VA_Hospital_Patient_Transportation_Voucher.pdf

VA Hospital Patient Transportation Voucher

Notes regarding issues particular to the specific transport, including recording oxygen, cardiac monitoring, and other services provided (i.e. material items, supplies).

Stretcher

BLS

O2

ALS

Monitor

CCT

Vent

Dry Run

IV

NO Show

VA Authorization

First Last

Printed Name:

Signature:

Original to VA Copy to Ambulance Service

Ambulance Service 1 (877) 832-8558

Date:______________

Patient Name:

Patient ID #:

Last 4 of Soc Sec.

Run #_____________

Pickup Origin:

Pickup Time:

Destination:

Time Of Delivery:

Mileage: ___________________

VHAANNStewaW Rectangle

VA Hospital Patient Transportation Voucher

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/HRV (Za stvaranje Adobe PDF dokumenata najpogodnijih za visokokvalitetni ispis prije tiskanja koristite ove postavke. Stvoreni PDF dokumenti mogu se otvoriti Acrobat i Adobe Reader 5.0 i kasnijim verzijama.)

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Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.)

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