Patient Outcome Request Form
This form is for requesting patient outcome information from EMS calls. You are only entitled to make a request for patient outcome information if you were a provder listed on the EMS run sheet. We will attempt to get information to you in as timely of a manner as possible, but please undersntad that these requests can and do take a significant amount of time to complete. Please DO NOT include a patient name in the request. If we require additional information we will contact you
Date of EMS Service
MM
/
DD
/
YYYY
Agency Providing EMS Transport
Run Number of Patient Encounter
Your answer
Hospital Patient Transported To
EMS Provider Making Request
Your answer
EMS Provider Email Address
Your answer
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