Hopkinsville Fire & EMS Ambulance Request

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Select the type of Ambulance request below:* This field is required.
Patient Transport
Special Event/Standby
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Does the patient have or do they wish to have a Do Not Resuscitate order (DNR)?* This field is required.
YESNO
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DO NOT RESUSCITATE (DNR) Information - Kentucky law forbids EMS from recognizing any DNR request unless it's specifically spelled out on the "Kentucky Emergency Medical Services Do Not Resuscitate (DNR) Order or on the Medical Orders for Scope of Treatment (MOST) form. Furthermore, the original form should be accessible by EMS when arriving to transport the patient. "Hospital DNRs" cannot be honored. Therefore, if the patient wishes to not be resuscitated by EMS, please download one of the attached forms and fill it out following the supplied instructions. If you need assistance completing the forms, please advise the Captain and we will be happy to assist. Informational Document
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KY EMS DNRInformational Document
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What type of transport will this be?* This field is required.
JSMC or BACH Origin Only - Immediate request to transport a patient to another hospital (Not to Cumberland Hall or WSH).
JSMC or BACH Origin Only - Scheduled Transport to another Hospital (to include Cumberland Hall and WSH) for continued care
Discharge from a Hospital or facility
Scheduled Medical Transport (Dialysis, Wound-care, Appointments, etc.) in days or weeks from today.
Transportation directly to an Emergency Room from an out-of-hospital location.
A representative from HFD has directed you to choose this PCS-only option. **Please do not select this option unless you have been advised to do so**.
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STOP!

If the patient is to be transported directly to the Emergency Room it is considered to be an immediate request for service and must be processed through our Emergency Communications Center, even if you believe the patient's complaint or condition is not an emergency. Stop and call 911 or 270-890-1300 for an Ambulance.
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Does the patient have Medicare OR Medicaid?
YESNO
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Emergency Interfacility Transports

Complete this form first.

Then call the on duty Captain to confirm the request.

If no answer, contact ECC at 270-890-1300 and advise them to notify the Captain that an Emergency Transfer Request is holding.
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Non-Emergency Interfacility Transports

Complete this form and call the EMS phone to make arrangements.

If there is NO ANSWER

0700-2100: Leave a message. Command Staff members may be on another emergency response and are unable to answer. If after 30 minutes, you do not receive a call back, call again.

2100-0700: If no answer, call ECC at 270-890-1300 and advise them that you have a non-emergent transfer holding.
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Convalescent Transportation (Dialysis, wound-care, appointments, etc.)

Complete this form and someone will contact you within 8 hours for scheduling and within the hours of 0800 and 2000.

24 hour notice is required except due to extenuating circumstances.

The time you request is not guaranteed and is based on available resources.
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Discharges

Complete this form. A representative will contact you within 1 hour.

Discharges will be arranged for JSMC ED 24/7, if resources allow.

Discharges from any other location will only occur between the hours of 8am and 8pm except for extenuating circumstances. A representative will return your call during these hours to confirm transport.
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