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2. Date of Transport
   Date of Transport
3. Firehouse Incident Number
5. Patient Initials
6. Patient Date of Birth
   Patient Date of Birth
8. Ambulance Crew
10. Lead Paramedic
12. EMT / Paramedic
14. EMT / Paramedic
16. Shift
    -- Select One --ABC
18. Transferred care to:
20. Your Name
21. Date:
    Date:
23. Employee ID #
25. This form is only to be filled out by the lead paramedic that provided care to the patient.
    
    The attempt to use this service by anyone who was not the lead paramedic is a violation of the Health Insurance, Privacy and Accountability Act (HIPAA) and will result in punishment up to and including termination of employment.
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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