EMS FollowUp

EMS Patient Follow-Up

Fill out this form to receive feedback/patient update on your patient via phone call (540-536-5587) by the Valley Health EMS Liaison. Please forward any questions to rneely@vaems.org

By checking this box, I attest that I provided direct patient care for the patient I am requesting an update on.

I attest
I acknowledge that HIPAA Identifiers can NOT be put on this form. HIPAA Identifiers include name, date of birth, address, MRN, and CSN.*

I acknowledge

EMS Provider Name (DO NOT SHARE PATIENT NAME)*

First NameLast Name
Email
example@example.com
Phone Number (you will be contacted at this number)*
Please enter a valid phone number.

Transport Destination *
If other:
Date of EMS Transport*

MonthDayYear
Date
Estimated Time of Transfer of Care to Hospital*

Hour Minutes

Transporting Agency*

Frederick CountyCity of WinchesterClarke CountyWarren CountyShenandoah CountyPage CountyOther
Other (if applicable)
Transporting Unit Number*
Helicopter/Other Unit/Other Agency (if applicable)

Patient Type*

Specific feedback requested, if applicable: **do NOT share any HIPAA-related information, such as patient name, date of birth, address, or MRN number. You may however include patient's age, gender and chief complaint.

If you do not receive follow-up within 3 business days of your request, please contact Perry at 540-536-5587 or pmcalist@valleyhealthlink.com to ensure your form was submitted and received.
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