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Patient Information Sheet

PATIENT INFORMATION SHEET
NON-EMERGENCY MEDICAL TRANSPORT

 

SCHEDULED DATE OF TRANSPORT: ____________________
TIME: _______________ (AM/PM)

 

Patient Name:

(Last) _________________ (First) _____________ (Middle) ________

Patient ID (Hospital ID Number): ___________________________________

Room _______________

DOB: ___ (Month) _____ (Day) _____ (Year)

Home Address: (Street) ________________________________________________
(City)_______________________ (State) _______ (Zip) _________

 

Family Member or Legal Guardian Contacts:

 

(1) Name ________________________________________

Relation to Patient _____________________________

Tel: __________________________________________

 

(2) Name ________________________________________

Relation to Patient _____________________________

Tel: ________________________

 

Discharging Physician:_______________________________

Tel: __________________________
Email: _____________________________

Receiving Hospital/Facility: __________________________

(Street)_________________________________________________

(City) _______________________ (State) _________ (Zip) ________

Tel: ___________________________

Email: _________________________

 

Receiving Physician: __________________________________

Tel: ______________________________

Email: ____________________________

Call our call center 24/7/365!
1-800-827-0745 or International (USA country code)+305.662.4006

 

**About Air Ambulance America (AAA): Air Ambulance America is an authorized indirect Air Carrier (IAC) utilizing the services of licensed Part 121 and 135 air carriers to meet your air ambulance transportation need. AAA does not own,lease or operate aircraft, and has no affiliation with any direct air carrier. As an IAC, AAA contracts for the provision of air transportation services in its own name and coordinates the provision of medical services for your flight.

Download the Patient Information Sheet

 

Sections:

Intro
1- Information Management
2- Logistics Expert
3- Patient Advocate
4- Liaison for Family Members

Forms:
Medical Transportation Checklist

Patient Information Sheet

Related Links:
Medicare Coverage for Non-Emergency Transports

Medical Transportation Glossary

Medical Considerations for Commercial Airline Patients

    Please contact us at:
    1-800-827-0745 or 305.662.4006

    Email: info@airambulance.net

What Our Happy Clients Speak

I would like to thank everyone involved from turning a potentially difficult experience into an enjoyable one. My mother,Mary, and I enjoyed the flight, and the flight nurse, was terrific. He really allayed all our fears, and we felt perfect confidence in him.

The pilot and first officer were also wonderful and instilled great confidence in us. All in all, it was a marvelous trip and we can’t thank you enough!!!

Martha Cooperman

This letter commends the efficiency and professionalism of your organization during the recent transport of our aunt, Lisa Cordero, from New York City to Cleveland. The flight crew was courteous and helpful. Your flight coordinators were exceptionally competent in arranging a quite difficult transfer.

Where we have had frustrations with lawyers, bankers, and doctors, we had only the most ‘can do’ attitude from all of your staff. We have recommended your service to a colleague and will continue to do so without hesitation.

John L. Youel & Barbara K Youel
We offer a Medical and Aerospace Professional service for Our Patients Call us : 1-800-827-0745
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Experience since 1984 means you are given quality care. Without incident by the licensed air carriers we utilize, we arrange safe and expert care around the world….read more >>

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