S *- 4 1 11, /lin ❑ P.D. TIME 10-8 PATIENT DESTINATION:-. . � �II`Lt FROM SCENE O ❑ FIRE TIME 10-97 T ' ❑ PSAP TIME 10.49 f7 `�"'fil"� •�j; = •� !" __ ` MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 ' P'DOCTOR' t c: r' ) PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST; ❑ FAMILY ❑ TRANSFER ' WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY:CA PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: e- U RESPONSE ZONE ,. 10 YES ❑.NO ❑ WALKED ❑ GUERNEY ❑ OTHER i PATIENT CONDITION: DRIVER t "EMT-1A ' _j TECHNICIAN PARAMEDIC Hx: DISPATCHER: 6 CHIEF COMPL�N.T: DRY RUN: ES ❑ NO REASON FOR DRY RUN {r1 O 1 J r 1!S AUTHO rJ A ON FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: .. INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: �C _ C/ ' 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 fl NO NIGHT: (19:00-07:00) CCHP/PPRP 0:1,1 1 ~t EMERGENCY RUN: MEDI—CAL N: s ( CODE 2/3 OTHER: w" 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) s1�J ""EMPLOYER: OCCUPATION: OTHER: ADDRESS: STATE- ZIP: COMMENTS: TOTAL: PATIENT RECEIVED BY:X 0 0 7 6 6 (StGNA TUBE) (fM5—I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M U� r CNECK OR FILL INAPPROPRIATE SPACES DATE: l '�+� 3 PATIENTS NAME 1 (� , 2 OM OF COMPANY i< ADDRESS AGE / CITY STATE ZIP DOB ❑ Sn O M O T ❑ W O Th Of- O S DRIVER'S LICENSE N _ PHONE----- NATURE OF DISPATCH— TYPE ISPATCH TYPE OF TRANSPORT: AMBULANCE Q OTHER O _ STATION 1(AI 2(B)_3(C)_4101_5(E)_ INCIDENT LOCATION: _ RESPONSE CODE: R UESTED BY: TIME-(24 HOUR CL�jCK)1 TO SCENE- 2 S.O. CALL RECEIVED VV o P.D. TIME toe Cts I PATIENT DESTINATION: FROM CENE-v O FIRE TIME 10-97 _ /O ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 I ` END TIME 10-98 DOCTOR PMD/ER START TIME 10-22 1-9 HOW CHOSEN: TOTAL STANDBY TIME !' ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME —_ ❑ PATIENT ❑ DIRECT O OTHER CALL BACK k: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 0 RESPONSE ZONE ❑ YESO O WALKED 11GUERNEY ❑ OTHER ',i.. ' UI PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN ARAMEDIC LZ fix; _ DISPATCHER: CHIEF COMPLAINT: 1 5 DRY RUN: YES ❑ NO REASON FOR DRY RUN !o r5- / AUTHORI ATION FOR DRY RUN(EMS USE ONLY) /9 PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S.S.M PRIVATE INS. CO.: BASE RATE: t KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS M: TOTAL MILES: X ' MEDICARE C E.O.B.ATT. ROUND TRIP: O YES O NO O YES ONO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDT-CAL 4: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ 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: f-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: AJ D c,vin AlCr,2 TOTAL: w PATIENT RECEIVED BY:X - Pr-eider r otn?. "it, «d T i r, c,• ;,, v,. nr• ..� (SIGNA-i URE) j CONTRA COSTA COUNTY AMBULANCE 7 �. PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES I DATE: ^�/ PATIENT'S NAME__�i1 C�/��� �J ��� ❑ M VF COMPANY# ADDRESS AGE_ CITY_.—`�� `.1'L�_ STA __ ZIP_J _a ^� j ` Sn 13 M O T O W O Th O F TE0B S DRIVER'S LICENSE# ._C2_U;� -6?UPHON61 _'���3 NATURE OF DISPATCH_1rl'3j o-��V TYPE OF TRANSPORT: AMBULANCE�l OTHER 11 __ _ STATION I(A_2(B)_3(C)_4(D)_.5(E)_ INCIDENT LOCATION: ,t RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR C K) ' Cu"�j n, TO SCENE- Z.O. CALL RECEIVED -4� L O P.D. TIME 1G-8 PATIENT DESTINATION: FROM SCENE /Z ❑ FIRE - TIME 10-97 i ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 OT L TIME 10-98 :1/ DOCTOR PMD/tJ START TIME 10-22 HOW HOSEN: TOTAL STANDBY TIME ///NEAREST O FAMILY ❑ TRANSFER / WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE CO P NY: PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: �.. RESPONSE ZONElly T_— YES ❑ NO ❑ WAL'<ED GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER �' IF M, -IA t^ TECHNICIAN ' PA MEDIC Hx; DISPATCHER: 7 P /�tC�' CHIEF COMPLAINT: � DRY RUN: ❑ YESREASON FOR DRY RUN NO - L't� —`. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ?�NO NO. OF PATIENTS: 1,�.� ��f✓ S.S. # U �C5 Io r PRIVATE INS. CO.: BASE RATE: /5`'c KAISER#: MULTIPLE PTS. BASE RATE / \BLUE CROSS#: TOTAL MILES: CI X MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ` OYES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: 30•Cp (i4 MEDT-CAL#: CODE 2/3 OTHER OXYGEN: (PER TANK) P.O.E. STICKER O YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: IPER ADMIN.) X DRUGS: (PER ADMIN.) X NAME: �" �[ ft-- �RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS:—� tiL w �' 1 ORAL AIRWAY: (IF NOT REPLACED) CITY: N�U! �1� STAT �_( ZI C-COLLAR: (IF NOT REPLACED) PHONE:'I F5J - 6S6 WORK PHONE: DRY RUN: (AUTHORIZED) C n EMPLOYER:41-TV 0 L(E OCCUPATION: OTHER: r ADDRESS: ( U i C,-J CITY: NL'�J Fl)('�r STATE: fl� r ZIP: COMMENTS: f'V r\ L) . TOTAL: a•;;, UU _ PATIENT RECEIVED white Provider rPtai4AT ) ® 17^ r, rxd Pfau Popp Se �tv Ye'1„�• ^np. t !T/£ uhen bf1'inp C9rP1 CONTRA COSTA COUNTY AMBULANCE �� PRE-HOSPITAL CARE FORM I UNIT r� AUTHORIZATION N a J /,/J/ 7��6 `L • CH[CK OR FILL INAPPROPRIATE SPACES DATE: l 'PATIENTS NAME u �M• ❑ F COMPANY N / `' 6) ADDRESS. AGE A CITY STATE zip.ZIP DOB O Sn ❑ M OT OW ❑ Th O F 96 ! DRIVER'S LICENSE N _ PHONE __ NATURE OF DISPATCH �'�S'Y��f L TYPE OF TRANSPORT: AMBULANC OTHER O STATION 1(A),2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION:• - (I •- RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK) 7 �y YkC' '�_ `J- w V TO SCENE S.O. CALL RECEIVED /L1 r J� . !. t)k �T� j ❑ P.D. TIME 10-8 -L-4 .:,_/ PATIENT DESTINATION:_ FROM SCENE ❑ FIRE TIME 10-97 1 ❑ PSAP TIME 10-49 +_ MILEAGE: O OTHER/PVT TIME 10-7 END TIME 10-98 A'DOCTOR'T;"" 1 N PMD/ER START TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME O NEAREST(': ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT C}OTHER CALL BACK N: AMBULANCE C MP9NY: •� . PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: SC7 RESPONSE ZONE_,,, ❑ YES ❑ NO O WALKED ❑ GUERNEY O OTHER PATIENT CONDITION: - DRIVER ' ��x 114 TECHNICIAN , l�,YL U PARAMEDIC Hx; DISPATCH R: L i C F COMPLAINT: A �G DRY RUN:LbCYES O NO REASON FOR DRY RUN 7.23 C�C THORIZ TION�ZOR DPY RU (EM USE ONLY) 'tiltXU T A. , PATIENT REFUSED SERVJCES: (SIGNATURE) X f T MEDICAL COVERAGE:, INDUSTRIAL ❑ YESNINO NO.OF PATIENTS: S.S. PRIVATE INS. CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: " TOTAL MILES: - X MEDICARE 0; E.O.B.•ATT. ROUND TRIP: O YES O NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ' CCHP/PPRP N: I EMERGENCY RUN: MEDT-CAL N: CODE 2/3 f OTHER: I OXYGEN: PER TANK) P.O.E.STICKER O YES--❑ NO NEONATAL: (INCUBATOR) DATES BILLED:_11, 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: 00779 PATIENT RECEIVED BY: X__ CONTRA COSTA COUNTY AMBULAVU 73 Us'PRE-HOSPITAL CARE FORM i UNIT AUTHORIZATION M CHECK OR FILL INAPPROPRIATE SPACES DATE: PATIENT'S NAME U ' "" _ 1 ► ''` a__ __,_—. __—___ >grM ❑ F COMPANY#ADDRESS -5- ��� _ �-��/� IAGE 0/J ` CITY— --- STATE—C —� Z(P�" DOB_ O Sn ❑ M ❑ T ❑ W O Th ❑ FIV � ER'S LICENSEa __ _ _ _.. .__ ____.. RHONE___—__....___.___-- NATURE OF DISPATCH_� TYPE OF TRANSPORT: AMBULANC THER❑ _._ ___--.—_ INCIDENT LOCATION RESPONSE CODE. REQUESTED BY: TIME— (24 HOUR CLOCK) M1 s / --- TO SCENE- S.O. CALL RECEIVED ❑ P.D. TIME 10-8 - c�_ : `S PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 _���._ ❑ PSAP TIME 10-49 _.__._._ _— MILEAGE: S3, ❑ OTHER/PVT TIME 10-7 -- END, TIME 10-98 DOCTOR _ _ — _—___ PM ER START-- _ TIME 1022 OW C OSEN: TOTAL -- STANDBY TIME NEAREST ❑ FAMILY ❑ TRANSFER 7, WAIT TIME -Cl PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPIY:� ; PT AMB ORY? PATIENT T ENT AMBULANCE: RESPONSE ZONE ❑ YES ❑ WAL'tED PINEY ❑ OTHER n( — ( PATIENT CONDITION: DRIVER. _ ., TECHNICIAN` �AARAMEDIC Hx: __�_._ _ _ ISPATCHERv r �/ CHI h1P AI _ DRY RUN: ❑ YES REASON FOR DRY RUN — _ ___ _ AUTHORIZATION FORD R N(EMS USE LY) 'ATIEN4 REFUSED SERVICES: (SIGNATURE) X ._- rL COVERAGE: — INDUSTRIAL ❑ YE S NO. OF PATIENTS: 0 _IVATfE INS. CO.:-- BASE RATE: KAISER It: __—_— MULTIPLE PTS. BASE RATE BLUE CROSS k _ __ _ -- TOTAL MILES: G X MEDICARE a: E.O.B. ATT. ROUND TRIP: ❑ YES 0 NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP a: _ EMERGENCY RUN: CODE 2/3 OTHER: OXYGEN: (PER TANK) u P. . . 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: ____—_ 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:. / fit- - - - - - - - �---�- //'/► .._ _ _ _. _. .___ _ _ PATIENT RECEIVED BY: t '�' --- - f�,r. r L'I n:.. ..r... ..+ Yr' i • ts.- (SIG NATURE) :Fr. hit" 0T,1 .4r 4. CONTRA COSTA COUNTY AMBULANCE �/ PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION AJ CHECK OR FILL IN APPR lA7E SPA S , DATE: PATIENTS NAME OM ❑ F COMPANY N ADDRESS I AGE — Ur Z U s CITY STATE ZIP DOB - 13 Sn 0 M ❑ T ❑W O Th ❑ F (3 S DRIVER'S LICENSE PHONE _ NATURE OF DISPATCH - TYPE OF TRANSPORT: AMBULANCE 0 OTHER 0 _ STATION I IA)_2(B)_31C1-4ID)_SIE)_ INCIDENT L CATION:! RESPONSE CODE' REQUESTED BY: TIME— (24 HOUR CLOCK) / TO SCENE- td-&0. CALL RECEIVED tJ P.U. TIME 10-8 ,4 �1, 1c• PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 t �1rc PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 END TIME 10-98 'DOCTOR' y PMD/ER STARTTIME 10-22 HOW CHOSEN: _, t TOTAL STANDBY TIME 0 NEAREST El FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT 0 OTHER CALL BACK N: AMBULANCE COMPANY:/ �_., PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: 7 RESPONSE ZONE ,�. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:. DRIVER EMT-1A r li ._J TECHNICIAN / Ll O PARAMEDIC Fez: DISPATCHER: �(1( CHIEF COMPLAINT: DRY RUN: 0 YES ❑ NO REASON FOR DRY RUN 7 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 4 l 5 PATIENT REFUSED SERVICES: (SIGNATURE) X lsa� MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: . S.S. N PRIVATE INS. CO.: BASE RATE: KAISER III: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: O YES ❑ NO O YES ❑ NO NIGHT: (19:00-07:00) CCHP%PPRP M: EMERGENCY RUN: MEDT-CAL 0: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ❑ NO NEONATAL: (INCUBATOR) C 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: 007 PATIENT RECEIVED BY: X !'rr f.fir rot.,!• L'6fr: r:/ ..r., .. .. r.. , (SIGNATURE) ►Mc I CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT 1 ' AUTHORIZATION N �� 1 DATE: CHECK Oq flLl IN APPgOPgIATE CES ] I'll V I \ I' ' ^ � PATIENTS NAME / I / I I 1 �V 1 - , M F COMPANY N ? / ADDRESSTT_S73-/ Ldp /Z 0 AGE ' CITY 6A STATE— ZIP—CL D04O9 L_.�1� 13 S ❑ M 11T ❑ W ❑ Th O F� DRIVER'S LICENSE M _ -�" �-�-�^`..__ PHONE 3 55 _._t-G _!. Y NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _._. _—_�—� STATION 1(A)_2(B)_3(C)_4(D)_5(E)_. - _� INCIDENT LOCATION: G RESPONSE CODE: RE S O STED BY: CALL RECEIVED CLOCK) y /'LICi E 2 /I TO SCENE - iiy'❑ P.U. TIME 10-8 PATIENT DESTINATION: 'L (/ ` FROM SCENE- ❑ FIRE TIME 10-97 : y� I��+� � /� l- ' / ❑ PSAP TIME 10-49 MILE_GE;., c+' ❑ OTHER/PVT TIME 10-7 :T� C/ END / � J TIME 10-98 DOCTOR�T� '`� PMD(ER / START TIME 10-22 HOW CHOSEN: TOTAL 57STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME -- ❑ PATIENT ❑ DIRECT pk OTHER CALL BACK N: AMBULANCE COMPANY: PT. MBULATORY? PATIENT TAKEN O AMBULANCE: RESPONSE ZONE ES ❑ NO ❑ WAL!<ED UERNEY ❑ OTHER PATIENT CONDITION: DRIVER��'1 '�" �S EMT-11A J TECHNICIANS Z S PARAMEDIC Hx: 5L _ DISPATCHER: �S CHIEF MPLAINT: In DRY RUN: ❑ YES YNO 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. N PRIVATE INS.CO.: y K�4�^ ev BASE RATE: l/z/o, -cz) KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO rev ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: w L'l� MEDT-CAL N: V h�L•^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: I.V.: (PER ADMIN.) X G DRUGS: (PER ADMIN.) X NAM ��'/ ! �l RELATIONSHIE.O.A.: (IF NOT REPLACED) ADDRESS:1 gn ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE- ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: ^l L'i^ Q OCCUPATION: OTHER: ADDRESS: CITY: !!STATE: ZIP:— COMMENTS: IP:COMMENTS: l.✓ `�/c =✓7t T� �/ TOTAL,26i. }---.._— 007804 PATIENT RECEIVED BY.X_ Vmui,for ,yr.tic vtii .. ! ISIGNATImr)` ✓ -�• CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION III CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENT'S NAME_- _ � M ❑ F COMPANY ADDRESS _� L C- 1 L=-� I)AC-e 1)/Z AGE / CITY!1 1 N V/I- C - STATE ZIP DOBcl_'v3 1 Sn ❑ M ❑ T ❑ W ❑ Th ❑ F Q S DRIVER'S LICENSE N _•�_ .� PHONE - NATUR/E\OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ - STATION 1(A).-_2(B)_3(C1-4(D)_5(E)_ / INCIDENT LOCAT RESPONSE CODE: RE STED 8Y: TIME-(24 HOUR CLOCK) F (�� Q TO SCENE - S.O. CALL RECEIVED G d 6~ {C�i C` N , A' !�{ 1 IV B .�� ❑ P.D. TIME tab PATIENT DESTINATION: FROM SCENE - ❑ FIRE TIME 10-97 H �' 1 c ❑ PSAP TIME 10-49 n MILEAGE y ❑ OTHER/PVT TIME 10-7 END___ q TIME 10-98 - DOCTOR PMD/ER START __ TIME 10-22 - -. HOW CHOSEN: TOTAL STANDBY TIME O NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME P ATIENT ❑ DIRECT ❑ OTHER f_) CALL BACK N: AMBULANCE COMPANY- - fS PT,tAMBULATORY? PATIENT TAKEN TO AMBULANCE: 5/o RESPONSE ZONE YES ❑ NO WAL'CED O GUERNEY ❑ OTHER `` } PATIENT CONDITION: DRIVER�,�p`'' - O L.% EMT-lA TECHNICIAN ct^'� PARAMEDIC Hx: _ DISPATCHER: OO CHIEF COMPLAINT: w~1'T 18 411 "` DRY RUN: ❑ YES NO REASON FOR DRY RUN AUTHORIZATION OR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICA�Lg RAGE: INDUSTRIAL ❑ YES NO NO. OF PATIENTS: S�� S.S. N (�� ^ _... PRIVATE INS. CO..N':"b4e . BASE RATE: KAISER N: 1d rIL= MULTIPLE PTS. BASE RATE BLUE CROSS N: TOTAL MILES: MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO _ ❑ YES ❑ NO NIGHT: (19:00-07:00) C% JCS CCHP/PPRP p: EMERGENCY RUN: l d'Cv lMEDT-CAL N: CODE 2/3 �?.JL) 1 OTHER: OXYGEN: (PER TANK__ Ec :1Z _ P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) 111-50 1 Y /i /.--r'o DATES BILLED: STANDBY: (OVER 15 MIN.) //, ---o E K.G.: (PER EPISODE) ' :C 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: _Eu�Q OCCUPATION: OTHER: ADDRESS: I CITY: STATE: ZIP: COMMENTS: TOTAL: 155 E� �J _.._..._. PATIENT RECEIVED BY:X Q 0 78, Pmvidrr r•vtc:r thin (SIGNATURE) � t �I�\ CONTRA COSTA COUNTY AMBULANCE 1 PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 E •� PATIENTS NAME GL' 1_. t.--/_1_____�_____� O M F COMPANYN ADDRESS •LZ _ ^iL_�N 1�_ S r _ AGE-_ CITY �aA ZV STATE CA 2tPL/S y�_ DOBL.J_q - 3KSn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE N ______- __-- __..._.._. PHONE . 7_ � 7�.{.� NATURE OF DISPATCH.— TYPE OF TRANSPORT: AMBULANCE OTHER❑ ._. ._______.. ____. _. STATION 1(A)-2161-3(C)_4(D)-5(E)_. INCIDENT LOCA TI RESPONSE CODE: RESTED BY TIME- (24 HOUR CLOCK) ,/n p / P v � N L �� / �� TO SCENE- � S.O. - CALL RECEIVED •� o p _ O P.U._ TIME 10-8 yy `�,` PATIENT DESTINATION: FROM SCENE - ^� O FIRE —�_ TIME 10-97 �� :1L_ "`1 O PSAP TIME 10.49 I t 17 MILEAGE: L ❑ OTHER/PVT TIME 10-7 -�� END— ' TIME 10-98 DOCTOR �"� f^ PMD/0? START y 7•�� TIME 10-22 HOW CHOSEN: TOTAL ' STANDBY TIME ❑ NEAREST O FAMILY O TRANSFER i WAIT TIMEjR —_ PATIENT Cl DIRECT O OTHER I.• ,i. 1 CALL BACK N: AMBULANCE COMPANY- KA OMPANY- PT AMBULATORY? [YATENT TAKEN TO AMBULANCE: RESPONSE ZONEYES O NO AL'(ED ❑ GUERNEY O OTHER rr PATIENT CONDITION: DRIVERyI EMT-1A TECHNICIAN PARAMEDIC — Hx: _ DISPATCHER }' '•� Lf C j�, CHIEF COMPLAINT: DRY RUN: O YES NO REASON FOR DRY RUN AUTHORIZATION FOR'DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL C9VERAG INDUSTRIAL OYES NO NO. OF PATIENTS: .� S.S. N rC 6 �{ S PRIVATE INS.CO.: BASE RATE: KAISER N: _ MULTIPLE PTS. BASE RATE BCUE CROSS -`' t �'l TOTAL MILES: X !� ARE N: - - E.O.B. ATT. ROUND TRIP. O YES O NO ❑ YES O NO NIGHT: (19:00-07:00) f CCRPIPPHP N: EMERGENCY RUN: ij 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("" EO.A.: (IF NOT REPLACED) AODRE/JSS/ Z S, 7 l�'1�` I% 3 % ORAL AIRWAY: (IF NOT REPLACED) CITY:I�.AY(,..ArZn STATE�_l_ZIP: C-COLLAR: (IF NOT REPLACED) _ PHONE: QA1�L� �— WQRK.PHONE _ DRY RUN: (AUTHORIZED) EMPLOYER:• _° �}bCC6^A OWC` "t' ' •OTHER: ADDRESS:63%11 ),CA/I(cr c- r- _ CITY: [),13LI N STATE:-ZIP: -. 3-f I -- - -- -- - --- COMMENTS: ---- TOTAL.. .•_:.. - - -- - PATIENT RECEIVED BY: X _ .- _A19-7 F'r•n(dvr roII r 61:•• (SIGNA,LIRE) : CONTRA COSTA• COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION �T' ' 'r CNECK OR nLL INAPPROPRIATE SPACES DATE: ' C l .13f PATIENTS NAME V` _z:7- n O'M O F COMPANY M ''' `" n ADDRESS t AGEN% ' CITY STATE-----,ZIP�_ DOB -�Sn O M O T O W O Th OF Os I . . l >� DRIVER'S LICENSE N __ -- - PHONE NATURE OF DISPATCH TYPE OF TRANSPORT:• AMBULANCE OTHER 0 _ — STATION I(A)_2(B)_31C) iD)_5(E)_ I INCIDENT LOCATION:, oR�tj 6 f� s; RESPONSE CODE: f1E0U0ESTED BY: CALL RECEIVEOR COCK) t1p. : a �! / �, I� -1/� TO SCENE- - c}' L (L� L�� C ��RNIt I ❑ P.D. TIME 10-8 'c' :7 t PATIENT DESTINATION: _. FROM SCE ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 i END TIME 10-98 :ybOCTOR I I PMD/ER START TIME 10-22 S HOW CHOSEN: _ TOTAL STANDBY TIME Via_ 13 NEAREST,—: ❑ FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMPANY: OL/►_-!::::, PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE PP-T Tr 11 YES 13 NO 11WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION:' ) DRIVE Rc Q L—"�-�MT-1 A TECHNICIAN !� /' PARAMEDIC Hx: DISPATCHER: ! yo� CHIEF COMPLAINT: DRY RUN: YES ❑ NO REASON FOR DRY RUNJQ YIN .9 FOR DRY RUN(EMS USE ONLY) y 9`i...:' PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES O NO NO. OF PATIENTS: S.S. PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE BLUE CROSS C TOTAL MILES: X MEDICARE C E.O.B. ATT. ROUND TRIP: ❑ YES O NO ❑ YES .O NO NIGHT: (19:00-07:00) CCHP/PPRP N:"l EMERGENCY RUN: MEDI-CAL N: I CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ONO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15:MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X ----NAME: ' RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ---CITY: STATE_ ZIP: C-COLLAR: (IF NOT REPLACED) ��tt PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) CG EMPLOYER: OCCUPATION: OTHER: ADDRESS: -CITY: STATE: ZIP: COMMENTS: TOTAL: n 785, PATIENT RECEIVED BY:X r•.....;,t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT I� AUTHORIZATION# CHECK ON FILL IN APPROPAIATE SPACES DATE: PATIENTS NAME DIM ❑ F COMPANY# J L J - `' ;n ADDRESS AGE--77- CITY STATE C��, ZIP 4y ) DOB�[LDj_-Sl7 Sn ❑ M ❑ T O W O Th ❑ F ❑ S DRIVER'S LICENSE# _ _- .__.___ _.. PHONES �/�-(Z)4�01.3ATURE OF DISPATCH ( 17111 TYPE OF TRANSPORT: AMBULANCIEK OTHER❑ _-__.—__-_..__.-_ ... STATION 1(AI L 2(B)_3(C)_4(D)._5(E)_. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY.. TIME- (24 HOUR C OCK) TO SCENE - 3�S.O. __ CALL RECEIVED ��- (\��� cc, CC ❑ P.U. __ _. TIME 10-8 _fi _ PATIENT DESTINATI N: FROM SCENE- ) ❑ FIRE —_ TIME 10-97 S],K t-� 3 ❑ PSAP TIME 10-49 ' 0 13 S '4 MILEAGE: ❑ OTHER/PVT TIME 10-7 END Ct i� `` TIME 10-98 t! } DOCTOR Y i u elS PMD/6R) START TIME 10-22 HOW CHOSEN: TOTAL ' Z STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME .PATIENT ❑ DIRECT ❑ OTHER /• CALL BACK#: AMBULANCE COMPANY: A PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: r RESPONSE ZONE YES ❑ NO ❑ WAL'<ED AGUERNEY ❑ OTHER PATIENT CONDITION: DRIVER - IF ✓ EMT-1A TECHNICIAN ftt C I '{, (n r PARAMEDIC X Hx: DISPATCHER: ), /O CHIEF COMPLAINT: d L iJ O 1DRY RUN: ❑ YES NO REASON FOR DRY RUN c��I AUTHORIZATION FOR DRY RUN (EMS USE ONLY) I PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: / INDUSTRIAL ❑ YES PT NO NO. OF PATIENTS: S.S. # �-� 2h- --�17�SSr PRIVATE INS. CO.: 6• BASE RATE: �/ I KAISER#: MULTIPLE PTS.BASE RATE t--,kLUE CROSS#: TOTAL MILES: X WEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 11 rr ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHIS�PPHP#: SEMERGENCY RUN: -%o MEDI- Al_#: CODE 2/3 OTHE : OXYGEN: (PER TANK) O.E. TICKER ❑ 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:£Srr•) SCLC.LScr RELATIONSHIP:`u C E.O.A.: (IF NOT REPLACED) ADDRESS: I['w. ORAL AIRWAY: (IF NOT REPLACED) -' CITY: a e i-f cyi STATE-C4 ZIP: C-COLLAR:,(IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER:L=e mv lll,Cj OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS: _ - --- TOTAL:-aw..-o-a--- -- - - PATIENT RECEIVEf) By. X 0.r.r. 8 CJI rr i.f..• roar'• L:"r. _—. ------ ... (:il(7NA T.IRf) .. CONI F:A COSTA COUNTY AMBULANCE PRE-NOSE IT AL CARE FORM I UNIT AUTHORIZATION N CHECK OR Flt: IN APPgOPRfATE SPACES DATE: ' PATIENT'S NAME.-` 'L ��f� � � C3 M Z F COMPANY III / ? _. ADDRESS �/ �__ �.r_ AGE STATE ZIP 11-_��DOD/ 1Z JZ� ❑ Sn ❑ M ❑ T OW O Th ❑ F O.S -- DRIVER'S LICENSE a PHONE( r-•13—L1 NATURE OF DISPATCH /" TYPE OF TRANSPORT: AMBULANCE OTHER❑ _. -. STATION 1(A),2(8)_3(C)_-_.4(D)_5(E)_- INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) f TO SCENE-- — S.O. CALL RECEIVED _C I ❑ P.D._ TIME 10-8 . PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 11 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10.7 �/ nn ZI.-END 1 '1_Ir TIME 10-98 �� DOCTOR __�___ __ PMD/ER START TIME 10.22 HOW CHOSEN: TOTAL =� •�� STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER /;\ WAIT TIME f: ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK k: AMBULANCE COMPANY' ,CnrT PT AMBULATORY? PATIENT TAKEN TO AMBULANCE: 5� RESPONSE ZONE— C3 YES NO ❑ WAL'CED/ZGUERNEY ❑ OTHER rJ 1 PATIENT CONDITION: DRIVER 2160 EMT-1A TECHNICIAN _mss.; / ¢iFlet�;c)rLr I PARAMEDIC - Hx: .- - �i7�7 1 /C- -- -- — DISPATCHER: !i L_:?CL.k,.' 1i? CHIEF COMPLAINT: _ �: _ - 7 '`"t� DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN . AUTHORIZATION FOR DRY RUN (EMS USE ONLY) L?f' PATIEtJ REFUSED SERVICES: (SIGNATURE) X__ MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: " S.S. a PRIVATE INS. CO.: BASE RATE: KAISER q: MULTIPLE PTS. BASE RATE BLU gyp. _ TOTAL MILES: X ,K(EDICAREy� � U �6'��'�� E.O"B. ATT. ROUND TRIP: ❑ YES ONO ❑ YES ❑ NO NIGHT: (19:00-07:00) ) CCHP/PPRP a:_ EMERGENCY RUN: MEDT-CAL CODE 2/3 OTHER:_ —_ OXYGEN: (PER TANK) ;J, P.O.E. STICKER ❑ YES ❑ NO NEONATAL (INCUBATOR) : DATES BILLED:_ 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) EMPLOYER: _ OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: COMMENTS:_ TOTAL _�_'. �"7 PATIENT RECEIVED BY: X 007-8-7 !SIGNATURE) CONTRA COSTA COUNTY AMBULANCE q3y 2 3 '. ;I 7 PRE-HOSPITAL CARE FORM I UNIT ® AUTHORIZATION M [V� CHECK OR FILL IN APP PRATE SPACES _ DATE: v PATIENTS NAMEYlA OM OF COMPANY I ADDRESS AGE\ �J�v CITY STATEZIP�, D08 9n ❑ M O T ❑W D Th 13F ❑S DRIVER'S LICENSE 0 1 PHONE NATURE OF DISPATCH Gl7 vS On. TYPE OF TRANSPORT: AMBULANCE r�OTHER❑ STATION I(A)_2(8)_3(C)_4(D)_5(E)_ INCIDENT LOCATION% �' ` RESPONSE CODE: TED BY: TIME- (24 HOUR CLOCK) .�;^ ;�1..� ' TO SCENE-• CALL RECEIVED J �J ,y`' 1.T f ❑ P.D. TIME 10-8 / `~ PATIENT DEQ (NATION: FROM SCEN ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 �n KbOCTOR ' PMD/ER STARTTIME 10-22 HOW CHOSEN: , . TOTAL STANDBY TIME Z'j�3_O NEAREST, O FAMILY O TRANSFER WAIT TIME O PATIENT ❑ DIRECT O OTHER CALL BACK K: AMBULANCE COMPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE iT 1. ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER ' PATIENT CONDITION:, I DRIVER l�Sy A, `� � � FMT-14 D;4119 I TECHNICIAN PARAMEDIC Hx: DISPATCHER: CHIEF COMPLAINT: DRY RUN: p YE ❑ NO REASON FOR DRY RUN z z S K� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ctyk, yyy• PATIENT REFUSED SERVICES:(SIGNATURE) X S L�'✓\/ls !�2 MEDICAL COVERAGE: INDUSTRIAL DYES ❑ NO NO. OF PATIENTS: S.S.0 ) T . PRIVATE INS.CO.: BASE RATE: KAISER M: MULTIPLE PTS. BASE RATE BLUE CROSS 0: TOTAL MILES: X MEDICARE N - E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP EMERGENCY RUN: MEDI-CAL If: 1 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) c� `EMPLOYER: OCCUPATION: OTHER: ADDRESS: _ --CITY: STATE: ZIP: COMMENTS: TOTAL: _..... ..._.._... _. PATIENT RErFIVFD BY-X.___ �f ' � • II � �.r • CONTRA COSTA COUNTY AMBULANCE/L/ PRE-HOSPITAL CARE FORM I, 1 " UNIT AUTHORIZATION w 1.,�-;� r I _ J 1 CHECK OR FILL IN APPROPRIATE SPACES DATE: PATIENTS NAME M El COMPANY M / ADDRESS V1'1 AG , _ _ �-st-Atm/ ((,E ' // �l i. , �•I CITY - STATE � `/ ZIP DOB/ ,P' Sn ❑ M ❑ T ❑ W ❑ Th ❑ F ❑ S- DRIVER'S LICENSE 8 _ __ PHONE 7122 Z NATURE OF DISPATCH 1l -1-y TYPE OF TRANSPORT: AMBULANC OTHER❑ ___ _._—___ - STATION 1(A)_2(B)_3(C)_4(D)_5(E)A_ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME — (24 HOUR CLOCK) E-5 TO SCENE t"S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10-97 /J aZ 11PSAP TIME 10-49 ~'� MILEAGE: ❑ OTHER/PVT TIME 10-7 END 1 C) - TIME 10-98 j �.DOCTOR "- ) �D AMD R START TIME 10-22 HOW CHOSEN: TOTAL - I- STANDBY TIME ❑ NEAREST, ❑ FAMILY ❑ TRANSFER i t` WAIT TIME ❑ PATIENT Cl DIRECT 7iSL OTHERl ry / CALL BACK M: AMB f,C C MPANY: i PT. AMBULATORY? PATIENT TAKEN TO AMBU NCE: I RESPONSE ZONE J ' } ❑ YES tR NO ❑ WAL'<ED k GUERNEY OTHER PATIENT CONDITION: DRIVER ` t i EMT-1A ' TECHNICIAN _ I• (^) PARAMEDIC Hx: I: (� DISPATCHER: 1'•�l • i-(- A ' ' CHIEF COMPLAINT: LA DRY RUN: ❑ YES PNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSE SERVI (SIG TURE) X MEDICAL,C OVERAGE: INDUSTRIAL ��YES/RJNO NO. OF PATIENTS: `+ PRIVATE INS. CO.: BASE RATE: KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS#: TOTAL MILES: X J � MEDICAR E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) 1 CCHP/PPRP M: EMERGENCY RUN: MEDT-CAL k: CODE 2/3 IOTHER: OXYGEN: (PER TANK) nn P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) G DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) 2 NEAREST RELATIVE/ ESPONSIBLE PARTY I.V.: (PER ADMIN.) X y� DRUGS: (PER ADMIN.) X NAME J RELATIONSHIP: l E.O.A.: (IF NOT REPLACED) ADDRT.'�-04 3 ORAL AIRWAY: (IF NOT REPLACED) !� CITY: STATE— ZIP: C-COLLAR: (IF NOT REPLACED) PHONEZ� ��j 7 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: ��'� Gy ' COMMENTS: I PATIENT RECEIVED BY X Provider mcair, • opp �,.,,,, (SIG Tl1Rl 1 Vhi cc and Pi.:, r. .c �.� ,,.I�,. � ch• t CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT f AUTHORIZATION# I. CHECK OR FI[[IM APPROPRIATE SPAC[SDATE: PATIENT'S NAME_� !�! r •� ►C) t/ ('S I •1 �. (.� / — - M O F COMPANY# ADDRESS / �n rr !1_L�1 4? i T •� I � AGE Z'Z. � 3 CITY�- '� '-' �� LI STATER ZIP D013 7-'3-6 1 ��(C/ L )ISn OM OT OW C3 Th OF OS DRIVER'S LICENSE is __� PHONE___(_ - �� Z" NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE OTHER❑ _ - STATION 1(A)-2(B)_3(C)_4(D)_S(E)= INCIDENT LOCATION: RESPONSE CODE: RESTED BY: TIME- (24 HOUR CLOCK) ! �•� DA L ta� TO SCENE- '3 fd S.O. CALL RECEIVED - ❑ P.D. TIME 10-8 ' `r PATIENT DESTINATION: FROM SCENE- •� ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 -an I �. t h V/ MILEAGE:(rD(-\ O 13OTHER/PVT TIME 10-7 c.� END TIME 10-98 _2L J / 7 DOCTOR PMDJ0 START TIME 10-22 ) HOW CHOSEN: TOTALS STANDBY TIME . I ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME 1 CKPATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: , EdEMS BULATORY? PATIENT TAKEN TO AMBULANCE: Cn RESPONSE ZONE❑ NO ❑ Wtil':ED '�GUERNEY 11OTHER `J I PATIENT CONDITION: DRIVER_ " '00'or S Ir� EMT-1A .n TECHNICIAN✓ ` �'t ( PARAMEDIC--4K _ Hx: � DISPATCHER: HOLD �CL/+W )OO I I i, CHIEF COMPLAINT: ='y2"3-� �'� DRY RUN: ❑ YES ONO REASON FOR DRY RUN ' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) LI 'r PATIENT REFUSED SERVICES: (SIGNATURE) X_ '` �/ -y C �r •• MEDICAL fCOVERAGE: INDUSTRIAL ❑ VESXNO NO. OF PATIENTS: S.S. # -1 2-- 17 -I ? '15- {.. h� `� t PRIVATE INS. CO.: h fL BASE RATE: ��- CJ CL! KAISER a: MULTIPLE PTS.BASE RATE ' �� BLUE CROSS#: TOTAL MILES: / XZ :.. MEDICARE#: E.O.B. ATT. ROUND TRIP: Cl YES ❑ NO f7-1 i ❑ YES ❑ NO NIGHT: (19:00-07:00) /- 1 CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: h O h CODE 2/3 I �•-- OTHER: — OXYGEN: (PER TANK) r P.O.E. STICKER Cl YES ❑ NO NEONATAL: (INCUBATOR) 1 I�t) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X // DRUGS: (PER ADMIN.) X NAME: l�` rl RJ ��T 1 QRELATIONSHIP:�•?M E O.A. (IF NOT REPLACED) `� /- _ ADDR;E��SS, � L 7 L" r_EC " S n ORAL AIRWAY: (IF NOT REPLACED) CITY:1 7•1f� T _ STATE_A_ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: W FQK QNE: DRY RUN: (AUTHORIZED) EMPLOYER:��NATION � IjPATIdN: ~T OTHER: - ADDRESS: ` S ��� Z• / / /�'a2I CITY: �^-� G STATE:e'A ZIP: COMMENTS: TOTAL:- PATIENT RECEIVED BY: X r.....:,... (SIGNATURE) C CO RA COSTA COUNTY AMBULANCE �y PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATI N CNlCR OA Flll IN OPl1lATE Cf! DATE: al 73 //A •PATIENTS NAME-: OAA OF COMPANY N ` to ADDRESS­ AGE\ t CITY STATE .ZIP DOB Sn O M ❑ T Ow O Th OF OS DRIVER'S LICENSE N _ ' PHONE ._ NATURE OF DISPATCH� TYPE OF TRANSPORT: AMBULANC OTHER❑ — — STATION I(A)_2(8)_3(C) 4(D)_51E)_ INCIDENT LOCATION _ RESPONSE CODE: RE UESTED BY: TIME— (24 HOUR CLOCK) 7 TO SCENE- ' �.0. CALL RECEIVED V r� , 3 ❑ P.D. TIME 10-8 PATIENT DESTINATI FROM SCE ❑ FIRE TIME 10.97 :T_❑ PSAP TIME 10-49 �(ZJ ^fit f MILEAGE: ❑ OTHER/PVT TIME 10-7 END TIME 10-98 DOCTOR: R START TIME 10-22 HOW CHOSEN: .. TOTAL STANDBY TIME Z^`i ;•O NEAREST—? O FAMILY ❑ TRANSFER WAIT TIME O PATIENT O DIRECT ❑ OTHER CALL BACK N: AMBULANCE COMP t PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: F RESPONSE ZONE ❑ YES ❑ NO O WALKED ❑ GUERNEY ❑ OTHER I c� tT n PATIENT CONDITION:.—", DRIVER � _ EMT-1A • TECHNICIAN ^JPARAMEDIC : Hx: DISPATC z. as,j I�^ _ .! HIEF COMPLAINT: DRY ES NO REASON FOR DRY RU "t "h AUTH OR DRY RUN(EMS USE ONLY) �((�l1 s?.`• PATIENT REFUSED SERVICES:(SIGNATURE) X Q ) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO 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 C I 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: "'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) ' EMPLOYER: OCCUPATION: OTHER: ADDRESS: — CITY: STATE: ZIP: COMMENT 2 — � Q — TOTAL: _.� PATIENT RECEIVED BY X _� _ �.� .. fy 1 �` '� �f�