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.
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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.
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I acknowledge
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EMS Provider Name (DO NOT SHARE PATIENT NAME)
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First Name
Last Name
Email
example@example.com
Phone Number (you will be contacted at this number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Transport Destination
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Please Select
Winchester
Warren
Shenandoah
Page
Other
If other:
Date of EMS Transport
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Month
-
Day
Year
Date
Estimated Time of Transfer of Care to Hospital
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Hour Minutes
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Transporting Agency
*
Frederick County
City of Winchester
Clarke County
Warren County
Shenandoah County
Page County
Other
Other (if applicable)
Transporting Unit Number
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Helicopter/Other Unit/Other Agency (if applicable)
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Patient Type
*
Please Select
Medical
Trauma
STEMI
Stroke
Pediatric
OB
Other/unknown
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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.
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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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